[Mission (im)possible : Setting up a neurological center 12,000 km away with telemedicine]. / "Mission (im)possible" : Aufbau eines neurologischen Zentrums 12.000 km entfernt mittels Telemedizin.

BACKGROUND: Specialized neurological treatment decreases the mortality and morbidity of stroke patients. In many regions of the world an extensive coverage is not available. The cooperation between the Krankenhaus Nordwest (KHNW, Frankfurt, Germany) and the Government of Brunei Darussalam describes the set-up process of a specialized neurological center, including stroke unit, science and rehabilitation center. AIM: The aim of this project called to teach to treat - to treat to teach was to set up a center of excellence in neurology in Brunei Darussalam over a distance of 12,000 km. Treatment options were elucidated by teaching and taught by case examples. MATERIAL AND METHODS: The construction of the Brunei Neuroscience Stroke and Rehabilitation Center (BNSRC) began in July 2010. To overcome the large distance between the department of neurology and neuroradiology at the KHNW and the BNSRC, a telemedical network was established. We provided daily teleteaching for all professions involved in patient care as well as 24/7 availability of teleneurological services from Germany to support the local team on site. RESULTS: In the BNSRC unit over 1000 patients with ischemic and hemorrhagic stroke and all the various acute neurological conditions were treated from July 2010 until July 2016 as inpatients and over 5000 were treated as outpatients. Since 2010, a total of 52 patients with stroke were treated by thrombolysis within the thrombolytic window and 81 hemicraniectomies were performed. CONCLUSION: The project has shown that it is possible to convey specialized neurological knowledge over large distances to provide significant benefits for patients and caregivers.

CO oxidation on Pt(111) at near ambient pressures.

The oxidation of CO on Pt(111) was investigated simultaneously by near ambient pressure X-ray photoelectron spectroscopy and online gas analysis. Different CO:O2 reaction mixtures at total pressures of up to 1 mbar were used in continuous flow mode to obtain an understanding of the surface chemistry. By temperature-programmed and by isothermal measurements, the onset temperature of the reaction was determined for the different reactant mixtures. Highest turnover frequencies were found for the stoichiometric mixture. At elevated temperatures, the reaction becomes diffusion-limited in both temperature-programmed and isothermal measurements. In the highly active regime, no adsorbates were detected on the surface; it is therefore concluded that the catalyst surface is in a metallic state, within the detection limits of the experiment, under the applied conditions. Minor bulk impurities such as silicon were observed to influence the reaction up to total inhibition by formation of non-platinum oxides.

Neuropathic pain resulting from implant placement: case report and diagnostic conclusions.

Temporary or persisting dysesthesia of the nervus alveolaris inferior has often been described as a complication of implant surgery of the lower mandible. In most cases, lesion of the nerve results in anaesthesia of the innervated region, a symptom clearly indicative of correct diagnosis. In our case report, however, a minor perforation of the roof of the mandibular canal during implant placement apparently provoked discrete irritation of the nerve, resulting in persistent neuropathic pain without concomitant hypesthesia or dysesthesia. Because the canal could not be detected in conventional dental radiographs, this uncharacteristic situation made correct diagnosis difficult and led to unnecessary surgical procedures including extraction of adjacent teeth. Medical imaging [computed tomography (CT)] finally revealed the close proximity of the apex of the implant and the bony structure of the mandibular canal. The effect on the nervus alveolaris inferior was also demonstrated using an innovative high-resolution dental magnetic-resonance-imaging technique reflecting vascular reactions of the neurovascular bundle after potentially damaging surgical intervention. After removal of the causative implant, the pain gradually faded over a period of a year.

The German trial on Aciclovir and Corticosteroids in Herpes-simplex-virus-Encephalitis (GACHE): a multicenter, randomized, double-blind, placebo-controlled trial.

