The role of computerized rheoencephalography in the assessment of normal pressure hydrocephalus.

The aim of this study was to determine the relationship between arterial compliance derived from rheoencephalography (REG), and the slope of the regression line between pulse amplitude and mean ICP (AMP/P) recorded during a lumbar infusion study. A hypothetical link between these two variables has been suggested in the past. Resistance to the outflow of cerebrospinal fluid (R(out)) and the slope of the amplitude pressure regression line (AMP/P) were calculated in 62 patients diagnosed with posttraumatic normal pressure hydrocephalus (NPH). In all patients, the changes in cerebral electrical impedance related to the pulsatile component of blood flow were studied noninvasively using computerized rheoencephalography. We classified the REG pulse-related waveform (REGpw) according to the number of the inflection points in the ascending branch, which are a manifestation of the elastic properties of the small arteries. In normal subjects, REGpw corresponded with only one inflection point in the ascending branch (category I). For the purpose of this study, we assumed that the presence of three or greater number of inflection points was characteristic of the regressive changes of the arterial wall (category II). The slope of the AMP/P in patients with the category I REGpw was significantly lower than that in patients with category II (p < 0.05). The association between REGpw category II and the increased slope of the aAMP/P regression line may be related to the transmission of the pulse pressure waveform arterial wall to the CSF compartment, which in turn depends on the elastic properties of the cerebral arteries. The outcome of shunting in patients with REGpw category I was significantly better than that in patients with category II, suggesting that small artery disease may be linked to worse clinical outcomes. Our study indicates that REG examination has potential clinical value in diagnosis and prognosis of NPH.

Quality of survival of patients with brain gliomas treated with postoperative CCNU and radiation therapy.

This prospective randomized clinical trial compared the effectiveness of combined treatment with CCNU and radiation therapy to the use of radiation therapy alone for the postoperative management of supratentorial brain gliomas (67% anaplastic) in 198 patients. The results were evaluated with the aid of a specially developed weighted neuropsychological test battery providing single-value estimation of "life quality" of patients, as well as with a clinical performance scale. Based on these methods, it was established that patients improved within 6 months following therapy. This improvement was maintained in surviving patients during the 2-year follow-up period. The patients led a relatively normal life, but when their condition deteriorated their decline was rapid. The median survival time of patients treated with radiotherapy did not differ significantly from that of patients receiving chemotherapy in addition. Nor did the analysis of life quality and of changes in clinical performance show any benefit in supplementing surgery and radiation therapy with CCNU chemotherapy at the dosage used.

Labile products of vascular endothelium as mediators and modulators of the functions of the central nervous system.

A rapid development of the knowledge about vascular endothelial cell function as an "endocrine gland" releasing the labile, highly biologically active products, caused a major reapprisal of our concepts concerning the pathophysiology of our body. The publication summarizes the present understanding of the involvement of nitric oxide (NO), endothelins (ETs) and arachidonic acid products in the mechanisms underlying the regulation of the tonus of vessels supplying blood to the CNS, their known modulatory and mediatory role in CNS functions such as a development and memory, peripheral nonadrenergic noncholinergic, or sensory neurotransmission. The regulation intracellular Ca+ +ion levels as a proposed mechanism for the neuroprotective, as well as the neurotoxic effect of the described endothelial products is presented. The supposed therapeutical usefullness of compounds which can modulate their biosynthesis, substitute their activity, or modify its degradation are also summarized.

Primary malignant lymphoma of brain. A review of four cases diagnosed by means of CT-guided stereotactic biopsy.

