Computerized tomography and magnetic resonance guided stereotactic brain biopsy in nonimmunocompromised and AIDS patients

BACKGROUND

The utility of stereotactic brain biopsy (SBB) in AIDS patients still remains controversial. The authors investigated SBB-related diagnostic accuracy, complications, and postoperative sequelae in nonimmunocompromised (NIC) patients and AIDS patients. The role of bioptic yield in treatment planning was also studied in AIDS patients.

METHODS

From 1990-95, 200 computerized tomography (CT) or magnetic resonance imaging (MRI)-guided SBBs were performed in our Department; 172 bioptic procedures were performed in NIC patients (169), and 28 SBBs in AIDS patients (27). The statistical significance was evaluated using the Fisher exact t-test.

RESULTS

SBB accuracy was very high in both NIC (94.8%) and AIDS (92.9%) patients. Statistical analysis indicated nonsignificant (NS) differences between the two study groups (P > 0.05). Diagnostic yield resulted higher in contrast-enhancing (CE) brain lesions (98.6% in NIC and 95.0% in AIDS patients; P > 0.05; NS), than in non-CE lesions (74.1% in NIC and 87.5% in AIDS patients; P > 0.05; NS). The overall complication rate was similar in both groups (17.2% in NIC and 14.8% in AIDS patients, P > 0.05, NS). The most frequent complication was hemorrhage, with statistically negligible differences between the two study groups (P > 0.05). The frequency of complications involving minor/major morbidity or mortality was very low in NIC (5.9%, 0.6%, and 2.4%, respectively), and in AIDS (3.7%, 7.4%, and 0.0%, respectively) patients. Regarding the therapeutic impact of bioptic diagnosis for neuro-AIDS patients, the preoperative treatment attitude was modified in 23/27 cases (85.2%), and the empiric anti-toxoplasmosis regimen was changed or withdrawn in 17/21 patients (81.0%).

CONCLUSION

Our experience demonstrated SBB to be an accurate, manageable, and reasonably safe diagnostic tool in both NIC and AIDS patients. These results suggest also that timely SBB indication in selected AIDS patients, reaching an early diagnosis, may on one side prevent unnecessary and potentially toxic empiric therapeutic regimens, and on the other address the appropriate treatment, thereby improving length and quality of life in such patients.

SV40 early region and large T antigen in human brain tumors, peripheral blood cells, and sperm fluids from healthy individuals

SV40 T antigen (Tag) coding sequences were detected by PCR amplification followed by Southern blot hybridization in human brain tumors and tumor cell lines, as well as in peripheral blood cells and sperm fluids of healthy donors. SV40 early region sequences were found in 83% of choroid plexus papillomas, 73% of ependymomas, 47% of astrocytomas, 33% of glioblastoma multiforme cases, 14% of meningiomas, 50% of glioblastoma cell lines, and 33% of astrocytoma cell lines and in 23% of peripheral blood cell samples and 45% of sperm fluids from normal individuals. None of the 13 normal brain tissues were positive for SV40 DNA, nor were seven oligodendrogliomas, two spongioblastomas, one neuroblastoma, one meningioma, or four neuroblastoma cell lines. Expression of SV40 early region was found by reverse transcription PCR, and SV40-specific Tag was detected by indirect immunofluorescence in glioblastoma cell lines. DNA sequence analysis, performed in four positive samples, confirmed that the amplified PCR products belong to the SV40 early region. Sixty-one % of the neoplastic patients positive for SV40 sequences had an age excluding exposure to SV40-contaminated polio vaccines, suggesting a contagious transmission of SV40. The possible role of SV40 Tag in the etiopathogenesis of human brain tumors and the spread of SV40 by horizontal infection in the human population are discussed.

Familial cavernous hemangioma with atypical neuroimaging

Three members of the same family were studied, all of whom had multiple intracerebral cavernous angiomas for which a dominant autosomal inheritance was hypothesised. The proband suffered from headaches, and physical examination revealed evident right hemiparesis. The second case started with a hemorrhagic cerebral stroke and the third was asymptomatic on neurological examination. Nuclear magnetic resonance (NMR), performed in two of the three cases, showed lesions whose number and extent were not radiologically characteristic of cavernous angioma. A cerebral biopsy of the proband enabled the diagnosis to be made. Despite the recent introduction of NMR, the nosological classification of familial forms can be difficult when the radiological lesions are atypical. In such cases, cerebral biopsy is not only a valid diagnostic aid, but is also indispensable for obtaining adequate genetic information.

Shape recovery and volume calculation from biplane angiography in the stereotactic radiosurgical treatment of arteriovenous malformations

PURPOSE

A model for calculating the three-dimensional volume of arteriovenous malformations from biplane angiography.