INTRODUCTION: Comprehensive treatment of Herpes-simplex-virus-encephalitis (HSVE) remains a major clinical challenge. The current therapy gold standard is aciclovir, a drug that inhibits viral replication. Despite antiviral treatment, mortality remains around 20% and a majority of survivors suffer from severe disability. Experimental research and recent retrospective clinical observations suggest a favourable therapy response to adjuvant dexamethasone. Currently there is no randomized clinical trial evidence, however, to support the routine use of adjuvant corticosteroid treatment in HSVE. METHODS: The German trial of Aciclovir and Corticosteroids in Herpes-simplex-virus-Encephalitis (GACHE) studied the effect of adjuvant dexamethasone versus placebo on top of standard aciclovir treatment in adult patients aged 18 up to 85 years with proven HSVE in German academic centers of Neurology in a randomized and double blind fashion. The trial was open from November 2007 to December 2012. The initially planned sample size was 372 patients with the option to increase to up to 450 patients after the second interim analysis. The primary endpoint was a binary functional outcome after 6 months assessed using the modified Rankin scale (mRS 0-2 vs. 3-6). Secondary endpoints included mortality after 6 and 12 months, functional outcome after 6 months measured with the Glasgow outcome scale (GOS), functional outcome after 12 months measured with mRS and GOS, quality of life as measured with the EuroQol 5D instrument after 6 and 12 months, neuropsychological testing after 6 months, cranial magnetic resonance imaging findings after 6 months, seizures up to day of discharge or at the latest at day 30, and after 6 and 12 months. RESULTS: The trial was stopped prematurely for slow recruitment after 41 patients had been randomized, 21 of them treated with dexamethasone and 20 with placebo. No difference was observed in the primary endpoint. In the full analysis set (n = 19 in each group), 12 patients in each treatment arm achieved a mRS of 0-2. Similarly, we did not observe significant differences in the secondary endpoints (GOS, mRS, quality of life, neuropsychological testing). CONCLUSION: GACHE being prematurely terminated demonstrated challenges encountered performing randomized, placebo-controlled trials in rare life threatening neurological diseases. Based upon our trial results the use of adjuvant steroids in addition to antiviral treatment remains experimental and is at the decision of the individual treating physician. Unfortunately, the small number of study participants does not allow firm conclusions. TRIAL REGISTRATION: EudraCT-Nr. 2005-003201-81.

Clinical Trial Results Summary for Laypersons: A User Testing Study.

OBJECTIVE: To apply "user testing" to maximize readability and acceptability of a Clinical Trial Results Laypersons Summary-a new European requirement. METHODS: "User testing" (using questionnaire and semistructured interview) assessed whether people could find and understand key points. Findings were used to improve content and design, prior to retesting. Participants had a range of levels of health literacy and there was a higher education group. Participants accessed the summary on screen. In round 1 we tested 12 points of information. In round 2 a revised summary addressing round 1 findings was tested, leading to a third final version. RESULTS: In round 1, 2 of 12 points of information did not reach the target and interviews raised further format and content issues (some distracting technical explanations and inability to find or understand the 2 main study purposes). These findings informed revisions for the version tested in round 2, with 2 different points not reaching the target (inclusion criteria relating to duration of seasonal allergies and how researchers found out about participants' symptoms). Identified problems in both rounds were addressed and reflected in the final version. Despite improvements, participants did not consistently understand that summaries were intended for the public, or to only interpret results of single trials in the context of additional trials. All readers, including those with higher education, found the clear and straightforward language acceptable. CONCLUSIONS: Applying "user testing" resulted in a largely health-literate summary suitable for people across a range of backgrounds.

[Injury of craniocervical arteries: imaging findings and therapy]. / Kraniale und zervikale arterielle Gefässverletzungen: Bildgebung und Therapie.

Direct or indirect injury of craniocervical vessels may be the consequence of an accident, may result from tumor arrosion, or may even occur spontaneously. Many of these vascular lesions can be detected using modern non-invasive vascular imaging techniques such as CT angiography and MR angiography. These traumatic vascular lesions can usually be treated using endovascular techniques. This overview describes neuroradiological findings for traumatic lesions of cervical and cranial vessels as well as endovascular treatment options.

Setting up a Neuroscience Stroke and Rehabilitation Centre in Brunei Darussalam by a transcontinental on-site and telemedical cooperation.

Due to the world-wide aging population, there is a need for specialist neurological knowledge, treatment and care. Stroke treatment is effective in reducing mortality and disability, but it is still not available in many areas of the world. We describe the set-up process of a specialized Neuroscience, Stroke and Rehabilitation Centre in Brunei Darussalam (BNSRC) in cooperation with a German hospital. This study details the setup of a stroke-, neurological intensive care- and neurorehabilitation unit, laboratories and a telemedical network to perform all evidence-based stroke treatments. All neurological on-site services and the telemedical network were successfully established within a short time. After setup, 1386 inpatients and 1803 outpatients with stroke and stroke mimics were treated. All evidence-based stroke treatments including thrombolysis and hemicraniectomy could be performed. It is possible to establish evidence-based modern stroke treatment within a short time period by a transcontinental on-site and telemedical cooperation.

