CT perfusion predicts secondary cerebral infarction after aneurysmal subarachnoid hemorrhage

OBJECTIVE

To prospectively assess the diagnostic accuracy of CT perfusion (CTP) and transcranial Doppler sonography (TCD) for the prediction of secondary cerebral infarction (SCI) after aneurysmal subarachnoid hemorrhage (SAH).

METHODS

During 2 weeks after SAH, 38 consecutive patients completed an average of 3.5 CT/CTP and 10.7 TCD examinations at regular intervals as required by the study protocol. SCI was defined as delayed infarction on native CT between 3 and 14 days after SAH and developed in n = 14 patients (n = 24 without SCI). Analysis was based on examination dates before SCI. Common measures of diagnostic accuracy were calculated for qualitative CTP (visual color-map ratings from two blinded observers) and TCD assessments (mean flow velocity >120 cm/s in anterior, middle, and posterior cerebral artery territories). Quantitative measures, which for CTP were obtained from cortical a priori regions of interest corresponding to the vascular territories, were analyzed by binary logistic regression.

RESULTS

Time of prediction for SCI by CTP was at a median of 3 days (range 2 to 5 days) before manifestation of complete infarction on native CT. Visual assessment of time-to-peak (TTP) color maps performed best for the prediction of SCI with 0.93 sensitivity (95% CI: 0.7 to 1.0) and 0.67 specificity (95% CI: 0.53 to 0.7). On quantitative analysis, the odds ratio (OR) for 1 second of side-to-side delay in TTP was 1.4 (p = 0.01, Wald chi(2) = 8.57, CI: 1.07 to 1.82). Daily TCD measures were not significantly related to SCI at any time before complete infarction on native CT.

CONCLUSIONS

Time to peak as indicated by CT perfusion is a sensitive and early predictor of secondary cerebral infarction.

Influence of cerebral oxygenation following severe head injury on neuropsychological testing

Despite recent advances in the management of severe head injury the mortality and morbidity remains high. Intracranial pressure (ICP) and cerebral perfusion pressure (CPP) are crucial parameters for the correct management at the intensive care unit, due to their therapeutic and prognostic importance. In addition, regional brain tissue oxygenation (ptiO2) seems to be of importance. While different studies demonstrated the impact of cerebral hypoxia on outcome (mortality), no data are available focusing on morbidity (neuropsychological deficits). Therefore, our study is carried out to demonstrate a possible relationship between amount of cerebral oxygenation during acute stage after severe head injury and neuropsychological outcome. Besides ICP and CPP, ptiO2 was monitored in 40 severely head injured patients during the ICU stay from the day of admission until day 10. Monitoring data were stored and amount of hypoxic episodes were calculated. Besides outcome using the Glasgow Outcome Scale neuropsychological testing was performed 2-3 years after injury. Analysing the quality of brain tissue oxygenation, a relationship to the performance in neuropsychological tests could be found. Patients with low brain tissue oxygenation had a worse outcome in neuropsychological testing, especially concerning intelligence and memory. Associated with these deficits patients showed a reduced performance in their profession. Our data suggest a possible predictive value of brain tissue oxygen on morbidity analysing neurocognitive function after head injury. This may implicate monitoring and treatment of cerebral hypoxia.

Brain tissue oxygen guided treatment supplementing ICP/CPP therapy after traumatic brain injury

OBJECTIVE

To evaluate the effects of a brain tissue oxygen (P(ti)O(2)) guided treatment in patients with traumatic brain injury.

METHODS

P(ti)O(2) was monitored in 93 patients with severe traumatic brain injury. Forty patients admitted from 1993 to 1996 were treated with intracranial pressure/cerebral perfusion pressure (ICP/CPP) management alone (ICP < 20 mm Hg, CPP > 70 mm Hg). Fifty three patients admitted from 1997 to 2000 were treated using ICP/CPP management, but in this second group CPP was also increased as individually required to raise the P(ti)O(2) above 1.33 kPa (10 mm Hg) (P(ti)O(2) guided group).

RESULTS

Cerebral hypoxic phases with P(ti)O(2) values below 1.33 kPa occurred significantly less often in the P(ti)O(2) guided group. P(ti)O(2) values were higher over the whole monitoring period. No statistical differences could be observed in outcome at six months, despite a positive trend in the P(ti)O(2) guided group.

CONCLUSIONS

Cerebral hypoxic events can be reduced significantly by increasing cerebral perfusion pressure as required. To show a clear beneficial effect of P(ti)O(2) guided cerebral perfusion pressure management on outcome, a multicentre randomised trial needs to be undertaken.

Therapeutic aspects of brain tissue pO2 monitoring after subarachnoid hemorrhage

Prolonged phases of brain tissue hypoxia (ptiO2 < 10 mmHg) lead to cerebral infarction. Therefore, the present study investigates the role of ptiO2--monitoring to guide hypervolemic hypertensive therapy in patients suffering from severe subarachnoid hemorrhage (SAH). Besides transcranial doppler, neuromonitoring of ICP/CPP was supplemented by ptiO2 monitoring. The ptiO2 catheter was inserted into viable tissue in the vascular territory with the highest risk for vasospasm. Patients were divided in an infarction (n = 21) and a non-infarction group (n = 11). Critical CPP (< 70 mmHg) as well as hypoxic ptiO2 (< 10 mmHg) was significantly more frequent in the infarction group (CPP: 25 vs 13%, p < 0.001; ptiO2: 16 vs 7%, p < 0.001). In both groups, over 25% of the critical ptiO2 values occurred at a CPP > 90 mmHg. In the infarction group, 13 patients showed transient phases of hypoxia which normalized under induced hypervolemic hypertension and 5 patients developed persistent hypoxia. In the non-infarction group 6 patients showed transient hypoxia and in 5 patients no hypoxic values could be found. In conclusion, monitoring of ptiO2 provides an additional independent parameter to detect hypoxic events and to guide therapy.

