Photoablation of meningiomas and neurinomas by Holmium Yag laser radiation

Cranial rat bone was irradiated by 2.1 microns Holmium Yag laser radiation. Quantitative edge rates were calculated. Histologic sections were investigated by light and electron microscopy. Eighteen cases of hard fibrous or calcified spinal and cranial meningiomas and neurinomas were operated upon using pulsed laser beam. In rat cranial bone ablation rate ranged between 0.3-0.5 mm per pulse. Perifocal thermal damage was observed in a zone of 20-90 microns around the lesion. In all human cases tumors could be removed totally without additional neurological deficit. In vivo heat development was measured by an i.r.-camera.

Obstructive sleep apnoea and diabetes mellitus: the role of cardiovascular autonomic neuropathy

Knowledge of conditions associated with an increased prevalence of obstructive sleep apnoea (OSA) may help to identify patients with OSA and might give some insight into the pathogenesis of OSA and its sequelae. A number of earlier, smaller studies hinted at an association between diabetic cardiovascular autonomic neuropathy (AN) and OSA. The present study was, therefore, conducted with the aim of establishing the prevalence of OSA in diabetics with AN and of determining whether OSA is more prevalent in diabetics with AN, than in those without. We studied two groups of diabetic patients: 23 with and 25 without AN. All patients were evaluated for possible OSA (apnoea/hypopnoea index > or = 10) using initial ambulatory screening followed by polysomnography. Six patients with AN (26%) were found to have OSA, but none of the patients without AN met the diagnostic criteria (p<0.01). When the patients with OSA were compared to those without, no differences were found in terms of age, sex, body mass index or diabetes type or duration. In conclusion, about one in four diabetic patients with autonomic neuropathy suffers from OSA. Thus, obstructive sleep apnoea is more prevalent in diabetic patients with autonomic neuropathy, than in those without.

[Restriction enzyme mismatch polymerase chain reaction in the demonstration of Ki-ras-oncogene mutation in carcinoma of the pancreas]

A pilot study was undertaken to test whether combining the polymerase chain reaction with restriction fragment length polymorphism is suitable for the routine diagnosis of carcinoma of the pancreas. The method makes it possible to recognize point mutations in codon 12 of the Ki-ras oncogene. 60 cytological specimens from the pancreatobiliary tract, the bronchopulmonary system (by bronchoalveolar lavage or from pleural effusion) and ascites were tested. Results from nine pancreas carcinoma cell lines served as control. A PCR product was successfully amplified in all cell lines and 47 of the clinical specimens. In all eight samples in which a mutated Ki-ras oncogene was demonstrated, there was at least a suspicion of malignancy by cytological examination. A mutation was also found in four of five pancreas carcinomas. But no mutation was found in one, clinically certain, case of pancreas carcinoma. The described method is an elegant and, most of all, rapid means to complement and optimize any cytological diagnosis.

[Photoablation using Excimer laser irradiation--a suitable concept for microneurosurgery?]

The suitability of Excimer laser beam for microneurosurgery was investigated in an animal experimental study. Cranial bones, cortex and the nervus ischiadicus of the rat were irradiated with 193 nm argon fluoride, 248 nm krypton fluoride, 308 nm xenon chloride and 351 nm xenon fluoride. After survival times of up to 30 days microscopic and electron optic findings of laser lesions at the tissues mentioned above, were studied. By means of the Excimer laser beam high precision tissue effects without or with only low thermal damage to the surrounding tissue were produced with any desired depth of penetration or extension. In analogy with the experiences gathered from animal experiments, a possible use is discussed for the removal of bone tissue around cranial nerves or vascular structures, of epileptogenic foci, or for cutting off pathways in pain surgery (e.g. the zone of entry of the dorsal root of spinal nerves).

[Legal evaluation of intervertebral disk surgery including post-discotomy syndrome]

Although lumbar disc surgery (discectomy) definitely improves the overall situation of the patient in most cases, it does create problems of a hitherto absent kund in about 6% of the patients. Expertising of uncomplicated cases should not be too difficult. However, modulated by individual disposition, a syndrome may develop known as "failed back surgery syndrome" caused by intersegmental loosening, crumbling or fusing and scarification. The pain it causes is decisive for its assessment, not so much any motor or other neurological deficits. In mild cases the loss in capacity for gainful employment may be assessed at between 20% to at the most 30%, but the severely handicapped are unable to cope with their daily life without assistance, their incapacitation amounting to as much as 100%. If the patient concerned is on a job that places stress on this spine, he may be unfit for work even if the affliction is relatively mild.