[Trigeminal neuralgia: how often are trigeminal nerve-vessel contacts found by MRI in normal volunteers]. / Trigeminusneuralgie: Wie häufig gibt es einen Gefäss-Nerven-Kontakt bei schmerzfreien Probanden?

PURPOSE: To assess prospectively how often contacts are found between the trigeminal nerve and arteries or veins in the perimesencephalic cistern via MRI in normal volunteers. MATERIALS AND METHODS: 48 volunteers without a history of trigeminal neuralgia were examined prospectively (MRI at 1.5 T; T2-CISS sequence, coronal orientation, 0.9 mm slice thickness). Two radiologists decided by consensus whether there was a nerve-vessel contact in the perimesencephalic cistern. RESULTS: In 27 % of the volunteers, no contact was found between the trigeminal nerve and regional vessels, while in 73 %, such a contact was present. In 61 % of the cases, the offending vessel was an artery, in 39 %, it was a vein. In 2 volunteers, a deformation of the nerve was noted. CONCLUSION: Contrary to what has been suggested by retrospective studies, the majority of normal volunteers, if studied prospectively, do show a contact between the trigeminal nerve and local vessels. A close proximity between the nerve and regional vessels is thus normal and is not necessarily proof of a pathological nerve-vessel conflict.

Repeated digital substraction angiography after perimesencephalic subarachnoid hemorrhage?

BACKGROUND AND PURPOSE: In patients with perimesencephalic subarachnoid hemorrhage (pSAH) DSA is recommended to exclude aneurysms to due false negative findings in CT-angiography. However, whether a second DSA is indicated during the clinical course to exclude--in addition to aneurysms--fistulas, too, is still under debate. We aimed to evaluate the benefit of repeated DSA in patients with pSAH. METHODS: The source of data was a prospective database set up at the neurological, neurosurgical and neuroradiological departments in our institution. A total of 69 patients with pSAH were enrolled and analyzed by reviewing the medical records and neuroradiological findings. RESULTS: 68 patients presented with Hunt & Hess Grade I-II and one patient with Hunt & Hess Grade III. Median in-hospital stay was 8 days (3-22). In 2 patients mild vasospasm were diagnosed. DSA was performed in all patients at least once. DSA was repeated in 38 patients (55%) after a median of 7 (3-21) days. None of the repeated DSA did show any additional distinctive features with respect to the first DSA. CONCLUSIONS: In our opinion the procedure of repeating DSA in patients with pSAH is likely to become obsolete. One DSA should be performed prior to discharge--and subsequent to possible vasospasm--to exclude hemorrhage caused by aneurysms of the posterior circulation mimicking a perimesencephalic SAH pattern.

[Does the individual adaptation of standardized speech paradigmas for clinical functional magnetic resonance imaging (fMRI) effect the localization of the language-dominant hemisphere and of Broca's and Wernicke's areas]. / Beeinflusst die individuelle Anpassung standardisierter Sprachparadigmen für die klinische funktionelle Magnetresonanztomographie (fMRT) die Lokalisation der sprachdominanten Hemisphäre, des Broca- und des Wernicke-Sprachzentrums?

PURPOSE: Functional magnetic resonance imaging (fMRI) localizes Broca's area (B) and Wernicke's area (W) and the hemisphere dominant for language. In clinical fMRI, adapting the stimulation paradigms to each patient's individual cognitive capacity is crucial for diagnostic success. To interpret clinical fMRI findings correctly, we studied the effect of varying frequency and number of stimuli on functional localization, determination of language dominance and BOLD signals. MATERIALS AND METHODS: Ten volunteers (VP) were investigated at 1.5 Tesla during visually triggered sentence generation using a standardized block design. In four different measurements, the stimuli were presented to each VP with frequencies of 1/1 s, (1/2) s, (1/3) s and (1/6) s. RESULTS: The functional localizations and the correlations of the measured BOLD signals to the applied hemodynamic reference function (r) were almost independent from frequency and number of the stimuli in both hemispheres, whereas the relative BOLD signal changes (DeltaS) in B and W increased with the stimulation rate, which also changed the lateralization indices. The strongest BOLD activations were achieved with the highest stimulation rate or with the maximum language production task, respectively. CONCLUSION: The adaptation of language paradigms necessary in clinical fMRI does not alter the functional localizations but changes the BOLD signals and language lateralization which should not be attributed to the underlying brain pathology.