METHODS AND MATERIAL

Three-dimensional (3D) volume reconstruction is easily feasible with axial, coronal, or sagittal computer tomography (CT) and nuclear magnetic resonance (NMR) scans. On the other hand, radiosurgical treatment of arteriovenous malformations (AVM) is exclusively based on two orthogonal stereotactic projections, obtained with angiographic procedures. Most commonly, AVM volumes have been calculated by assimilating the nidus volume to a prolate ellipsoid. We present an algorithm dedicated to 3D structure reconstruction starting from two orthogonal stereotactic projections. This has been achieved using a heuristic approach, which has been widely adopted in the artificial intelligence domain.

RESULTS

Tests on phantom of different complexity have shown excellent results.

CONCLUSION

The importance of the algorithm is considerable. As a matter of fact: (a) it allows calculations of complex structures far away from regular ellipsoid; (b) it permits shape recovery; (c) it provides AVM visualization on axial planes.

Stereotactic brain biopsy in human immunodeficiency virus-infected patients

OBJECTIVE

To evaluate prospectively the diagnostic efficacy and safety of stereotactic brain biopsy and its impact on treatment, outcome, and survival in human immunodeficiency virus-infected patients with focal brain lesions.

METHODS

Computed tomography-guided stereotactic brain biopsy was performed in 26 patients, of whom 17 failed to respond to a 2- to 3-week anti- Toxoplasma regimen. Exclusion criteria for biopsy were overt acquired immunodeficiency syndrome for 2 years or longer, Karnofsky score less than 50, and severe coagulopathies.

RESULTS

A definitive diagnosis was obtained in 24 patients (92%), of whom 12 (46%) had primary brain lymphoma, six (23%) had progressive multifocal leukoencephalopathy, and four (15%) had Toxoplasma encephalitis. Two thirds of contrast-enhancing lesions on computed tomography were lymphoma and three fourths of contrast-negative lesions were leukoencephalopathy. Three patients had biopsy-related cerebral hemorrhages (morbidity, 11.5%). Median follow-up and survival for the entire group were 24 weeks (range, 6 to 135 weeks). Twenty patients (77%) received specific therapy and 13 (50%) responded to treatment. Of 11 patients with lymphoma undergoing irradiation treatment (whole-brain radiotherapy in seven and gamma-knife treatment in four), nine (82%) had clinical and radiologic response, with a median survival of 34 weeks (range, 13 to 57 weeks).

CONCLUSIONS

Stereotactic brain biopsy has high diagnostic efficacy and clinical benefit in carefully selected human immunodeficiency virus-infected patients. The procedure should be performed essentially in patients with contrast-enhancing lesions on computed tomography who have a high frequency of treatable cerebral diseases.

Gamma Knife radiosurgery for intracranial metastases: from local tumor control to increased survival

We have analyzed a series of 225 patients with intracranial metastases (343 lesions), treated in our department by Gamma Knife radiosurgery over a 30-month period. We have used a modified Pittsburgh protocol and performed 242 procedures on 164 single/78 multiple lesions. Primary tumors were mostly carcinomas of the lung (52%) and breast (11.6%). Neuroradiological localization of the target was usually performed by stereotactic computed tomography. Magnetic resonance imaging was only used in special circumstances. Routine dose planning was assisted by three-dimensional reconstruction programs. Mean tumor volume was larger than expected (5.7 ml). Mean prescription dose and average dose were 21.1 and 29.9 Gy, respectively. Middle- and long-term results were evaluated in a subset of 152 patients (236 lesions) with adequate (> 4 months) follow-up. Mean follow-up was 53.1 weeks with 61/152 patients still living. There was a predominance of retrospectively classified 'not fully eligible cases' among the survivors, mainly because of uncontrolled primary tumor. The 1-year local tumor control rate was 88.2%. Treatment-related radiological (3.9%) and clinical (1.6%) sequelae were minimal. Overall mean survival in these patients (40 weeks) turned out to be higher than that commonly reported after conventional surgical-radiation treatments. It was encouraging that the mean survival of 'fully' eligible patients was 51 weeks. Karnofsky performance status and neurological (Order Grading) performance scores were consistently high for most of the follow-up period. Functional Independence and the Palliative Index were not far from the value of mean survival. The main cause of death remains uncontrolled systemic disease (64.8%). On the other hand, the relative incidence of intracranial tumor progression was considerably decreased. This indicated that these patients should perhaps be treated more aggressively and underlines the need for randomized trials to determine the optimal treatment.