In a series of 66 CT-guided stereotactic biopsies (SB) of the brain performed in 1995-1998, four were found to be the primary non-Hodgkin's lymphomas (PCNSL). All cases were studied with immunohistochemistry (broad panel of antibodies; reactions performed mainly on cytological smears) and with the use of an electron microscopy. In an immunophenotyping all cases were positive for leukocyte common antigen (LCA) and 3/4 showed B-cell phenotype. Since the PCNSL are typically located in central, periventricular region of brain and the surgical removal does not bring any benefit, the stereotactic biopsy is a method of choice to make a definite diagnosis that opens the chances for implementation of chemo- and radiotherapy. The diagnostic difficulties that are derivatives of an extremely small amount of the available biopsy material were discussed and the role of the immunophenotyping and of the electron microscopy for avoiding the possible diagnostic mistakes was stressed. Cytological smears stained with H&E and the smears and histological slides with immunohistochemical reaction against glial fibrillary acidic protein (GFAP) showing sometimes extremely dense network of astrocytes mingled with neoplastic lymphoma cells are especially interesting and seem to suggest the involvement of astroglia in the pathogenesis of PCNSL.

CT-guided stereotactic biopsy of brain. Three years of experience.

In our center from 1995 up to now (08.06.99) we have performed 78 CT-guided stereotactic biopsies (SB) of brain. In all cases the stereotactic biopsy was performed as the first surgical, diagnostic procedure. Indications for SB were as follows (in brackets, the number of SBs): diffuse, inoperable tumor (43), tumor of central region of brain (19), multiple tumors (7), a change of the obscure nature in CT/NMR scan (15), stereotactic assistance of the "classic: craniotomy and surgery of tumor (4). Among 78 SBs in 49 cases the primary and in 13 cases--secondary (metastatic) brain tumors were diagnosed. In the remaining 16 cases nonspecific changes like gliosis or necrosis were found. Of 49 primary tumors 40 were gliomas. Different pathomorphological methods, including especially immunohistochemistry with GFAP, vimentin, p53, Ki-67, and topoisomerase II alpha if applied together, may at least partially help to overcome the problems of the differentiation of reactive and neoplastic gliosis. We found a grading system of gliomas according to Daumas-Duport very useful in interpretation of SB material. Our preliminary observations suggest that immunolabelling of the biopsy material by means of topoisomerase II alpha antibody may be very useful in SB since it gives technically very good results on smears and because on the grounds of what is known on this enzyme it is the "target" of many antineoplastic drugs and hence may indicate the potential sensitivity to drugs.

The Kluver-Bucy syndrome.

Evolution of psychological disorders following head injury including memory disorders and other cognitive ones are common. The best known are psychiatric disturbances of various kind after lesions of frontal lobes. Cognitive, behavioural and emotional disorders are not usually seen in patients with bilateral temporal lesions. In our Department of Neurotraumatology we observed 4 patients with post-traumatic lesions localized bitemporally. They developed Kluver-Bucy syndrome--rarity in human pathology--with combination of three or more the following syndromes: increased oral activity, hypersexuality, hypermetamorphosis, memory disorders, placidity, loss of people recognition, bulimia. Several symptoms responded dramatically to carbamazepine. We conclude that it may be a useful agent in treatment of this unusual syndrome.

[Diagnosis and treatment of recurrent brain glioma]. / Rozpoznawanie i leczenie wznowy glejopochodnych guzów mózgu.

In the period from Jan 1 1984 to Dec 31 1990 clinical and radiological evidence of brain glioma was found in 120 cases treated previously surgically. The group comprised 55 women (46%) and 65 men (54%). At the time of tumour diagnosis their age was ranged 40 to 60 years. All patients received non-radical surgical treatment, supplemented with Co60 radiation in 104 cases, in 3 cases Co60 treatment was given together with chemotherapy (CCNU) and 12 patients received no complementary treatment. Thirty four patients (28%) had reoperations, in two cases even twice. In 86 cases (72%) treatment was palliative. Three types of secondary tumour regrowth were discerned. Reoperation prolonged survival and its effectiveness was greatest in regrowth type I. The shortest survival till the appearance of regrowth signs and the shortest survival after recurrence were in type II of regrowth.

[Thrombosis of the cavernous sinus]. / Zakrzep zatoki jamistej.