[Infectious diseases of brain parenchyma in adults: imaging and differential diagnosis aspects]. / Infektiöse Erkrankungen des Hirnparenchyms bei Erwachsenen: Bildgebung und differenzialdiagnostische Aspekte.

Infectious diseases of the central nervous system have often to be considered in differential diagnosis, particularly in immunocompromised persons. Neuroimaging, specifically advanced techniques such as diffusion-weighted MRI and perfusion MRI contribute much to the differentiation of various brain infections and to delineation of brain infections from other, for instance, neoplastic diseases. In this review we present the imaging criteria for the most important brain infections in adults and discuss in detail differential diagnostic aspects.

A randomized trial of the efficacy and tolerability of the COX-2 inhibitor rofecoxib vs ibuprofen in patients with osteoarthritis. Rofecoxib/Ibuprofen Comparator Study Group.

BACKGROUND: Nonsteroidal anti-inflammatory drugs (NSAIDs) inhibit both cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2). It is not known whether a specific inhibitor of COX-2 will provide efficacy in osteoarthritis (OA) comparable with NSAIDs. Therefore, we compared the efficacy and safety of the rofecoxib, which specifically inhibits COX-2, with those of the NSAID ibuprofen in patients with OA. OBJECTIVE: To compare the clinical efficacy and tolerability of rofecoxib (12.5 and 25 mg once daily) with ibuprofen (800 mg 3 times daily). METHODS: A randomized, double-blind trial of 809 adults with OA was conducted. Patients with OA in whom the knee or hip was the primary source of pain were randomized to 1 of 4 treatment groups on demonstration of disease activity: placebo; rofecoxib, 12.5 or 25 mg once daily; or ibuprofen, 800 mg 3 times daily. Clinical efficacy and safety were monitored during a 6-week treatment period. RESULTS: Both doses of rofecoxib demonstrated efficacy clinically comparable with ibuprofen as assessed by 3 primary end points (pain walking on a flat surface [Western Ontario and McMaster Universities Osteoarthritis Index], patient global assessment of response to therapy, and investigator global assessment of disease status) according to predefined comparability criteria. Both rofecoxib doses and the ibuprofen dose provided significantly (P<.001) greater efficacy than placebo on all primary end points. Results from secondary end points were consistent with those of the primary end points. All treatments were well tolerated; the overall incidence rates of clinical adverse experiences were not significantly different (P>.05) among the treatment groups. CONCLUSION: Rofecoxib was well tolerated and provided clinical efficacy comparable with a high dose of the NSAID ibuprofen.

Hemorrhagic acoustic schwannoma: radiological and histopathological findings.

A 49-year-old man on anticoagulation treatment with phenprocoumon presented with acute right sided 7th and 8th cranial nerve palsy, acute hearing loss, headache, vertigo, and vomiting. CT and MRI revealed a cerebellopontine angle tumor 15mm in diameter and acute intratumoral hematoma. A cellular schwannoma composed predominantly of Antoni A tissue with dilated thin-walled vessels, surrounded by old hemorrhage with hemosiderin-laden macrophages was found histologically.

Global storm time depletion of the outer electron belt.

The outer radiation belt consists of relativistic (>0.5 MeV) electrons trapped on closed trajectories around Earth where the magnetic field is nearly dipolar. During increased geomagnetic activity, electron intensities in the belt can vary by orders of magnitude at different spatial and temporal scales. The main phase of geomagnetic storms often produces deep depletions of electron intensities over broad regions of the outer belt. Previous studies identified three possible processes that can contribute to the main-phase depletions: adiabatic inflation of electron drift orbits caused by the ring current growth, electron loss into the atmosphere, and electron escape through the magnetopause boundary. In this paper we investigate the relative importance of the adiabatic effect and magnetopause loss to the rapid depletion of the outer belt observed at the Van Allen Probes spacecraft during the main phase of 17 March 2013 storm. The intensities of >1 MeV electrons were depleted by more than an order of magnitude over the entire radial extent of the belt in less than 6 h after the sudden storm commencement. For the analysis we used three-dimensional test particle simulations of global evolution of the outer belt in the Tsyganenko-Sitnov (TS07D) magnetic field model with an inductive electric field. Comparison of the simulation results with electron measurements from the Magnetic Electron Ion Spectrometer experiment shows that magnetopause loss accounts for most of the observed depletion at L>5, while at lower L shells the depletion is adiabatic. Both magnetopause loss and the adiabatic effect are controlled by the change in global configuration of the magnetic field due to storm time development of the ring current; a simulation of electron evolution without a ring current produces a much weaker depletion.