Gamma Knife stereotactic radiosurgery for uveal melanoma: clinical results after 2 years

We report on 36 cases of uveal melanoma treated at our center between March 1993 and September 1995. There were 16 men and 20 women, aged 57 +/- 11 years. The choroid was affected in 35 patients and the ciliary-body in 1. The same preoperative and follow-up protocol was adopted for all cases. The procedure included fixation and positioning of the eye with a retrobulbar injection of long-lasting anesthetic and two extraocular muscle sutures, application of the frame, computed tomography scan localization, dose planning and treatment with the Gamma Knife. The patients were divided into three groups. Group A: 10 patients with a follow-up of 24 +/- 4 months, treated with a high dose (surface dose 58 +/- 9 Gy, maximum dose 81 +/- 15 Gy, mean dose 66 +/- 11 Gy). Group B: 9 patients with a follow-up of 16 +/- 2 months, treated with a lower dose (surface dose 41 +/- 3 Gy, maximum dose 76 +/- 10 Gy, mean dose 53 +/- 11 Gy). Group C: 17 patients with a follow-up of 6 +/- 3 months, treated with a lower dose (surface dose 42 +/- 3 Gy, maximum dose 72 +/- 16 Gy, mean dose: 54 +/- 6 Gy). In group A, we observed marked tumor regression in 9 cases, tumor recurrence in 1 case and severe complications in 5 cases (neovascular glaucoma and/or radiation retinopathy and/or radiation optic neuropathy). In group B, significant local control of the tumor was obtained with minor complications (cotton wool spots hard exudates, intraretinal hemorrhages). In group C, to date we have observed a regression of the tumor in 7 cases and 1 severe complication (neovascular glaucoma). Our data show that uveal melanomas may be adequately controlled by a high radiosurgical dosage (50-70 Gy), though there are significant side effects. Comparable levels of local tumor control may be obtainable using lower doses (40-45 Gy) which would hopefully reduce the rate of complications. However, a longer follow-up is needed for further validation of these results.

Gamma Knife radiosurgery in skull base meningiomas. Preliminary experience with 50 cases

Gamma Knife radiosurgery was performed on 50 patients (10 males and 40 females) with skull base meningiomas (SBMs) between February 1993 and September 1995. The patients ranged in age from 25 to 78 years (mean age 56 years). The location of the tumors was anterior fossa (n = 4), sphenoorbital (n = 2), sellar region (n = 5), cavernous sinus (n = 26), petroclival (n = 12), and occipital foramen (n = 1). The tumor volume ranged from 0.6 to 20 cm3 (mean 8.6 cm3). The mean values for dose planning were edge isodose (EI) 46.7%, edge dose (ED) 18.0 Gy, maximum dose 39.8 Gy, average dose (AD) 25.4 Gy, and average number of isocentres 5.7. The patients were analyzed for five parameters: tumor volume (< 7.5 vs. > or = 7.5 cm3); EI (< 50 vs. > or = 50%); ED (< 18 vs. > or = 18 Gy); AD (< 25 vs. > or = 25 Gy), and primary versus residual or recurrent tumors. The overall frequency of tumor growth control (TGC) was 98%, with 1- and 2-year TGC rates of 97% and 100%, respectively. The most favorable neurological results were obtained with a tumor volume < 7.5 cm3 (p < 0.05), EI > or = 50% (NS), ED > or = 18 Gy (NS) and with primary SBMs (p < 0.01). A favorable TGC was demonstrated at follow-up imaging examinations when the tumor volume was > or = 7.5 cm3 (100% TGC rate), EI < 50% (100%), ED > or = 18 Gy (100%), AD > 25 Gy (100%), in both primary SBMs (100%) and residual or recurrent SBMs (96.5%). To date, only 3 (6%) of the 50 patients have presented signs of neurological worsening related to the Gamma Knife radiosurgery. While no early complications were noted, neuroradiological follow-up did show delayed transient imaging complications (3 edema and 1 radionecrosis; 8% of all patients). In conclusion, our preliminary results seem to confirm that Gamma Knife radiosurgery is an effective and safe adjuvant or a feasible alternative primary treatment in controlling or preventing SBM progression.

High incidence of BK virus large-T-antigen-coding sequences in normal human tissues and tumors of different histotypes

T-antigen (TAg) coding sequences specific for BK virus (BKV) were detected, by PCR amplification followed by Southern-blot hybridization, in a high percentage of human tumors and tumor-cell lines, as well as in normal tissues, by analysis of 189 specimens. Specifically, the BKV early region was detected in 85% of brain tumors and in all normal brain tissues, in 78% of osteosarcomas, in 38% of Ewing's tumors, in 40% of normal bone specimens and in 71% of normal peripheral blood cell samples. Wilms' tumor tissues used as a control were all negative for BKV sequences. RT-PCR analysis indicated that TAg coding sequences were expressed in specimens carrying BKV early region, ranging from 64% of the osteosarcomas to 100% of glioblastomas, Ewing's tumors, peripheral blood cells and normal bone. Moreover, DNA sequencing performed in 12 different positive samples revealed that the amplified PCR products are identical to the early-region sequence of wild-type BKV. The role of BKV TAg and its possible mechanism of action in human tumorigenesis are discussed.