The authors describe a case of cavernous sinus thrombosis in a female aged 59 years referred to hospital with suspected tumour at the base of the brain. With the present broad use of sulphamides and antibiotics the incidence of septic thrombosis of the cavernous sinus has decreased considerably. In the reported case the infectious focus giving rise to the thrombosis was in the palatine tonsils or in teeth with gangrenous changes. The thrombosis was associated with infarction of the left hemisphere. The correct diagnosis was established after CT of the head.

[Fate of patients after surgical treatment of premature closure of cranial sutures]. / Losy chorych po przebytym leczeniu operacyjnym z powodu przedwczesnego zarosniecia szwów czaszki.

From 1954 to 1971, 69 operations in patients with crs, resulting in relieving the intracranial hypertension symptoms, were performed. The patients were aged 1-34 years. In 1989, i.e. 20-29 years after the operation (mean 22.8 years), 14 patients were submitted again for a neurological, neuropsychological, EEG and brain CT check-up. The patients were divided into 3 groups: I gr. (3 patients)--with negligible disorders of attention and memory, without neurological changes in the EEG and CT--in a good social and occupational status. II gr. (4 patients)--with slight headaches, with discrete neurological and neuropsychological symptoms, slight generalized changes with the moderate burst activity in EEG, signs of hydrocephalus in CT scan. III. gr (7 patients)--with seizures, deficit symptoms, some with symptoms of mental impairment, generalized epileptic changes in EEG, signs of cortical and subcortical atrophy in CT scan. In this group some patients did not work and had no families. We have found that the frequency of epileptic seizures in the crs patients is higher, and their social and occupational status is worse.

[Diagnostic problems in epidural hematoma of the posterior cranial fossa]. / Trudnosci diagnostyczne w krwiaku nadtwardówkowym tylnej jamy czaski.

Posttraumatic posterior cranial fossa haematoma is a rare occurrence. In our material it accounted for 1.5% of all intracranial haematomas. Due to its infrequency and diagnostic difficulties these patients are referred with delay to neurosurgeons and often die with signs of brain stem lesion. The reported case was a 25-year-old man with this haematoma and considerable diagnostic difficulties were encountered despite the application of modern imaging techniques. These difficulties hamper the qualification of the patient for operation which is the method of choice in these cases.

[Treatment of iliac vein thrombosis by use of filter placed in the inferior cava vein in a female patient after reoperation of meningioma of the smaller section of the sphenoid bone]. / Leczenie przy pomocy "filtru" zakrzepu zyly biodrowej lewej siegajacego do zyly glównej dolnej u chorej po reoperacji oponiaka skrzydla malego kosci klinowej.

Deep phlebothrombosis is a one of the postoperative complications in neurosurgery in 90% localized in lower extremities. The brain contains the highest concentration of tissue thromboplastin compared with the other organs. That fact plays an important roll in pathophysiology of thrombo-embolic process in neurosurgery. The most frequent places of thrombogenesis are venous sinus of soleus muscle and gastrocnemius muscle, next: deep veins of crus, femoral veins and iliac veins. We describe the case of the efficient treatment of femoral vein and iliac vein thrombosis using filter placed under control of monitor in the inferior caval vein higher than the thrombus.

[Autotransfusion in neurotraumatology and neurosurgery]. / Autotransfuzje w neurotraumatologii i neurochirurgii.

In the years 1991-1993, 145 patients suffering from central nervous system diseases were operated on using autotransfusion in the Institute of Neurology in Cracow. In 141 cases patients were given blood taken formerly. There were no side effects following blood treatment. In the authors opinion autotransfusion deserves wider use for medical and economic reasons.

[Post-traumatic cerebral vasospasms]. / Pourazowe skurcze naczyn mózgowych.

Posttraumatic vasospasms occur according to various authors in 5-10% of cases, and in our material they were demonstrated in 6% of the patients, that is about 8 times less frequently than in cases of bleeding from a vascular malformation. Computed tomography of the head showing posttraumatic vasospasm complicating "normal" clinical course is ever less frequent which does not mean that this disturbance is not occurring, but rather it shows that CT is insufficient for its demonstration. It was shown that in every case of unclear aetiology in which the clinical condition is not correlating with CT pattern of the head angiography of brain vessels should be performed or cerebral blood flow should be determined by other making possible early institution of adequate (targeted) treatment.