[Cerebrovascular disorders and administration of oral contraceptives containing gestodene--causal relation or coincidence?]

During the last two years oral contraceptives containing gestodene were suspected to cause cerebrovascular disorders. 52 cases with adverse neurological side effects were registered up to October 31, 1990. Anonymous protocols received from the Companies Schering AG and Wyeth Pharma were analyzed from a clinical point of view. There are different arterial and venous, thrombotic and embolic disorders caused by different pathogenetic principles. Only one third of the cases was documented by neuro-imaging to render possible actual diagnostic reliability. Suspected cases represent a great number of different cerebrovascular disorders usually observed in neurological and neurosurgical series, concerning both men and women, OC-users and non users.

Ifosfamide, vindesine and recombinant alpha-interferon combination chemotherapy for metastatic renal cell carcinoma

Among 29 evaluable patients with progressive metastatic renal cell cancer treated by interferon alpha 2b in combination with vindesine and ifosfamide, we have observed an objective (complete and partial) response rate of 24.1% and an overall (complete and partial response and stable disease) response rate of 58.6%. The median duration of remission has not yet been reached, but the survival of responding patients is considerably longer than that of non-responders. Because we could not find any differences (sex, age, WHO performance status, prior therapy, site of metastatic disease) between responding and non-responding patients, we believe that the treatment might modify intrinsic characteristics of the tumour growth and/or host-tumour relationship in the long term. Although the toxicity recorded is high, the results are sufficiently positive to justify further investigation of this approach.

[Perioperative preventive use of antibiotics in neurosurgery. Experience with a fixed antibiotic combination of mezlocillin and oxacillin (optocillin)]

We report a retrospective account of 200 patients who have been surveyed after having undergone neurosurgical intervention. They received as perioperative antibiotic prophylaxis a combination of Mezlocillin and Oxacillin in a ratio of 2:1 (Optocillin) in their management. The clinical and bacteriological efficacy including the side effects was examined with standardisation of sterility measures in the operating theatre, careful standardised operative procedures and ward after care. No problems in wound healing were found. There was no certain evidence of side effects.

Prophylaxis of fungal infections with itraconazole in immunocompromised cancer patients

During a period of 32 months (August 1986 until April 1989) 108 patients (74 women, 34 men; mean age 53 years) with neoplastic diseases (59 patients with solid tumors, 45 patients with lymphomas, two patients with acute leukaemias, one patient with chronic myelogenous leukaemia, one patient with aplastic anaemia) were studied in the Department of Internal Medicine of the University Erlangen-Nuremberg. Most were treated with a cytostatic chemotherapy. In order to prevent a mycotic infection in these immunocompromised patients, itraconazole, a new broad-spectrum antimycotic drug of the azole group, was given in an oral dosage of 100 mg day-1 (mean duration of prophylactic treatment 24 months). Localized Candida infections involving the oropharynx and the female genital organs were diagnosed in 16 patients (14.8%). Candida endophthalmitis occurred in one patient (0.9%). The serum concentration of Candida antibodies was significantly elevated in one patient (0.9%) without evidence of fungemia. Itraconazole had to be discontinued in four cases (3.7%) due to minor side effects of the drug (nausea, stomach complaints). Itraconazole appears to be a safe and effective antimycotic drug in long-term use in neutropenic patients.