Risk factors for cerebral glioma in adults: a case-control study in an Italian population

A case-control study on risk factors for cerebral tumors was conducted on an adult Italian population by the four Neurosurgical Departments of the Veneto Region, i.e. Padua, Treviso, Verona and Vicenza. The study recruited 195 cases of histologically-confirmed cerebral glioma. One hospital control was selected for each case. Cases and controls were matched for age, sex, data of hospitalization and residence. Information on both cases and controls was obtained from a relative. Uninvolved interviewers administered a structured questionnaire including items on the subject's education, occupation, lifestyle, medical history, exposure to radiation for diagnosis or therapy, head trauma and blood group and the medical history of family members. The series of cerebral tumors was first considered as an indistinct set: none of the risk factors examined showed a statistically significant association. A positive association was found with blood group A (OR = 6) when low-grade astrocytomas (n = 41) were considered separately. As for the malignant astrocytomas (n = 132), there was a suggestive but not statistically significant association with the presence of CNS tumors among first- and second-degree relatives (OR = 7.0). On the whole, this study yielded no clear and meaningful association for the various risk factors analyzed.

Cervical arachnoidal cyst with basilar impression and Arnold-Chiari malformation: a case report

A case of cervical spinal arachnoidal cyst is presented. The association with basilar impression and Arnold-Chiari malformation is a peculiarity seldom reported. The clinical aspects with remission and exacerbation are discussed. The importance of the neuroradiological findings and the usefulness of the neurophysiological examination (evoked potentials) are suggested.

Experience in "radical" surgery of supratentorial gliomas in adults

This study reports the preliminary results obtained in a series of 107 patients with histologically proven malignant gliomas (86 glioblastomas and 21 anaplastic astrocytomas) operated upon between 1986 and 1989, with an aggressive attitude aimed to achieve extensive and possible "radical" excision of the tumor. Gross total removal was achieved in 62% of cases, while in the remaining the postoperative contrast enhanced CT scan showed more than 10-15% of residual tumor mass. There was no operative and postoperative mortality. The one-year survival rate was 60% in patients with total removal and 24% in those with partial resection. Furthermore the Karnofsky rating at discharge was improved in the former group while was unchanged in the latter. Although preliminary, these data seem to confirm the primary positive role of radical surgery in the combined management of malignant gliomas.

Heterogeneity and modulation of tumor-associated antigens in human glioblastoma cell lines

Seven human glioblastoma cell lines established in vitro from primary tumor explants were studied. A marked heterogeneity of glial fibrillary acidic protein was observed whereas vimentin was uniformly expressed by all cell lines. Indirect immunofluorescence and flow cytofluorometry revealed a heterogeneous distribution of surface GE 2 and CG 12 tumor-associated antigens (TAA's): three cell lines were positive (greater than 69% TAA-positive cells) and three cell lines were negative (less than 9% TAA-positive cells). One cell line (Hu 228) was moderately positive at early culture passages and subsequently acquired a TAA-negative phenotype. The difference in the relative amounts of surface TAA's of the three positive cell lines was less than twofold. In spite of the heterogeneous distribution of surface TAA's, all cell lines exhibited considerable amounts of intracellular TAA. Treatment with phorbol esters and density-dependent growth arrest decreased the percentage of the TAA-positive cells and the amount of cell-surface TAA's in one cell line (Hu 195). Interferon-gamma treatment in vitro increased the percentage of CG 12-positive cells by 12% and the amount of cell-surface CG 12 antigens by 38% as compared to untreated cells. The percentage of TAA-positive cells among phorbol ester-treated cells of the Hu 195 cell line was lowest 48 hours after treatment, but returned to normal values within the next 48 hours. Reduction of 3H-thymidine incorporation preceded the decrease in number of TAA-positive cells by about 18 hours. Two-color fluorescence analysis performed in positive cell lines for simultaneous determination of surface TAA's and deoxyribonucleic acid content or reactivity with the proliferation-associated Ki67 intracellular marker indicated that GE 2 and CG 12 antigens are expressed preferentially by actively proliferating glioma cells. The results of this study indicate the existence of two different phenotypes in cultured human glioblastoma cells: surface TAA-positive/cytosol TAA-positive and surface TAA-negative/cytosol TAA-positive cell populations. In addition, modulation of TAA expression was dependent on the cell-cycle differentiation stage, culture conditions, and proliferative state of the cells.