[Determination of melatonin concentrations in patients with consciousness disturbances after craniocerebral trauma. Preliminary communication]. / Badanie stezenia melatoniny u chorych z zaburzeniami swiadomosci po urazach czaszkowo-mózgowych. Doniesienie wstepne.

The study was performed in cooperation of the Department of Neurotraumatology and the Department of Clinical Biochemistry Jagiellonian University in Cracow. In patients with central nervous system injury, diagnosed upon computerized tomography scan, melatonin levels were measured. The most frequent reason of damage was severe craniocerebral trauma. Consciousness, assessed according to Glasgow Coma Scale, was between 3 to 13 points. Melatonin levels were measured at 8 a.m. The investigation could not demonstrate any correlations between consciousness disturbances after head injury and serum melatonin levels in the morning. To draw a final conclusion further experiments are necessary. They will help to explain the role of endogenous melatonin in patients after craniocerebral injury.

[Results of surgical treatment of anaplastic cerebral gliomas]. / Wyniki leczenia operacyjnego chorych z anaplastycznymi glejakami mózgu.

In the years 1971 through 1977 247 patients with anaplastic cerebral gliomas were treated. Out of this material a group of 119 patients was completed who were treated only surgically and had follow-up examinations or responded to an inquiry form sent to them. In the light of this follow-up study it was established that the survival time was shortest, only up to 6 months, in the patients with preclinical symptoms lasting up to 3 months. In the remaining patients the survival time was longer, reaching over one year in 11 cases and over 2 years in 3 cases. In view of the mode of spread of recurrent neoplasm the authors differentiated exophytous expansion - with the infiltration filling the postoperative tissue defect and extending beyond its margins, infiltrative expansion - with the infiltration spreading on the walls of the postoperative tissue defect, destructive expansion - with the neoplasm infiltrating and destroying the brain tissue. Two latter modes of growth were most frequent and led to death of the patients without producing signs of intracranial hypertension.

[Results of combined treatment (by surgery, ionizing radiation and the cytostatic drug CCNU) of patients with anaplastic glial neoplasms of the brain]. / Wyniki skojarzonego leczenia (operacyjnego, promieniami jonizujacymi i cytostatykiem CCNU) chorych z anaplastycznymi glejopochodnymi nowotworami mózgu.

For estimating the effectiveness of combined treatment of cases of anaplastic gliomas of the cerebral hemispheres retrospective analysis was undertaken of 83 patients treated only surgically and prospective analysis of 81 patients treated by the combined method. In the group treated only surgically 47 patients had glioblastoma multiforme, and 36 had anaplastic oligodendroglioma. The general condition and the neurological status were evaluated using the score of Karnofsky. In the group of combined treatment the patients were given telegammatherapy from Co-60 cobalt source by the method of Skolyszewski and CCNU (Belustine) every 6-8 weeks for 1 year in doses of 100 mg/m2. In about 25% of patients transient leucopenia was observed, and 20% had transient thrombocytopenia. In about 30% of cases transient increase of intracranial pressure occurred. In the compared groups it was possible to establish, using the statistical method of representation probability of Kaplan-Meier and statistical analysis of Gehan as modified by Wilcoxon, that the mean survival time in the surgically treated patients was 6.25 months, while in the patients treated by combined method it was 13.97 months.

[Brain stereotactic procedures in the Department of Neurotraumatology CM UJ in Cracow]. / Operacje stereotaktyczne guzów mózgu w materiale Kliniki Neurotraumatologii CM UJ w Krakowie.