Medulloblastoma displays distinct regional matrix metalloprotease expression

Matrix metalloproteases (MMPs) play an important role in tissue remodeling and neoangiogenesis during tumor progression. Little is known about the presence and regional distribution of MMPs in medulloblastomas. Based on immunohistochemical, immunocytochemical and zymographical analysis is the present study illustrates the differential pattern of MMP expression for the medulloblastoma compared to that of glioma and ependymoma. In 10 examined medulloblastoma tumors gelatinase-A was strongly expressed by clusters of tumor cells. Gelatinase-B was, similar to glioma and ependymoma, predominantly found around endothelial cells. The DAB signal for macrophage metalloelastase was seen around macrophages and matrilysin was expressed by single tumor cells. Stromelysin-1 protein was detected in medulloblastoma but not in glioma or ependymoma. From the presented data it follows that each tumor entity might display its own characteristic MMP expression pattern.

Intra-Operative electromyographic monitoring of extra-ocular motor nerves (Nn. III, VI) in skull base surgery

BACKGROUND

Extraocular motor nerves (Nn. III, IV, VI) are at risk of damage during skull base surgery. A new recording technique was employed in 18 patients suffering from various skull base tumours in order to extend intra-operative EMG monitoring to the extra-ocular muscles.

METHODS

Selective intra-operative EMG recordings were obtained from extra-ocular muscles by placement of single-shafted bipolar needle electrodes under the guidance of B-mode ultrasound to visualise the needle tip within the target muscle in the orbital cavity.

FINDINGS

Following bipolar electrical stimulation, the oculomotor nerve (N.III) was intra-operatively identified in 5 out of 7 cases, and the abducens nerve (N.VI) in 12 out of 18 cases. Postoperative (3-6 months) oculomotor nerve function remained unchanged in 5 and improved in 2 patients. No permanent deterioration was observed. Abducens nerve function deteriorated in two patients and improved in one case, but remained unchanged in 15 cases. No side effects occurred. There was neither any distinct relation of ocular motor nerve function to the kind and extent of SMA ("spontaneous muscle activity") patterns, nor could such relationship be detected with concern to neurophysiological parameters (latencies, amplitudes) of electrically evoked CMAP ("compound muscle action potentials").

INTERPRETATION

The EMG technique proposed proved to be mainly effective as a mapping tool for intra-operative localisation and identification of ocular motor nerves in skull base surgery. However, the predictive value of conventional neurophysiological parameters for clinical outcome, seems to be rather poor. Further studies on a larger number of patients are therefore required to develop new quantification techniques which enable an intra-operative prediction of ocular motor nerve deficits. Further efforts are also necessary to extend this technique to the trochlear nerve.

Ultrasound-guided neuronavigation of deep-seated cavernous haemangiomas: clinical results and navigation techniques

The aim of this study was to evaluate guidance techniques and patient outcomes of ultrasound-guided neuronavigation of deep-seated intracerebral cavernous hemangiomas (CAs). Thirty-five patients with deep-seated intracerebral CAs with sizes ranging between 7 and 45 mm were operated upon only with ultrasound-guidance. Twenty-seven were located in or near eloquent regions. In 30 patients dissection to the lesion was performed through sulci and fissures. The best approach to a lesion based on surface anatomy and depth was determined using sonographic information. Navigation was done sonographically. In five patients the shortest approach via a corticotomy was determined sonographically. Twenty-six patients had no neurological deficit postoperatively. Preoperative deficits improved in seven of nine patients. Fifteen of 19 patients suffering epileptic seizures had no seizures postoperatively. Intraoperative sonography revealed residual CA tissue after microsurgical extirpation in two cases. This report shows that intraoperative sonographic navigation provides safe guidance to deep-seated CAs with good clinical outcome independent of size.

Clinical cerebral microdialysis: brain metabolism and brain tissue oxygenation after acute brain injury

While continuous monitoring of brain tissue oxygenation (P(ti)O2) is known as a practicable, safe and reliable monitoring technology supplementing traditional ICP-CPP-monitoring, the impact of cerebral microdialysis, now available bedside, is not proven extensively. Therefore our studies focused on the practicability, complications and clinical impact of microdialysis during long term monitoring after acute brain injury, especially the analysis of the correlation between changes of local brain oxygenation and metabolism. Advanced neuromonitoring including ICP-CPP-p(ti)O2 was performed in 20 patients suffering from acute brain injury. Analysis of the extracellular fluid metabolites (glucose, lactate, pyruvate, glutamate) were performed bedside hourly. No catheter associated complications, like infection and bleeding, occurred. However, longterm monitoring was limited in 5 out of 20 patients caused by obliteration of the microdialysis catheter after 3-4 days. In the individual patients partly a correlation between increased lactate levels as well as lactate pyruvate ratios and hypoxic brain tissue oxygenation could be found. Analysing the data sets of all patients only a low correlation was detected indicating physiological and increased lactate and lactate/pyruvate ratio during sufficient brain oxygenation. Additionally, concentrations of excitatory amino acid glutamate were found in normal and elevated range during periods of hypoxic oxygenation (P(ti)O2 < 10 mmHg) and intracranial hypertension. Our data strongly suggest partly evidence of correlation between hypoxic oxygenation and metabolic disturbances after brain injury. On the other hand brain metabolism is altered without changes of cerebral oxygenation. Further studies are indicated to improve our pathophysiological knowledge before microdialysis is routinely useful in neurointensive care.