Human recombinant interleukin-4 inhibits lymphokine-activated killer activity of sheep erythrocyte rosette-forming (E+) and -non-forming (E-) human lymphocytes

The effect of human recombinant interleukin-4 (rIL-4) on lymphokine-activated killer activity (LAK) of peripheral blood lymphocytes (PBL) as well as sheep erythrocyte rosette-forming (E+) and -non-forming (E-) lymphocytes stimulated by human recombinant interleukin-2 (rIL-2) has been investigated. rIL-4 drastically inhibited LAK activity of PBL cultured for 18 hr and for 5 days in the presence of rIL-2. Distribution of T, B and IgG Fc-receptor-bearing lymphocytes, as assessed by immunofluorescence and flow cytometry, was no different at the end of the culture in the presence of rIL-2 plus rIL-4 than with rIL-2 alone. LAK activity of E+ and E- lymphocytes was similarly inhibited. Finally, rIL-4 did not affect the natural killer (NK) activity of rIL-2-activated PBL as assessed by the capacity of these cells to kill the appropriate NK target.

Spontaneous spinal haematomas

A series of 10 surgically treated "spontaneous" spinal haematomas (7 cases with epidural, 3 with intramedullary location), is presented. Symptomatology was rarely acute. Clinical onset was mostly dominated by spinal or radicular pain, followed by severe motor deficit. Surgical outcome was satisfactory in the majority of cases. Age, duration of symptoms, haematoma site and size appeared to have no influence on final outcome. This was significantly correlated only with the preoperative neurological condition.

Establishment and Characterization of a New Human Melanoma Cell Line (HU 214) with a High Growth Potential and Stable Properties

A human melanoma cell line (HU 214) with high growth potential was established from a lymph node metastasis of a patient with advanced cutaneous melanoma. The cells of this line were able to grow in monolayer (according to the Rosenblum technique) and in agar (according to the Courtenay-Mills method), and formed tumors when injected in nude mice. The line has been maintained in culture for more than 47 passages. The cell cultures were periodically characterized (every 6-8 passages) by immunohistochemistry using a panel of monoclonal antibodies (MoAbs) including MoAbs against tumor-associated antigens (antimelanoma, antiglioma and anti-LLA), against vimentin, and against major histocompatibility antigens, and including also Ki 67, a MoAb which reacts with a nuclear antigen associated with cell proliferation. The results of this characterization indicate that we have established a human melanoma cell line with a stable antigenic phenotype during subculturing, poorly differentiated cells, and a high growth potential.

Human glioma cell lines: tumour associated antigens distribution and sensitivity to antibody-toxin or ligand-toxin conjugates. A preliminary report

We have investigated the phenotype of seven human glioma cell lines established in vitro from primary tumour explants. Indirect immunofluorescence and flow cytofluorimetry revealed a heterogeneous distribution of surface GE 2 and CG 12 Tumour Associated Antigens (TAA). In one group of cell lines TAA were detected both at the cell surface and in the cytosol, whereas in a second group of glioma cell lines TAA were found only in the cytosol. We have also investigated the sensitivity of glioma-derived cell lines to antibody-toxin and ligand-toxin conjugates (Immunotoxins). Monoclonal antibodies anti GE 2 antigen linked to ricin toxin A subunit (RTA) showed poor cytotoxicity, which increased about 50 fold when the whole toxin was linked to anti GE 2 monoclonals. Treatment with human recombinant interferon gamma (IFN-gamma) greatly augmented the percentage of HLA-DR+ cells and the amount of HLA-DR antigens per cell. IFN-gamma treatment resulted in a net increase of sensitivity to anti HLA-DR Immunotoxins (IT). Human diferric transferrin linked to RTA exhibited a potent cytotoxic effect against human glioma-derived cells when used in the presence of the lysosomotropic carboxylic ionophore monensin.

Investigation of resistance to DNA cross-linking agents in 9L cell lines with different sensitivities to chloroethylnitrosoureas

The 9L-2, 9L-7, and 9L-8 cell lines, derived from the 9L in vivo rat brain tumor, were treated with nitrosoureas that can alkylate and cross-link DNA and carbamoylate intracellular molecules to various extents. Compared to 9L cells, 9L-2 cells were very resistant to the cytotoxic effects of 1,3-bis(2-chloroethyl)-1-nitrosourea, and to 2-[3-(2-chloroethyl)-3-nitrosoureido]-D-deoxyglucopyranose. The sensitivity of 9L-7 and 9L-8 cell lines to these drugs was intermediate between 9L and 9L-2. Treatment of 9L, 9L-2, 9L-7, and 9L-8 cell lines with 1,3-bis(trans-4-hydroxycyclohexyl)-1-nitrosourea produced approximately the same level of cell kill. Compared to 9L cells, 9L-2 cells are 10-fold more resistant to the cytotoxic effects, 34-fold more resistant to the induction of sister chromatid exchanges, and have 40% fewer DNA interstrand cross-links caused by treatment with 3-(4-amino-2-methyl-5-pyrimidinyl)methyl-1-(2-chloroethyl)-1-nitrosourea . In contrast, treatment of 9L and 9L-2 cells with 1-ethylnitrosourea produced approximately the same level of cell kill and induction of sister chromatid exchanges. Our results suggest that the resistance of 9L-2, 9L-7, and 9L-8 cells is related to DNA cross-linking and not to alkylation or carbamoylation. We studied the effects of other agents that form DNA cross-links with structures different from those formed by treatment with chloroethylnitrosoureas (CENUs) in 9L and 9L-2 cells. In contrast to results obtained with CENUs, 9L-2 cells were 2-fold more sensitive to the cytotoxic effects, 2-fold more sensitive to the induction of sister chromatid exchanges, and had 3-fold more cross-links formed than 9L cells treated with nitrogen mustard. However, the amount of cell kill, number of sister chromatid exchanges induced, and the DNA cross-linking were the same for 9L and 9L-2 cells treated with cis-diamminedichlorplatinum(II). Our results indicate that cellular resistance to CENUs is highly specific and that the mechanism of resistance does not allow cross-resistance with other DNA cross-linking agents. These and other results suggest that when DNA repair processes mediate cellular resistance to CENUs, other cross-linking agents will not be cross-resistant unless they form alkylation products that are affected by repair processes that mediate resistance to CENUs.