Studies on the glycoprotein nature of the thyrotropin receptor: interaction with lectins and purification of the bovine protein with the use of Bandeiraea (Griffonia) simplicifolia I affinity chromatography.

The TSH receptor from Triton-solubilized bovine microsomal membranes was found to bind to a substantial extent to columns of the immobilized lectins Bandeiraea (Griffonia) simplicifolia I, Ricinus communis I, wheat germ, and Concanavalin A, whereas it was not retained by Dolichos biflorus. Elution of TSH receptor activity from these lectins could be achieved with the appropriate saccharides in all cases except Concanavalin A. The most extensive adsorption of the receptor occurred on B. simplicifolia I-agarose (84%), and the terminal alpha-D-galactosyl specificity of this interaction was substantiated by its susceptibility to alpha-galactosidase treatment. Whereas TSH itself was not bound to this immobilized lectin, a complex of this hormone with its receptor did interact and could be eluted with methyl-alpha-D-galactoside. Purification (800-fold) of the bovine TSH receptor was achieved by a combination of TSH and B. simplicifolia I affinity chromatographies. Polyacrylamide gel electrophoresis of the purified TSH receptor after radioiodination revealed three major components with apparent mol wt of 316,000, 115,000, and 54,000.

Edema and brain trauma.

Brain edema leading to an expansion of brain volume has a crucial impact on morbidity and mortality following traumatic brain injury (TBI) as it increases intracranial pressure, impairs cerebral perfusion and oxygenation, and contributes to additional ischemic injuries. Classically, two major types of traumatic brain edema exist: "vasogenic" due to blood-brain barrier (BBB) disruption resulting in extracellular water accumulation and "cytotoxic/cellular" due to sustained intracellular water collection. A third type, "osmotic" brain edema is caused by osmotic imbalances between blood and tissue. Rarely after TBI do we encounter a "hydrocephalic edema/interstitial" brain edema related to an obstruction of cerebrospinal fluid outflow. Following TBI, various mediators are released which enhance vasogenic and/or cytotoxic brain edema. These include glutamate, lactate, H(+), K(+), Ca(2+), nitric oxide, arachidonic acid and its metabolites, free oxygen radicals, histamine, and kinins. Thus, avoiding cerebral anaerobic metabolism and acidosis is beneficial to control lactate and H(+), but no compound inhibiting mediators/mediator channels showed beneficial results in conducted clinical trials, despite successful experimental studies. Hence, anti-edematous therapy in TBI patients is still symptomatic and rather non-specific (e.g. mannitol infusion, controlled hyperventilation). For many years, vasogenic brain edema was accepted as the prevalent edema type following TBI. The development of mechanical TBI models ("weight drop," "fluid percussion injury," and "controlled cortical impact injury") and the use of magnetic resonance imaging, however, revealed that "cytotoxic" edema is of decisive pathophysiological importance following TBI as it develops early and persists while BBB integrity is gradually restored. These findings suggest that cytotoxic and vasogenic brain edema are two entities which can be targeted simultaneously or according to their temporal prevalence.

MR imaging of traumatic lesions of the inferior alveolar nerve in patients with fractures of the mandible.

BACKGROUND AND PURPOSE: The objective of this study was to assess whether MR imaging can image the neurovascular bundle in patients with fractures of the mandible. In addition, an attempt was made to evaluate whether MR images provide information regarding the continuity of the inferior alveolar nerve before surgery and regarding signal intensity changes after trauma. METHODS: We analyzed preoperative MR images of 23 patients with mandibular fractures. Object-oriented sagittal view proton density- and T1-weighted sequences (before and after the administration of contrast agent) were used not only in an attempt to obtain purely qualitative information regarding nerve continuity in the neurovascular bundle (inferior alveolar nerve, artery, vein) but also to perform quantitative region-of-interest measurements of signal intensities at four defined measurement sites. The measurements were compared with those obtained for a patient population with healthy mandibles. RESULTS: It was possible to interpret MR images in 21 cases. MR imaging findings showed that the neurovascular bundle had been cut in two patients and was intact in the remaining 19 patients. These MR imaging findings were confirmed intraoperatively in all cases. Although we found no significant signal intensity differences between patients with intact nerves and patients with cut nerves, we found significant differences between patients with mandibular fractures and patients with unremarkable mandibles. CONCLUSION: It is possible to diagnose the interruption of nerve continuity by using MR imaging. Signal intensity measurements in the neurovascular bundle provide no information regarding nerve continuity.