Combined intra-operative monitoring of hearing by means of auditory brainstem responses (ABR) and transtympanic electrocochleography (ECochG) during surgery of intra- and extrameatal acoustic neurinomas

BACKGROUND

Although being established as a standard procedure in intra-operative monitoring in acoustic neurinoma surgery, auditory brainstem responses (ABR) represent a far-field technique bearing some technical limitations. This prospective study was designed to evaluate electrocochleography (ECochG) as a supplementary tool for hearing preservation.

METHOD

84 patients with unilateral intra-/extrameatal acoustic neurinomas (extrameatal diameter: 5-55 mm) preserving serviceable hearing, were operated on using a combined (neuro-/otosurgical) suboccipital approach. ECochG was recorded simultaneously to ABR following transtympanic insertion of a steel needle electrode into the promontory under otoscopic view.

FINDINGS

Serviceable hearing (Class 1-3 according to Gardner/Robertson) was preserved in 43 out of 84 patients (51.2%), of whom 40 showed both ECochG and ABR being preserved. All 24 patients with loss of both modalities became deaf. Hearing preservation was observed in 4 out of 12 patients with preserved ECochG but loss of ABR (waves III-V). The reverse was observed in 2 cases with postoperative deafness. While both ECochG and ABR amplitudes were significantly correlated with pre- and postoperative hearing, latencies of ECochG summating (SP) and action potential (AP) proved to be more reliable indicators for preserved hearing than ABR (peak I/III/V) latencies. The predictive value of baseline ABR amplitudes for postoperative hearing, however, was superior to ECochG parameters. Only in large neurinomas (extrameatal diameter: >2 cm) tumour size was found to be a significant predictor for the preservation of hearing. Apart from three cases with postoperative otoliquorrhea and one further case presenting with local bleeding within the external acoustic meatus, no side effects were observed.

CONCLUSIONS

In combination with ABR monitoring, ECochG proved to be a useful supplementary tool for hearing preservation in acoustic neurinoma surgery. It is particularly helpful during electrocautery and drilling, since no averaging is required. Special applications are: (1) small tumours with good serviceable hearing; (2) and/or a large intrameatal portion; (3) cases with lost or endangered contralateral hearing (e.g. bilateral acoustic neurinomas), when the preservation of poor or even non-functional hearing is desirable.

Surgical management of tethered spinal cord in adults: report of 54 cases

OBJECT

The clinical features specific to tethered cord syndrome (TCS) in adults as well as factors determining outcome and prognosis have rarely been addressed systematically. The authors studied 56 patients, 54 of whom were treated surgically over the last 16 years.

METHODS

In 17 patients who had been asymptomatic during childhood, TCS was diagnosed 8 years after onset of symptoms. Tethered cord syndrome was diagnosed 4 years after worsening in 39 patients with neurological signs or symptoms since childhood. The patients were followed for an average of 8 years. Features specific to adult-age presentation included nondermatomal pain aggravated by movement in 34 patients and conditions such as pregnancy and childbirth (in five of 11 pregnant patients). The most frequent tethering lesions were lipoma in 32, tight terminal filum in 28, and split cord malformation and secondary adhesions in 12 patients, respectively. Improvement or stabilization of symptoms at 6 months after surgery was noted in 46 (85%) of 54 patients. Improvement in pain status was most frequent (86%) followed by improvements in spasticity (71%), bladder dysfunction (44%), and sensorimotor deficits (35%). Factors associated with adverse outcome included preoperative duration of neurological deficits more than 5 years and incomplete untethering. On average, 8 (80%) of 10 patients with incomplete untethering developed recurrent symptoms 5 years after surgery compared with only seven (16%) of 44 patients in whom complete untethering was achieved. Seven patients underwent reoperation and in five of them stabilization of symptoms was attained. At a mean follow up of 8 years, 46 (85%) of the 54 surgically treated patients were in stable neurological condition, including those in whom reoperation was performed.

CONCLUSIONS

Surgery for TCS is as beneficial in adults as it is in children. Its success depends on early diagnosis and complete untethering of the spinal cord.