Age-related chemosensitivity of stem cells from human malignant brain tumours

After radiation therapy and chemotherapy for malignant glioma, patients aged 50 or under survive longer than patients over 50. Data from Brain Tumor Study Group trials show that, without treatment, these age groups have similar survival; therefore unperturbed tumour growth does not account for the difference. Sixteen consecutive patients with malignant glioma were studied, half of whom were less than or equal to 50 years of age; none had been treated before initial surgery, and all were subsequently treated with radiation and chemotherapeutic agents (in all but two patients, with nitrosoureas). Median survival of those aged greater than 50 was less than or equal to 50 years was 54 + weeks whereas that of those aged greater than 50 was 37 weeks. The longer survival for younger patients could not be attributed to tumour type, size, or location, pretreatment Karnofsky status, or mode of treatment. In-vitro sensitivity testing of clonogenic cells obtained from biopsy specimens showed that tumour cells from seven of eight patients aged less than or equal to 50 years were sensitive to 1,3-bis (2-chloroethyl)-1-nitrosourea (greater than 40% cell kill at clinically achievable concentrations) compared with only one patient with sensitive cells out of eight older patients. Patient age was inversely correlated with in-vitro cell kill, and patients with sensitive cells were significantly younger than those with resistant cells. Therefore influence of age on survival after treatment of malignant gliomas is probably due to inherent differences in the sensitivity of clonogenic cells to radiation and/or chemotherapeutic agents.

Posttraumatic intraventricular haemorrhages

Of a series of 350 patients studied for blunt head trauma by CT scan 10 were found to have an intraventricular haemorrhage (IVH); in 8 cases we could find concomitant CT abnormalities as well as intracerebral contusion or haemorrhage, and in two cases no other CT abnormality was noted. CT scan represents the first reliable and non-surgical tool for identifying this process. Two possible mechanisms that govern the formation of an IVH are postulated: a) an erosion of the ventricular wall by an intracerebral haemorrhage; b) the rupture of subependymal veins deformed by the negative pressure following dilatation of the ventricular wall. The prognosis in our cases is severe.

Long-term immunological investigation of malignant intracranial gliomas

In this study, 118 consecutive adult patients with supratentorial gliomas underwent preoperative immunological monitoring, with particular regard to B-lymphocyte and T-lymphocyte markers. Most patients were treated surgically and with radiotherapy. Three months later, they were readmitted for postoperative immunological investigation and follow-up control. A total of 76 cases could thus be completely investigated and were statistically eligible for evaluation. A pronounced failure of T-cell-mediated immunity was observed: "E-active" rosette-forming cells and mitogen-induced blastogenesis tests turned out to be markedly depressed, with a slight postoperative recovery. Spontaneous cell-mediated cytotoxicity was significantly (p less than 0.01) increased both in preoperative and postoperative findings. The main immunodiagnostic patterns (immunoglobulins assay, surface immunoglobulins, "mouse" rosettes) concerning the B-cell-dependent "pool" were found to be within normal limits.

Gliomas of the optic nerve and chiasm. A clinical review

A series of 24 children with anterior optic gliomas, observed and for the most part operated upon in a neurosurgical service, is reviewed. A low incidence of unilateral nerve tumors and of associated neurofibromatosis, and a rather high frequency of precocious or pseudoprecocious puberty were noted in comparison with other series. Most tumors were low-grade growths. The results of surgical treatment reflect a good prognosis for unilateral tumors and an increasing prognostic ominousness for the posterior neoplastic development. Cerebrospinal fluid shunts and radiation treatment do have a role as adjuncts to surgical exploration and biopsy, which are generally indicated since no preoperative test seems to grant an absolute diagnosis. The opinion that chiasmal tumors should not be treated at all is not shared. When the treatment of an illness falls as far short of the ultimate, as does the therapy of neoplastic disease, then it is necessary to reconsider frequently the principles upon which it is based and the results it achieves. These results are two-fold, curative and palliative and, while our efforts are directed toward the former, we realize only too frequently that the best results will sometimes lie in palliation. The disappointment in accepting this lesser goal must not allow us to underestimate its importance or neglect the help it may give.