Stereotactic procedures using Leksell frame have been performed in that Department since 1995, and as jet 199 such operations were carried out. The most frequent complication after stereotaxic biopsies was intracerebral haemorrhage occurring in 0.6 to 7.2% of cases, according to various authors. In the presented material it occurred in 1.3% of biopsies. Besides biopsy, the stereotactic procedures (105 cases) were applied for reducing the size or removal of tumours, including multiple tumours in one or both hemispheres, in one-step operations. The histological diagnoses were based on the examination of HE-stained smears, immunocytochemical reactions and electron microscopic studies. The effectiveness of the operations was assessed in control examinations (CT). The greatest group of cases undergoing stereotaxic surgery were metastatic tumours (47 cases, 61.3%), primary brain tumours were treated in 22 cases (28.57%), meningiomas in 4 (5.19%), abscesses in 3 cases (3.89%). In patients with metastatic tumours improvement was obtained in 97% of cases. One patient died from disseminated malignancies with cardiorespiratory failure. In the remaining patients no worsening of the objective status was noted after stereotaxic surgery.

[Piracetam in severe cranio-cerebral injuries]. / Piracetam w ciezkich urazach czaszkowo-mózgowych.

A group of 100 patients treated immediately following a cranio-cerebral injury was analyzed. The patients, administered piracetam either in an intravenous infusion (GCS 3-8) or orally (GCS above 9), were divided into groups depending on the dose and clinical status. Piracetam participates in the activity of the majority of neurotransmitters, increases glucose and oxygen consumption in the ischaemic nervous tissue and increases blood flow through cerebral terminal vessels. In cranio-cerebral injuries, piracetam is employed to achieve cytoprotection and improve cerebral blood flow. In patients with neurological deterioration following the administration of 6-10 mg/day, no good results were obtained. A dose of 24-30 mg/day had a significant positive effect on therapeutic results providing certain conditions were met, such as ensuring proper partial oxygen pressure (oxygen therapy) and proper blood glucose levels. The use of piracetam is justified immediately after an injury; after the discharge oral piracetam therapy is recommended.

[Analysis of the results of combined treatment of poorly differentiated brain gliomas]. / Ocena wyników skojarzonego leczenia niskozróznicowanych glejaków mózgu.

In a group of 139 patients with poorly differentiated brain gliomas controlled clinical trial was carried out for assessment of two methods of postoperative treatment. After possibly radical removal of the glioma the patients were treated by radiotherapy with 60Co teletherapy in doses of 60 Gy (30 fr) in depth during 6 weeks, and randomly chosen patients received also CCNU in one dose of 100 mg/m repeated at intervals of 6-8 weeks. The administration of CCNU failed to improve the therapeutic results. The median survival time in the whole group was 49 weeks. The survival rate after 1, 2 and 3 years was 45.4%, 22.8% and 14.9% respectively. The survival times of cases of glioblastoma multiforme were not significantly different from those of patients with other poorly differentiated gliomas independently of the treatment method. The complications were not troublesome.

[Effect of general anesthesia induction on cerebral circulation in subacute and chronic subdural hematoma assesssed by computerized rheo-encephalography]. / Wplyw indukcji znieczulenia ogólnego na krazenie mózgowe w podostrym i przewleklym krwiaku podtwardówkowym na podstawie skomputeryzowanej reoencefalografii.

Cerebral circulation in 21 patients with subacute (SSH) and chronic subdural hematoma (CSH) were studied by computerized rheoencephalography before and after induction of general anesthesia. ECG and REG courses were sampled with a frequency of 62.5 Hz during a period of 15 minutes, and both sets of data points were fitted by an cubic polynomials. We introduced the classification of the REG pulse related waveform (PRW) according to the number of the inflection points in the anacrotic branch. The cases of normal pulse form, with almost vertical systolic upstroke corresponded with only one inflection point in the ascending branch (grade I). We assumed that the presence of three or greater number of inflection points reflected more gradual systolic rise, is characteristic for regressive changes of the arterial wall (grade II). The relative duration of the anacrotic branch was calculated. The first obtained result was the significant correlation between REG and clinical status. The unfavorable effect of induction on cerebral circulation corresponded with less favorable results of treatment. Our preliminary results indicate the clinical value of REG examination in the preoperative evaluation of the cerebral circulation.