New ultrasound techniques and their application in neurosurgical intra-operative sonography

We describe a variety of new ultrasound techniques by their physical background, potentials and applications regarding usefulness during intra-operative neurosurgical procedures. Transducers like high-frequency and small rotating probes fitting into neuroendoscopes, imaging techniques as extended field-of-view technique, harmonic imaging, echo-enhancers, 3-D imaging and the real-time integration of neurosonography with pre-operative CT- or MR-data are mentioned. The technical or physical principles are explained, followed by a discussion of these techniques from available literature dealing with their intra-operative neurosurgical applications and the experience of the authors with the techniques. With higher frequencies micromillimeter imaging is possible and small probe allows endoneurosonography. Echo-enhancers and harmonic imaging improve the signal-to-noise ratio and 3-D imaging and extended field-of-view techniques allows a better understanding of the pathoanatomy. With the real-time integration of intra-operative ultrasound images and pre-operative CT or MR images additional information, like hemodynamic pattern, are available for the neurosurgeon. Although until now only a limited number of reports about new sonographic techniques during intra-operative application in neurosurgery exist, the methods seem to be promising in creating images easier to understand, incorporating more information about pathoanatomy and supplying the neurosurgeon with information additional to that provided by CT and MRI.

Intra-operative electromyographic monitoring of the lower cranial motor nerves (LCN IX-XII) in skull base surgery

The functional preservation of lower (motor) cranial nerves (LCN) is endangered during skull base surgery. Intra-operative EMG monitoring of the LCN IX-XII was investigated in 78 patients undergoing 80 operations on various skull base tumors with regard to technical feasibility and clinical efficacy. Ongoing 'spontaneous muscle activity' (SMA) and 'compound muscle action potentials' (CMAP) following supramaximal bipolar stimulation were intra-operatively recorded applying needle electrodes into the soft palate (CN IX: n=76), the vocal cord (CN X: n=72), the trapezius muscle (CN XI: n=18), and the tongue (CN XII: n=71). From 24/22/8 cases with LCN IX/X/XII deficits (despite monitoring) only 5/6/4 remained unchanged (3-6 months postoperative). An irreversible plegia of the LCN IX/X/XII occurred in three (1/1/1) patients. In 7/6/1 patients postoperative (3-6 months) LCN IX/X/XII function was better than preoperatively. In all patients accessory nerve function remained unchanged. 'Pathological' SMA of the LCN IX/X/XII occurred in 12/16/8 cases, but in only 6/5/3 cases corresponded to postoperative LCN deficits. Corresponding 'pathological' SMA patterns were found in 18/17/5 out of 24/22/8 cases with postoperative LCN IX/X/XII dysfunction. Reproducible CMAP of LCN IX/X/XI/XII could be recorded in 59/56/11/32 patients. Approximate 'normal' values were calculated and compared to (very few) data so far given in the literature. Electromyographic monitoring proved to be a safe tool for the intra-operative identification and localization of the LCN contributing to their anatomical and functional preservation. The predictive value of standard neurophysiological parameters for functional outcome, however, is limited.

Medulloblastoma displays distinct regional matrix metalloprotease expression

Matrix metalloproteases (MMPs) play an important role in tissue remodeling and neoangiogenesis during tumor progression. Little is known about the presence and regional distribution of MMPs in medulloblastomas. Based on immunohistochemical, immunocytochemical and zymographical analysis is the present study illustrates the differential pattern of MMP expression for the medulloblastoma compared to that of glioma and ependymoma. In 10 examined medulloblastoma tumors gelatinase-A was strongly expressed by clusters of tumor cells. Gelatinase-B was, similar to glioma and ependymoma, predominantly found around endothelial cells. The DAB signal for macrophage metalloelastase was seen around macrophages and matrilysin was expressed by single tumor cells. Stromelysin-1 protein was detected in medulloblastoma but not in glioma or ependymoma. From the presented data it follows that each tumor entity might display its own characteristic MMP expression pattern.

Extraneural metastases of primary brain tumors

Extraneural metastasis (ENM) of primary brain tumors is arare occurence. Based on acritical analysis of the literature the present review focuses on illustrating special common features of these tumors with regard to immunological, cytokinetical and tumorbiological issues. In this respect much can be learned from the specific conditions following organ transplantation which is extensively discussed.

Advanced neuromonitoring including cerebral tissue oxygenation and outcome after traumatic brain injury

For 51 patients suffering from traumatic brain injury (GCS < 9), we compared the prognostic value of critical parameters derived from neuromonitoring of intracranial pressure (ICP), cerebral perfusion pressure (CPP) and brain tissue oxygenation (PiO2) during different time periods after trauma (< or = 12, < or = 24, < or = 48, < or = 72 and < or = 96 h). For patients with good outcome (GOS = 4-5, n = 30) the proportion of critical ICP values (> 40 mmHg) was about 0.2% during all time periods. The corresponding proportions for patients with bad outcome (GOS = 1-3, n = 21) rose from 0.2% to 4.7% during increasing time periods. The frequency of critical ICP values was significantly related to outcome (p < 0.001) for time periods > 48 h after trauma. Differences of critical CPP (< or = 50 mmHg) and hypoxic PiO2 (< or = 5 mmHg) between both outcome groups were less pronounced and for both parameters significant relations to outcome were only obtained for the longest time period (< or = 96 h, p < or = 0.05). Higher thresholds for CPP (< or = 60 mmHg, < or = 70 mmHg) did not reveal any relation to outcome. For all neuromonitoring parameters significant relations between the frequency of critical values and outcome could be determined. Critical ICP values provide the earliest and highest prognostic power, while critical CPP and hypoxic PiO2 only showed prognostic power in later time periods.

Is there a benefit of preoperative meningioma embolization?