Intracranial aneurysms of childhood

15 cases of cerebral aneurysms in children between 8 and 15 years of age, all operated upon in a 20-year span (1956--1976), are reported. 7 of them were the carriers of large aneurysms (3 'giant'). Surgical mortality was limited to 2 patients with aneurysms of the middle cerebral artery and large intracerebral hematomas. All other patients are in satisfactory conditions, with a follow-up ranging from 2 to 22 years. A direct approach to the aneurysm was used in all but 3 cases. Certain features of cerebral aneurysms in children are discussed pertinently to this series.

Anterior optic gliomas with precocious or pseudoprecocious puberty

5 patients with gliomas of the anterior optic pathways, histologically assessed or with strong diagnostic evidence, who developed precocious or pseudoprecocious puberty (2 cases) before the operation or after radiation treatment, are presented. Only 2 patients presented familial and/or personal evidence of neurofibromatosis. The production mechanism of these sexual changes is discussed.

Tuberculoma of the anterior optic pathways. Case report

A tuberculoma, encasing the anterior optic pathways in a neoplastiform growth, was found in a 25-year-old man complaining of severe visual loss, diabetes insipidus, and sexual impotence following tuberculous meningitis. Following biopsy and anti-tuberculosis treatment, a satisfactory restoration of sight in one eye allowed the patient to resume an almost normal life.

Exophthalmos from aneurysmal bone cyst of the orbital roof

An aneurysmal bone cyst of the orbital roof, causing a monolateral exophthalmos in a 15-month-old child with no previous history of head injury, was operated upon and histologically misdiagnosed as a giant cell tumor. Radiation treatment in a dosage (3,740 rad) appropriate for the latter diagnosis apparently caused a massive calcification of the residual mass with persisting exophthalmos. At a second operation the lesion was removed completely and a radical change in the histopathological features was found. 12 years after surgery, there is no evidence of residuals upon roentgenographic and CT scan examinations and the exophthalmos has practically disappeared, while there is a normal visual function in the affected eye. Some points of histopathological and gross pathological differential diagnosis between aneurysmal bone cysts and giant cell ("myeloplaxis") tumors are discussed.

Opto-chiasmatic arachnoiditis: a review of traditional neuroradiological diagnosis (82 cases, 1951--1976)

A retrospective appraisal of traditional neuroradiological techniques (such as direct röntgenograms, cerebral angiography RISA-cisternography, and pneumo-cisterno-encephalography, as opposed to the "new" technique of computer-assisted tomography) was carried out in a series of 82 cases of opto-chiasmatic arachnoiditis, all surgically verified. It is concluded that none of these examinations can provide a reliable diagnosis of opto-chiasmatic arachnoiditis, which preoperatively can only be a tentative diagnosis that becomes final only when confirmed by surgical findings. In the presence of certain progressive neuro-ophthalmological symptoms and signs, a negative neuro-radiological investigation should not deter the neurosurgeon from exploring the chiasmatic region. Computer-assisted tomography, of which the authors have no personal experience in these cases, may hold the future answer to the diagnostic problem.

Cystic suprasellar and retrosellar arachnoiditis: a clinical and pathologic follow-up case report

A patient, previously operated upon for a supra-and retrosellar arachnoid cyst, had again to undergo surgery for a recurrence and died in the early postoperative course. The gross and microscopic pathologic evidence obtained through necropsy is described: it seems to confirm the inflammatory nature of the arachnoid cyst, thus legitimating the term cystic optochiasmatic arachnoiditis used for the description of the same case in a previous report.

Immunobiology of primary neoplasms of the C.N.S. Preliminary results

A preliminary report on the immunological monitoring of primary intracranial neoplasms is presented. The most important findings concerning B-cells and T-cells mediated immunity and delayed hypersensitivity reactions in this kind of patients, are discussed. Among the fairly significant immunobiological pictures, the Authors stress the "normal behaviour" of the B-cells dependent pool, the undebatable depression of the delayed hypersensitivity reactions, and the noticeable failure of the T-cell dependent pool, particularly marked in malignant gliomas, which are also characterized by the presence of cells with natural cytotoxic activity.

[Temporal post-traumatic epilepsy: corticographic and ultrastructural study of a case]

A case of post-traumatic temporal epilepsy, submitted to a temporal lobectomy, is reported. During surgery, electrocorticography was carried out in order to differentiate epileptic areas from normal tissue. The ultrastructural study of nervous tissue removed from both normal and epileptogenic areas showed diffuse and aspecific process of neuronal alterations without a correlation to the electrographic epileptic areas. The importance of trauma in the evolution of these alterations is discussed.

