Acta Neurochirurgica

  The authors evaluated the impact of motion artefacts on presurgical mapping of the sensorimotor cortex with functional magnetic resonance imaging (fMRI). Different mapping paradigms were compared with regard to the frequency of motion artefacts and the resulting signal increase.   94 surgical candidates with mass lesions near the central region were investigated using BOLD1-contrast T2* weighted multislice multi-echo EPI gradient echo sequences on a 1,5 T Philips Gyroscan. Three functional paradigms were performed: a) repetitive self-paced clenching of the hand to a fist (68 runs); b) repetitive finger-to-thumb opposition (46 runs); c) sensory stimulation by repetitive brushing of the palm (15 runs). Task-related haemodynamic changes were identified by statistical analysis with the Kolmogorov-Smirnov-test. MR signal increase in percent was calculated for each of the paradigms. Motion artefacts were rated on a scale from 1 to 3.   Severe motion artefacts occurred in 8 hand clenching runs and in 2 finger opposition runs. Artefacts were more pronounced in hand clenching than in finger opposition. There were no motion artefacts in any of the sensory stimulation runs. Concerning the percent MR signal change there was no significant difference between hand clenching and finger opposition (T-test: p>0,5) but a highly significant difference (p<0,0001) between both motor tasks and the sensory paradigm (hand clenching: 2.68±0.75; finger opposition: 2.76±0.79; sensory stimulation: 1.72±0.65).   Sensory stimulation causes by far less artefacts than motor paradigms but it also has to be considered less sensitive as it produces a smaller MR signal increase. Therefore in presurgical evaluation sensory stimulation should be kept in reserve for cases in whom motion artefacts are very likely to occur, i.e. patients with severe forms of paresis.

A prospective observational study of the pathophysiology of sodium and water disorders in patients with pituitary region tumours after surgical excision was carried out in 20 patients. Serial pre-operative and post-operative fluid and sodium balance, plasma and urine elctrolyte biochemistry and their derived parameters, and circulating hormones associated with fluid balance, atrial natriureic peptide (ANP) and antidiuretic hormone (ADH) were documented to correlate with the patients' clinical conditions. Ten out of these twenty cases developed diabetes insipidus (DI) requiring ADH replacement therapy, although in the majority (6 cases), this way only a transient event. Of the nine patients who developed hyponatraemia, six had symptoms such as impaired consciousness and convulsions. Four patients developed alternating hypoatraemia and hypernatraemia, which constituted a difficult group, where appropriate sodium and fluid management, and ADH replacement therapy were based upon twice daily plasma and urine biochemistry and their derived parameters. Whilst DI in this group of patients was the result of a low circulating ADH level, hyponatraemia was not associated with an exaggerated ADH activity (6.0 ± 2.3 vs 7.4 ± 2.3 pmol/ml, mean ± SEM). Rather, hyponatraemia was strongly associated with an elevated circulating ANP concentration (82.4±10.5 vs 30.0 ±3.1 pmol/ml, mean ± SEM, p < 0.001), resulting in salt wasting and hypovolaemia.

Es wurde über die Vorzüge des korialen Autotransplantates gegenüber dem alloplastischen Material bei der Operation der Kraniostenose berichtet.

Five cases of intracranial gangliomas in their clinical, diagnostic and surgical aspects are presented. In four cases we arrived at the diagnosis by CT-scan, which showed in all of them, calcified lesions without a mass effect. Total surgical resection was performed in four cases, and there is no evidence of recurrence either clinically or in the CT-scan after different follow-up periods. Although infrequent, these kinds of tumours should enter the differential diagnosis at any time when there a calcified mass exists in children or young patients with a long history of seizures. In our experience, seizures were the most important sign in all cases with supratentorial gangliogliomas.

Im allgemeinen können bei Rückenmarkstumoren die Resorptionsbahnen oberhalb des spinalen Blockes die Behinderung der besonders wichtigen Liquorabflußbahnen im Konus- und Caudabereich ausgleichen. Wenn es in seltenen Fällen — besonders bei caudalen spinalen Prozessen — zu einer Erhöhung des intracraniellen Druckes und der Entwicklung einer STP kommt, so dürften neben der mechanischen Abflußbehinderung noch weitere Faktoren beteiligt sein. Neben einer sich in der Liquorproduktion auswirkenden ausgeprägten vegetativen Labilität ist vor allem eine supraläsionelle Eiweißerhöhung wirksam, die das Liquorproduktions- und Resorptionsgleichgewicht stört. Dies geht aus der Zusammenstellung von 21 in der Weltliteratur veröffentlichten Fällen und einem eigenen Fall hervor. Auffällig häufig wurden im Cisternen- und Ventrikelliquor Werte über 100 mg% Gesamteiweiß gemessen, wobei manchmal nur eine unerhebliche Dissoziation zwischen Cisternen- und Lumballiquor vorlag.

Background. We studied the use of 201Thallium SPECT and L-[1-11C]-tyrosine PET in patients with a primary glioblastoma multiforme treated with 192Ir brachytherapy after surgery and external beam radiation therapy. We hypothesised that the patients most likely to benefit from further surgery after deterioration would be those with radiation necrosis and would be recognised by a negative emission tomography scan. Methods. Twenty-one patients underwent 201Thallium SPECT performed before brachytherapy, and this was repeated in 19 patients when recurrence was suspected. Nine patients also underwent a PET scan at the same time. Nine patients underwent a second operation. Findings. SPECT and PET were highly concordant concerning the prediction of radionecrosis and/or tumour recurrence. Repeat surgery did not lead to a significant increase in survival. There was no significant association between the duration of survival and tumour-to-background ratio but the number studied was small. Both SPECT and PET showed highly active lesions, which were proved to be recurrent tumour by clinical and histological follow-up. Conclusion. Although PET and SPECT are both highly sensitive in detecting active tumour tissue, emission tomography was not clinically valuable in the investigation of patients with a primary glioblastoma treated with brachytherapy.

Clinical manifestations, findings, management and outcome of a series of 177 cases with tumours of the limbic and paralimbic systems are presented. There was no operative mortality. Postoperatively 95% of them had no or only minor neurological deficits. Most of them were able to resume work. Pre-operatively 77% of the patients had epilepsy, but 84% became seizure-free after tumour removal. All 77 cases with malignant tumours died within 1–5 years. In the past many neurosurgeons were reluctant to attempt complete tumour removal in these areas. This series demonstrates the efficacy of highly skilled microneurosurgery.