OBJECTIVE

To evaluate the effect of preoperative embolization of meningiomas on surgery and outcomes.

METHODS

In a prospective study, 60 consecutive patients with intracranial meningiomas who were treated in two neurosurgical centers were included. In Center A, embolization was performed for none of the patients (n = 30). In Center B, 30 consecutive patients with embolized meningiomas were treated. Preoperatively, tumor size and location, neurological status, and Barthel scale score were recorded. In Center B, the extent of tumor devascularization was evaluated using angiography and postembolization magnetic resonance imaging. Intraoperatively, blood loss, the numbers of blood units transfused, and the observations of the neurosurgeon concerning hemostasis, tumor consistency, and intratumoral necrosis were recorded. Postoperatively, the neurological status and duration of hospitalization were recorded. Six months after surgery, the outcomes were assessed using the Barthel scale and neurological examinations.

RESULTS

The mean tumor sizes were 22.9 cc in Center A and 29.6 cc in Center B (P > 0.1). The mean blood losses did not differ significantly (646 ml in Center A versus 636 ml in Center B; P > 0.5). However, for a subgroup of patients with subtotal devascularization (>90% of the tumor) on postembolization magnetic resonance imaging scans in Center B, blood loss was less, compared with the entire group in Center A (P < 0.05). The observations of the neurosurgeon regarding hemostasis, tumor consistency, and intratumoral necrosis did not differ significantly. There were no surgery-related deaths in either center. The rates of surgical morbidity, with permanent neurological worsening, were 20% (n = 6) in Center A and 16% (n = 5) in Center B. There was one permanent neurological deficit (3%) caused by embolization.

CONCLUSION

In this preliminary study, only complete embolization had an effect on blood loss. The value of preoperative embolization for all meningiomas must be reconsidered, especially in view of the high costs and risks of embolization.

Near-infrared spectroscopy--not useful to monitor cerebral oxygenation after severe brain injury

Since its development more than twenty years ago, non-invasive near-infrared-spectroscopy (NIRS) has been widely used to monitor cerebral oxygenation. Despite of its growing number of users, the diagnostic value of near-infrared spectroscopy still remains unclear, especially in case of acute brain injury and long-term neuromonitoring, necessary during intensive care therapy. To evaluate quality and sensitivity of NIRS measurements compared to invasive ICP-, CPP- and regional brain tissue--pO2 (p(ti)O2) monitoring, 31 patients, suffering from severe brain injury due to subarachnoid hemorrhage or severe head injury, were studied. NIRS measurements were only possible in 80% (using the INVOS oximeter) and in 46% (using the CRITIKON monitor), while good data quality was obtained in 100% from ICP, CPP and p(ti)O2. Major reasons for the failure of NIRS measurements were: (1) a wet chamber between sensor and skin, (2) galea hematoma or (3) subdural air after craniotomy. Different tests were performed to compare the sensitivity of regular oxygen saturation (NIRS) with the sensitivity of invasively determined p(ti)O2. Only induced hyperoxia (FiO2 = 1.0) revealed a significant correlation between both parameters (r = 0.67, p < 0.01). Lower or no correlation was found after changing paCO2 and administration of mannitol. The high failure rate and the limited sensitivity does not make the clinical use of near-infrared spectroscopy suitable as a part of neuromonitoring after acute brain injury at the present time.

Vascular endothelial growth factor-driven glioma growth and vascularization in an orthotopic rat model monitored by magnetic resonance imaging

OBJECTIVE

The goal of the present study was to develop an orthotopic in vivo model for the investigation of vascular endothelial growth factor (VEGF)-dependent glioma growth and vascularization.

METHODS

C6 glioma cells were infected with viruses encoding sense or antisense VEGF. Expression of the transgene was controlled by Northern blot analysis, Western blot analysis, and immunohistochemistry. Spheroids generated from both clones as well as from wild-type and mock-transfected cells were implanted in the brains of Sprague-Dawley rats. Growth and vascularization were assessed using magnetic resonance imaging after 7 and 11 days. Histology was studied using hematoxylin and eosin staining, immunohistochemistry with anti-von Willebrand staining, anti-VEGF, anti-CD8, and assessment of vessel density.

RESULTS

Cell proliferation, migration, and invasion in vitro were very similar in all cell clones. Sense gliomas demonstrated by far the fastest growth in vivo, with intense contrast enhancement meeting criteria for highly malignant tumors. Histological examination revealed masses of von Willebrand- and VEGF-positive tumor vessels with a high vessel density. Antisense gliomas depicted the radiological features of low-grade gliomas, with slow growth and poor vascularization, although they were highly infiltrative. Wild-type and mock-transfected gliomas demonstrated similar growth and vascularization patterns intermediate between sense and antisense gliomas. Any influence of the allogeneic response of the hosts on different tumor sizes could be excluded.

CONCLUSION

Our model elucidates glioma growth and vascularization as strongly VEGF dependent, which is consistent with human gliomas. Thus, this model is suitable for testing antiangiogenic strategies to interfere with the VEGF/VEGF receptor system, as well as for exploring VEGF-independent mechanisms using the antisense-transfected clone.