[Phase II study with pirarubicin in pretreated progressive head-neck neoplasms]

Sixteen heavily pretreated patients (pts) (4 surgery + chemotherapie + radiotherapy; 4 chemotherapy + radiotherapy: 6 surgery + radiotherapy; 2 chemotherapy) and one previously untreated patient, who refused surgery and or radiotherapy, all with progressive disease, with advanced squamous cell carcinoma of the head and neck were included in a phase II study with pirarubicin 60 mg/m2 i.v. day 1 every 3-4 weeks (CT). All pts received at least one course of CT. 15 pts were evaluable for response, all 17 pts were evaluable for toxicity. Female (male ratio 1/16; mean age 56 (42-68) yrs, mean performance status 70% (50-70). Seventeen pts received a mean of 3 (1-8) courses, 2 pts had received only one course of CT. Response and toxicity were assessed according to WHO classification. Results after 1-8 courses of CT: 1 (7%) complete remission; 1 (7%) partial remission; 9 (60%) no change; 4 (26%) progressive disease. No toxicity of grade IV was observed. Mean duration of remission 16 weeks. Median survival time 7 (1-10) months. 9 pts died and 8 pts are alive; six of them had progressive disease.

Degenerative and regenerative processes in the peripheral nerve after disconnection and reanastomosis using the Neodym Yag laser

The development of neuroma after peripheral nerve surgery is still an unsolved problem. Such lesions are not yet controllable by conventional methods. Reports of results achieved using various types of laser surgery appear contradictory. In this experimental study on rats, the Neodym Yag laser was found to be superior the conventional methods. After severance and reanastomosis of the sciatic nerve using this type of laser, no development of neuroma was observed in any of the animals during the first three months of observation.

[The effect of various surgical technics on neuroma development using the neodymium laser]

The development of neuroma after surgery of peripheral nerves is an unsolved problem. Conventional methods like suture after cutting by seizure or bipolar coagulation cannot control it until today. Contradict results are reported since different types of laser were introduced in surgery. In an animal experimental study on rats the Neodym Yag laser is superior to conventional methods described above. After severance and reanastomosis of the sciatic nerve by laser in none of these cases a development of neuroma could be observed until three months of surviving.

[Clinical aspects of hypophyseal metastases]

Metastatic tumors within the pituitary gland are rare. The incidence--reported by series of autopsies--differs from 1.8-12% of metastatic tumors. Most of the primary tumors are breast cancers, followed by cancers of the gastro-intestinal system. Only 20% of these metastases are clinically diagnosed. Diabetes insipidus is the main symptom, correlating with the greater incidence of metastatic lesions in the posterior lobe. The unusual features of a reported case are discussed. In this case the dysfunction of cranial nerves passing the sella turcica led to the diagnosis. Therapy with Flutamid initiated a remission. Survival of 18 months is remarkably long.

[A new model for producing occlusive hydrocephalus in animal experiments]

Production of hydrocephalus in animal experiment has been difficult and not uniformly successful so far. The preparation Ethibloc (supplied by Ethicon, Hamburg-Norderstedt), which is a protein solution in alcohol, and which has been in use in abdominal surgery for occluding the pancreatic duct system, enables production of an obstructive hydrocephalus easily and with reproducible results. The authors report on 24 cases of development of an obstructive hydrocephalus in rabbits after Ethibloc had been introduced into the ventricular system.

Synovial fluid involvement in null cell acute lymphoblastic leukemia diagnosed with monoclonal antibodies

Rheumatic symptoms in patients with leukemia are not uncommon. Often they delay correct diagnosis and therapy. We describe a patient presenting with oligoarticular joint disease in whom immunological analysis of synovial fluid (SF) led to the detection of leukemic cells in the joint. Moreover, analysis with a variety of monoclonal antibodies established the diagnosis of acute lymphoblastic leukemia of null cell type with phenotypically identical malignant cells present in the bone marrow, peripheral blood and SF. Our investigations demonstrate that analysis with monoclonal antibodies is helpful in characterizing joint involvement in patients with leukemia.

Prevention of neuroma formation by Neodym Yag laser--experimental observations

The influence of Laser radiation on neuroma formation was investigated in rat sciatic nerves. Peripheral nerve trunks were divided by focused Neodym Yag Laser and compared with those transected by microscissors. The nerves were re-exposed at different time intervals up to 240 days after initial operation. True neuroma formation could not be observed after laser transection. Sharp division resulted in widespread amputation neuromas consisting of regenerating axons and connective tissue. Neodym Yag laser radiation by its scattering effect may cause deep coagulation necrosis and thrombosis of vasa nervorum thus sealing the dome of the divided nerve trunk. The formation of amputation neuromas may be suppressed by laser application.