Characterization of the acid beta-D-galactosidases from human urine.

Acid beta-D-galactosidases (EC 3.2.1.23) from human urine samples have been characterized using GM1-ganglioside, asialofetuin, and 4-MU-beta-D galactopyranoside. Sepharose 6-B column chromatography of crude urine supernatant fluids resolved three forms of acid beta-D-galactosidase activity with apparent molecular weights of 500 X 10(3)--700 X 10(3) (I), 90 X 10(3)--120 X 10(3) (II), and 20 X 10(3)--27 X 10(3) (III), which hydrolyzed 4-MU-beta-D-galactopyranoside, GM1-ganglioside and asialofetuin. The crude urine supernatant fluids and the separated forms of acid beta-D-galactosidase exhibited similar apparent KM values for the respective substrates. Starch gel electrophoresis of urine samples at pH 7.0 revealed a slow anodally migrating form of acid beta-D-galactosidase which electrophoretically corresponded to form I and a faster anodally migrating form corresponding to form II. Form III migrated as a composite of forms I and II suggesting that aggregation to the larger molecular weight activity forms occurred during starch gel electrophoresis. This report represents the first characterization of urinary acid beta-D-galactosidase with respect to naturally occurring glycolipid and glycoprotein substrates. In addition, data is presented to indicate that the enzyme may be composed of an enzymatically active form with an apparent molecular weight of 20 X 10(3)--27 X10(3), which is also capable of hydrolyzing the glycolipid and glycoprotein substrates.

[Benign diseases of the mandible in MRI]. / Benigne Erkrankungen des Unterkiefers im MRT.

Diseases of the mandible affect the soft tissues aside from the osseous manifestation. This can be shown clearly and in great detail by magnetic resonance imaging (MRI). MRI is the gold standard in the diagnostic evaluation of any internal derangement of the temporomandibular joint. Dental MRI requires high resolution techniques and in some cases also intravenous administration of contrast material. These techniques allow delineation of the neurovascular bundle. In the past few years new indications were formulated, for example, the evaluation of the integrity of the inferior alveolar nerve in trauma and in radicular cysts. New quantitative methods now enable insights into the pathophysiology. The objective of this review is to communicate accepted indications for MRI of the mandible and to present innovative applications.

[Preoperative functional magnetic resonance tomography (FMRI) in patients with rolandic brain tumors: indication, investigation strategy, possibilities and limitations of clinical application]. / Prächirurgische funktionelle Magnetresonanztomographie (fMRT) bei Patienten mit rolandischen Hirntumoren: Indikation, Untersuchungsstrategie, Möglichkeiten und Grenzen der klinischen Anwendung.

Preoperative functional magnetic resonance imaging (fMRI) localizes the primary motor and somatosensory cortex in relation to rolandic brain tumors and determines plastic cortical reorganization. Functional landmarks help to assess the indication for surgery and to plan for safer surgical procedures that protect the functional cortex during resection even when morphologic landmarks are no longer identifiable on anatomic images. Despite its successful application, preoperative fMRI has not yet reached the status of an established clinical diagnostic procedure since special stimulation systems, standardized fMRI protocols and medically approved software are still lacking. Following a brief review of the image display of the functional and morphologic anatomy, the different indications for preoperative fMRI in patients with rolandic brain tumors are presented. A robust preoperative protocol enables clinical MR units with magnetic field strengths of 1.0 Tesla or higher to perform reliable fMRI during contralateral hand movements. Optimized investigation strategies and stimulation modalities are proposed for patients with rolandic tumors distant from the cortical hand representation, for patients with preexisting sensorimotor deficits and for patients with poor compliance. Representative cases illustrate the clinical application. Possibilities and limitations of preoperative fMRI are presented and discussed.