Models for assessment of angiogenesis in gliomas

In the last two decades, much attention has been focussed on mechanisms of glioma vascularization including the investigation of growth factors and receptors involved. Recently, these efforts resulted in various approaches for antiangiogenic treatment of experimental brain tumors. These basic science and preclinical trials need an assortment of models, which should allow investigating a variety of questions. Several objectives concerning basic endothelial cell (EC) characteristics can adequately be studied in vitro using EC monolayer assays. Three-dimensional spheroid techniques respect the more complex cell-cell and cell-environment interplay within a three-dimensional culture. To optimize the imitation of the crucial interaction of human gliomas with host endothelial cells, immunological cells and extracellular matrix, animal models are mandatory. An essential rule is to utilize an orthotopic model, since tumor-host interaction is organ specific. To avoid alloimmunogenic responses, it is desirable to use weakly or not immunogenic glioma grafts, what is best accomplished in a syngeneic model. However, since rat gliomas poorly resemble human glioma growth patterns, human glioma xenografting into immunocompromized animals should be considered. In vivo monitoring techniques like videoscopy via a cranial window or magnetic resonance imaging (MRI) allow for functional studies and improve the validity of the model employed. Finally, it is essentially to recognize the limitations of each model considered and to select that model, which seems to be most appropriate for the objectives to be investigated.

Acoustic neuroma surgery as an interdisciplinary approach: a neurosurgical series of 508 patients

OBJECTIVES

To evaluate an interdisciplinary concept (neurosurgery/ear, nose, and throat (ENT)) of treating acoustic neuromas with extrameatal extension via the retromastoidal approach. To analyse whether monitoring both facial nerve EMG and BAEP improved the functional outcome in acoustic neuroma surgery.

METHODS

In a series of 508 patients consecutively operated on over a period of 7 years, functional outcome of the facial nerve was evaluated according to the House/Brackmann scale and hearing preservation was classified using the Gardner/Robertson system.

RESULTS

Facial monitoring (396 of 508 operations) and continuous BAEP recording (229 of 399 cases with preserved hearing preoperatively) were performed routinely. With intraoperative monitoring, the rate of excellent/good facial nerve function (House/Brackmann I-II) was 88.7%. Good functional hearing (Gardner/Robertson 1-3) was preserved in 39.8%.

CONCLUSION

Acoustic neuroma surgery via a retrosigmoidal approach is a safe and effective treatment for tumours with extrameatal extension. Functional results can be substantially improved by intraoperative monitoring. The interdisciplinary concept of surgery performed by ENT and neurosurgeons was particularly convincing as each pathoanatomical phase of the operation is performed by a surgeon best acquainted with the regional specialties.

Prognostic significance of advanced neuromonitoring after traumatic brain injury using neural networks

While the therapeutic impact of tissue oxygenation (PtiO2) supplementing ICP-monitoring is proven by several clinical studies, its prognostic value is not well studied. In the following study artificial neural networks (ANN) were used to analyze the accuracy of outcome prediction after traumatic brain injury (TBI) for different combinations of clinical data and parameters derived from neuromonitoring. The total group included 95 patients suffering from TBI. For all patients clinical data (age, GCS, pupillary response etc.) were recorded and outcome was classified using Glasgow outcome scale after 6 months. In a first step a subgroup of 60 patients was chosen to train a neural network to predict outcome based only on clinical data. In a second step the resting 35 patients all having continuous neuromonitoring with automatic data storage of ICP and PtiO2 were chosen. Different network models were composed using the former clinical model plus up to three additional input units for the following parameters: (a) relative number of ICP > 40 mmHg, (b) relative number of PtiO2 < 5 mmHg and (c) relative number of ICP > 30 mmHg with simultaneous PtiO2 < 10 mmHg. For each model the following time periods were analyzed: day 1-2, day 1-3 and day 1-4 after trauma and additionally day 1-4 after trauma plus last day of neuromonitoring. Pure clinical data allowed to predict outcome with 74.3% accuracy. A combination of clinical data with ICP (a) significantly increased the confidence levels of outcome prediction in all time periods (p < 0.05) with accuracy rates rising up to 82.9% for the longer time periods. The combination of clinical data and ICP & PtiO2 (c) lead to comparable results. In contrast, no significant increases were observed in the early time periods when combining clinical data with PtiO2 (b) while accuracy rates rose up to 80% for extended time periods after trauma. A combination of all parameters lead to results lying between the above results. The results indicate that prediction of outcome can be improved by combining clinical and neuromonitoring data. The prognostic value of ICP might be superior to that of PtiO2.

[Value of transcranial doppler ultrasonography compared with scintigraphic techniques and EEG in brain death]

Since 1991 transcranial doppler sonography has been accepted in Germany as a technical confirmatory test for the assessment of a cerebral circulatory arrest in patients fulfilling the clinical criteria of brain death. This study correlated transcranial doppler findings to established scintigraphic methods such as planar scintigraphy, 99mTc-HMPAO SPECT and EEG patterns. 21 patients (15 males/6 females, mean age 15-69 yrs.) fulfilled all clinical criteria of brain death. They suffered from head injuries and spontaneous bleedings. All clinical and technical investigations were performed within 60-90 minutes. In 14/21 patients clinical findings and all confirmatory tests were consistent with brain death. Planar scintigraphy and SPECT gave completely corresponding results in all 21 patients. 7 patients showed not corresponding results. In two head-injured patients with skull defects TCD yielded an oscillating flow in the MCA but SPECT/planar scintigraphy gave a residual perfusion in the related brain areas. A corresponding residual EEG pattern was seen in one case. A patient with osteoclastic skull defect showed a collateral flow from the external carotid artery and another case a secondary reperfusion in depth of a regular expected MCA signal 12 hours after definitely verification of systolic spikes in the Circle of Willis. No cerebral perfusion was detectable in the scintigraphique techniques. In the three remainder with rest activity in EEG, TCD and radionuclide methods showed no intracranial perfusion. In the presence of open skull fractures, external liquor drainages and osteoclastic craniotomies oscillating flow in TCD does not constantly represent a cerebral circulatory arrest. Awaiting of systolic spikes is absolutely necessary, if no radionuclide method is available. Determination of brain death by TCD should be carried out by an experienced investigator since unexpected collateral flow signals can be misinterpreted.