[Pseudomeningocele following lumbar intervertebral disk surgery]

Pseudomeningoceles have been observed several times after closed traumatic injuries of the cervical plexus resulting in avulsion of the nerve roots. Following lumbar puncture or lumbar disc operation meningoceles are seldom occurring events. The first report of perineural cysts causing sciatic pain was made by Bancroft (1) in 1941. Since that time about 50 cases have been reviewed by the literature (10, 11). In this paper we report another case of an iatrogenic pseudomeningocele developed following surgical treatment for herniated lumbar disc attempting to outline their clinical and radiological findings.

[Therapy and prognosis of spontaneous intracerebral hemorrhages with ventricular involvement]

Clinical experiences on intracerebral hematomas with intraventricular involvement are recorded, and cases from 1976 to 1982 are surveyed. Important criteria for conservative and operative procedure are concluded. Localization of hematoma and follow-up clinical condition of the individual cases are the most reliable indicators in the choice of treatment. Good prognosis of hemorrhages caused by angioma is emphasized, if these are operated upon.

[Reversible panmyelopathy following captopril treatment]

In a 46-year-old female patient suffering from renal hypertension due to polycystic kidney degeneration with creatinine values between 3 and 5 mg/dl leucopenia developed 3 weeks after beginning antihypertensive therapy with the angiotensin-converting-enzyme inhibitor captopril. On continuation of treatment signs of haemorrhagic diathesis appeared 7 months later. Cytology and histology led to the diagnosis of panmyelopathy which, from the clinical findings and the close patient follow-up, was to be regarded as captopril-induced. Bone-marrow regeneration could be shown 6 months after discontinuing the drug. In renal insufficiency, captopril treatment should be monitored using regular haematological tests and the drug withdrawn when leuco- or thrombocytopenia occurs.

[A case of transverse spinal cord syndrome following contamination of a peridural catheter]

Two weeks after removal of a peridural catheter a transverse lesion of the cord with paraplegia developed. At operation a paravertebral abscess, osteomyelitis of the lamina L2 and L3, and epidural abscess, a phlegmonous duritis and myelitis of the conus-cauda region by transmigration was found. The catheter had been in position for four days. The infection was caused by staphylococcus epidermidis. After laminectomy L2 and L3 as well as local and systemic application of antibiotics, according to the results of sensitivity tests, neurological deficits disappeared nearly completely.

Pharmacokinetic studies of high-dose metoclopramide with and without forced diuresis

The pharmacokinetics of high-dose metoclopramide (10 mg/kg body wt. in five infusions of 2 mg/kg body wt. each) was studied in 11 patients (5 females, 6 males) in two groups: group A with and group B (consisting of five patients) without forced diuresis. When the drug was infused, forced diuresis had no influence on the pharmacokinetics of metoclopramide (serum level after the 1st infusion was 851 +/- 361 ng/ml in group A versus 840 +/- 348 ng/ml in group B; after the 5th infusion it was 2,005 +/- 588 ng/ml in group A versus 2,463 +/- 1,350 ng/ml in group B). There were significant differences in the 24-h serum levels (582 +/- 308 ng/ml in group A versus 379 +/- 170 ng/ml in group B; P less than 0.05) and in the elimination half life (8.5 +/- 2.6 h in group A versus 6.1 +/- 1.1 h in group B; P less than 0.05). The results demonstrate that the dosage regimen originally suggested by Gralla for cytostatic drugs, with forced diuresis for high-dose metoclopramide therapy, may also be applied, with no dosage reduction, with to other cytostatic drugs which do not require forced diuresis.