Intracerebral venous angiomas as a cause of exophthalmos

Three cases of an infrequent cerebral vascular malformation, venous angioma, are reported. The first 2 of these cases, with the lesion in a supratentorial location, exhibited exophthalmos as a presenting symptom, together with palpebral or intraobital angiomatous formations, and also impairment of visual function. The first patient was operated upon and the "venous angioma" could be confirmed histologically. An angiographic follow-up of the same patient at an 18 year interval was also possible. The diagnostic work-up to be performed in cases of exophthalmos is discussed and the need for angiography is stressed.

Opto-chiasmatic arachnoiditis in brothers

Six patients (3 couples of brothers) with adhesive arachnoiditis of the opto-chiasmatic cistern, surgically verified, are presented. Only one couple of brothers offered a possible family history of a similar condition in one maternal uncle. The visual damage had almost constantly a sudden onset and was predominantly of the axial type. No gross pathology, other than the arachnoiditic involvement of the chiasmal cistern and alterations of the anterior optic pathways, was found at surgery. Pneumocisternoencephalographic findings did not prove constantly reliable for a preoperative diagnosis of the condition when compared with surgical pathology. The overall results of the neurosurgical operations (exploration of the chiasm and removal of the adhesions) can be considered as favorable and this type of treatment is once again recommended as the therapy of choice without undue delay when general or local medical treatment proves of no avail after a reasonable length of time.

Immunobiology of paediatric intracranial tumours. A preliminary report

Preliminary findings in the evaluation of the immune response of children with primary neoplasms of the CNS, mainly medulloblastomas, are reported and discussed. A broad scheme for the monitoring of B- and T-cell-dependent immunity and of delayed hypersensitivity reactions in this type of patient is presented. The most important immunobiological findings are discussed. Special attention is given to the striking failure of the T-cell-dependent pool (currently identified by "active" RFC and blastigenesis tests) and to the remarkable decrease of hypersensitivity reactions (depressed skin-test response), both of which seem to be related to the degree of malignancy of the tumour. A very peculiar feature, i.e., the appearance of cells with natural cytotoxic activity, is dealt with in some detail. Our present knowledge concerning the immunobiology of primary CNS neoplasms is still very incomplete, but seems to suggest a possible role for immunotherapy in paediatric neurosurgery.

CSF levels of cyclic nucleotides in primary intracranial neoplasms: a preliminary report

Recent evidence indicates that cyclic nucleotides are of importance for general and neurosurgical oncology, especially with respect to the contact-inhibition mechanisms and tumour cell growth. This preliminary report deals with the CSF levels of c-AMP and c-GMP in primary neoplasms in children and to problems related to the blood-brain barrier. Some cases of medulloblastoma were studied as well as a few cases of brain stem glioma and cystic astrocytoma. The importance of some rather unusual findings seems undebatable, i.e., the marked increase in c-GMP values usually observed in medulloblastoma and the decrease of c-AMP, that is fairly common in all malignant neoplasms. The main changes in the c-AMP/c-GMP ratio are also discussed.

[Accumulation of glutamic acid and glycine in human cerebral tumors in vitro]

Preliminary results are given on transport of glycine and L-glutamate into human cerebral tissue, normal and tumoral. In comparison with normal tissue, glycine transport is diminished in meningioma and oligodendroblastoma, unaffected in neurinoma, sharply increased in medulloblastoma. Glutamic acid transport is lowered in neurinoma and oligodendroblastoma; increased in medulloblastoma. Such preliminary observations are briefly discussed.

The dysraphic state of the posterior fossa. Clinical review of the Dandy-Walker syndrome and the so-called arachnoid cysts

The Authors report their case material concerning some basic items of the dysraphic pathology of the Posterior Fossa: 22 cases of Dandy Walker syndromes (DWS) and "Arachnoid Cysts" (PFC). The mean clinical findings (predominant involvement of the vestibular structures of the brain stem in the DWS, frequent epileptic seizures and some cases of hypothalamic disturbances in the PFC) are discussed in the light of current embryological theories on Weed's "area membranacea". Finally the results of differential surgical treatments are examined: good or satisfactory results were obtained with shunts, while still debatable seems to be the direct surgical approach.

Ocular involvement in recurrent cyst of Rathke's cleft: Case report

Cysts of Rathke's cleft are considered as benign lesions, a practically permanent cure of which can be achieved by aspiration of the fluid content and ample opening of the capsule. The case of a patient who suffered from a recurrence of the cyst, 13 years after a first operation carried out according to such surgical criteria, is reported in order to signal the actual possibility of recurrence of such lesions.