Inhibition of Ras farnesylation by lovastatin leads to downregulation of proliferation and migration in primary cultured human glioblastoma cells

BACKGROUND

Malignant astrocytomas are the most common primary intracranial human tumors. All therapeutic approaches are limited due to their high proliferative capacity and their ability to diffusely invade the brain. Amplification of tyrosine kinase receptors and their signaling pathways have been implicated as contributing to the molecular pathogenesis of astrocytomas, providing possible new targets for therapeutic intervention. In particular, astrocytomas, although lacking oncogenic Ras mutations, have elevated levels of activated Ras. Lovastatin, an inhibitor of the beta-hydroxy-beta-methylglutary CoA reductase (HMG-CoA-reductase), is currently used to treat patients with hypercholesterolemia. In addition, it inhibits isoprenylation of several members of the Ras superfamily of proteins and therefore has multiple cellular effects including the reduction of proliferation.

MATERIALS AND METHODS

In this study, we investigated the impact of lovastatin on two human glioma cell lines and on 15 primary cell cultures established from biopsies of patients with glioblastoma multiforme (GBM,) Proliferation of glioma cell lines and primary tumor cells was determined by cell counting and by using the MTT assay. The cell morphology was analyzed by staining of actin filaments with phalloidin. Apoptosis was measured using the TUNEL assay. To investigate the influence of this drug on glioma cell motility, tumor cell migration was investigated using three dimensional spheroid disintegration assays. In addition, tumor cell invasion was analyzed with a confrontational assay between tumor spheroids and rat brain aggregates.

RESULTS

Inhibition of farnesyl biosynthesis using lovastatin led to a block in Ras mediated signaling, indicated by lower MAPK activity. Consequently, tumor cell proliferation was reduced up to 80%. Lovastatin appeared to decrease glioma viability by inducing apoptosis, as indicated by morphological changes and increase of TUNEL positive cells. Lovastatin acts through isoprenoid depletion, because supplementation of the media with 50-100 microM mevalonate restored all tau eta epsilon effects. Invasion of tumor cells into brain tissue was not effected while migration was reduced beta upsilon about 30-40% in cells treated with high concentrations (> or = 100 microM) of lovastatin. This was surprising because drug treatment at lower concentrations led to a disruption of the actin cytoskeleton, as indicated by Phalloidin staining.

CONCLUSION

Our data strongly suggest that inhibition of elevated Ras activity by lovastatin effectively targets the MAPK and probably other signaling pathways thus offering a pharmacological based approach for a potential treatment of human astrocytomas.

Quantitative parameters of intraoperative electromyography predict facial nerve outcomes for vestibular schwannoma surgery

OBJECTIVE

Facial nerve monitoring is an established method that is routinely used during cerebellopontine angle tumor surgery. The aim of this study was to determine quantitative electromyographic (EMG) parameters that were predictive of facial nerve outcomes.

METHODS

In 137 patients with intra-/extrameatal vestibular schwannomas, the most proximal (the exit from the brainstem) and distal (the fundus of the internal auditory canal) parts of the facial nerve were stimulated after total tumor removal. A quantitative analysis of absolute values and ratios (proximal/distal) of evoked EMG parameters (amplitude, latency, and duration) was performed, and parameters were correlated with postoperative (1 and 6 wk and 6 mo) facial nerve function (FNF).

RESULTS

Absolute values of EMG amplitudes were statistically correlated with FNF (P < 0.05). Amplitude ratios (proximal/distal) demonstrated an even greater predictive power. The risk of exhibiting facial palsy 6 months after surgery increased from 1.6% (amplitude ratio of >0.8) to 75% (ratio of <0.1). For EMG latencies, only the ratios revealed a significant correlation with FNF. The latency ratio-dependent risk of facial palsy after 6 months increased from 2.9% (ratio of <1.05) to 33% (ratio of >1.35). The durations of the muscle responses were not significantly correlated with clinical outcomes.

CONCLUSION

The predictive power of the amplitudes and latencies of electrically evoked muscle responses could be improved by calculating proximal/distal ratios. The proximal/distal amplitude ratio proved to be the most powerful parameter for intraoperative assessment of postoperative FNF.

Symptomatic intraspinal air entrapment

A 59-year-old man who had undergone the removal of a lipoma of the thoracic spine presented with progressive weakness of the lower limbs when lumbar puncture followed drainage of a subcutaneous collection of cerebrospinal fluid. Computed tomography showed entrapped intraspinal air which compressed the spinal cord. This rare, but serious complication can occur in a patient with altered intrathecal pressure following spinal surgery.