Antiemetic efficacy of moderately high-dose metoclopramide in patients receiving varying doses of cisplatin. Controlled comparison with a combination of methylprednisolone and metoclopramide

In 29 patients (48 courses of chemotherapy), a randomized double-blind crossover study was undertaken to establish the antiemetic effectiveness of a combination of metoclopramide at a moderately high dose (5 mg/kg body weight) with 1 g methylprednisolone (treatment A) as compared with metoclopramide monotherapy (5 mg/kg body weight; treatment B). With cisplatin doses of 60 mg/m2, a good antiemetic effect (0-1 vomiting episodes in 24 h) was observed in 9 out of 10 patients under treatment A as well as under treatment B. With a cisplatin dose of 120 mg/m2, treatment A produced a good antiemetic effect in 9 out of 11 patients (82%), while treatment B produced such an effect in only 3 out of 11 patients (27%; p less than 0.5). The results obtained permit the following conclusions to be made: At doses of cisplatin of up to 60 mg/m2, the antiemetic effect produced by metoclopramide (5 mg/kg body weight) given alone is adequate. At doses of cisplatin of 120 mg/m2 and more, high-dose methylprednisolone has a good additive antiemetic effect vis-à-vis metoclopramide (5 mg/kg body weight). The antiemetic effect of this combination corresponds approximately to the antiemetic effect produced with high-dose metoclopramide (10 mg/kg body weight) administered alone.

[A new material in neurosurgery]

A new alcoholic prolamine solution is now available (ETHIBLOC, supplied by Ethicon, Norderstedt) which can be used in neurosurgery for a variety of purposes. This material hardens quickly in an aqueous medium. Animal experiments have not shown any damaging action on the brain, meninges, or bone. The excellent tolerance of the material was seen in a total of 22 patients operated on with the help of Ethibloc. It is particularly well suited for closing frontal CSF fistulas, incised frontal sinuses, and for rearranging or shunting in case of cerebral vascular deformities. It can also be used as a carrier of antibiotics in osteomyelitis, for covering up minor defects of the dura mater, for dura sealing, and for closing the bone after trephination. The preparation is transformed completely to connective tissue within a period of 40 to 90 days. New techniques of surgery are described which have become possible by the use of Ethibloc.

[A new technic for the sealing of a frontobasal cerebrospinal fluid fistula. Experiences with a hardening alcoholic protamine solution]

Fractures of the frontal base of the skull are often accompanied by rhinoliquorrhea. To prevent infections of the brain they must always be closed surgically. We report on a new method of closing the dura mater defect using an alcoholic prolamine solution, which hardens within a few minutes. After 40 to 90 days the mass has been replaced by connective tissue. We describe our experience with 24 patients who were successfully operated on using this method and followed up for two years.

[Chemotherapy of malignant tumors, vomiting and nausea--what to do?]

Very marked nausea and vomiting are the most frequently observed side effects of modern cytostatic agents, and make it necessary to include powerful anti-emetic drugs in any oncological chemotherapeutic concept. The selection of suitable anti-emetics, however, often proves difficult. The reasons for this are discussed. A number of important basic rules that should be observed with any anti-emetic treatment are proposed. Finally, a standardised stepwise anti-emetic plan is suggested for discussion.

[Treatment of non-small cell bronchial cancer with high-dosage cisplatin and vindesine. Results of a prospective study]

Thirty-seven patients with advanced, histologically confirmed non-small-cell lung cancer received combination chemotherapy with high-dose (120 mg/m2, day 1 and 29, thereafter every 6 weeks) cisplatin and vindesine (3 mg/m2, day 1, 8, 15, 22, and 29, thereafter every two weeks). All patients had measurable disease and had not previously received chemotherapy. 20 out of 37 patients responded to therapy. Two patients with adenocarcinoma, and one patient with squamous carcinoma of the lung experienced complete remission, 11 out of 37 patients partial remission, three patients a minor response, while in three patients the tumour neither remitted nor progressed. Despite chemotherapy cancer progressed in 17 out of 37 patients. Under supportive care including prehydratation, diuresis, administration of high-dose metoclopramide this aggressive chemotherapy was well tolerated. The response rate was similar to that of other chemotherapeutic regimens. The remission duration (9.5 months) and the survival time (16.5 months) are, however, somewhat better.

[Changes in blood sedimentation and blood counts. Practical value for the early diagnosis of severe illness]

The practical importance of BSR and blood cell changes for the early recognition should not be overestimated. But every symptomless person with raised BSR should be examined very carefully, especially for occult hepatic diseases (active hepatitis, liver cirrhosis), for anaemias, leukaemias, malignant lymphomas and other malignant diseases. The practical use of the diagnosis of blood cell changes is the possible recognition of anaemias, leukaemias and malignant lymphomas.