Retinoids inhibit human glioma cell proliferation and migration in primary cell cultures but not in established cell lines

OBJECTIVE

Retinoids are known to exhibit a broad spectrum of biological activities, and they participate in the onset of differentiation and the inhibition of growth in a wide variety of cancer cells. Some of these vitamin A derivatives are already in clinical use. However, data on retinoid actions in glial tumors are rather sparse. Therefore, we studied the effects of the natural retinoic acid (RA) forms all-trans-RA, 9-cis-RA, and 13-cis-RA on glioma cell lines and primary cultures from patients with glioblastomas multiforme.

METHODS

Six human glioma cell lines, one rat glioma cell line, and 20 primary cultures established from biopsies from patients with glioblastomas multiforme were investigated. Tumor cell proliferation was assessed using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide and cell-counting assays. Random migration out of tumor spheroids was quantified using a video-morphometry system. Invasion was investigated using a confrontational coculture test system. Retinoid receptor (RA receptor [RAR]alpha, -beta, and -gamma and retinoid X receptor [RXR]alpha, -beta, and -gamma) expression status was determined using reverse transcription-polymerase chain reaction studies.

RESULTS

Treatment of five human glioma cell lines with the different retinoids at concentrations up to 10(-5) mol/L produced no reduction of proliferation, using various incubation times. For one human glioma cell line (U343MG-A) and one rat glioma cell line (C6), which were previously reported to be sensitive to retinoids, we could confirm strong inhibitory effects on proliferation and clear changes in morphological features after retinoid treatment. Application of the different retinoids to low-passage primary cultures of human glioblastomas resulted in marked inhibition of proliferation (30-95%) for all tested samples. Using three-dimensional spheroid cultures, we detected retinoid-induced decreases in cell migration (24-65%). Invasion was not affected by these vitamin A derivatives. In an analysis of the expression patterns for retinoid receptors (RARs and RXRs), all primary culture samples yielded positive results for RAR gamma and RXR alpha and negative results for RAR alpha, RAR beta, and RXR gamma, whereas the results of RXR beta expression were heterogeneous among different patients. The cell lines, irrespective of their RA sensitivities, did not exhibit any major differences in receptor expression.

CONCLUSION

Retinoids strongly inhibit proliferation and migration in primary cultures of human glioblastomas multiforme. Our data support a clinical trial of retinoids for the treatment of human malignant gliomas. We observed that most established cell lines were not sensitive to RA. This difference between long-term cell lines and primary cultures cannot be explained by different retinoid receptor expression patterns.

Interrelations of laser doppler flowmetry and brain tissue oxygen pressure during ischemia and reperfusion induced by an experimental mass lesion

The objective of this study was to assess interrelations between bilateral changes of cortical laser doppler flowmetry and intraparenchymal, subcortical partial tissue oxygen tension in the course of an experimental trauma. Ten animals served as a sham group, 8 Sprague-Dawley rats received an unilateral, focal parietal mass lesion. The bilateral course of cortical blood flow measured by laser doppler flowmetry (LDF) was correlated with subcortical, intraparenchymal partial tissue oxygen tension [p(ti)O2]. In the sham-operated group, laser doppler mean flow values drifted between 9.0% and 9.5% and showed no significant changes over time neither between the hemispheres nor within each hemisphere. Absolute mean p(ti)O2 in sham-operated animals was 32.4 mm Hg in the left and 30.5 mm Hg in the right hemisphere. In the trauma group, mean laser doppler flow values during maximum brain compression decreased ipsilateral to 20.3% and contralateral to 34.4% of the baseline values. P(ti)O2 decreased ipsilateral from 25.9 to 6.6 mm Hg (25.4%) and contralateral from 22.6 to 9.8 mm Hg (43.6%). After balloon deflation, cortical LDF was restored much faster compared to p(ti)O2, but did not reach baseline values [ipsilateral 61.6% (p < 0.05); contralateral 75.8% of baseline values]. The p(ti)O2 values reached 25.2 mm Hg (97%) ipsilateral and 23.7 mm Hg (105%) contralateral. A temporary phase of reactive hyperemia occurred sporadically shortly after decompression. Both parameters showed a significant but rather weak correlation (r = 0.56; p < 0.001). Based upon these findings, we conclude that intraparenchymal, subcortical p(ti)O2 measurements supplemented on-line cortical CBF monitoring and score out discontinuous alternative measurement techniques in detecting hemodynamically relevant events. The small spatial resolution of LDF and p(ti)O2 probes, however, which in the small animal model may be of negligible influence, does raise the question whether the values obtained represent the microcirculatory situation of the human brain.

[Cerebral aneurysms in the posterior circulation. Treatment results in 44 consecutive cases]

PURPOSE

Evaluation of clinical and morphological results in 44 consecutive patients with 45 aneurysms of the posterior circulation.

METHODS

Retrospective analysis of patient charts and angiograms of all vertebrobasilar aneurysms diagnosed in our department between 10/95 and 08/99. All aneurysms were treated.

RESULTS

36/44 pts had a hemorrhage. Hunt/Hess (HH) gradings were as follows: HH1 in 10, HH2 in 6, HH3 in 9, HH4 in 10 cases, and HH5 in 1 case. 38 pts with 39 aneurysms were treated exclusively in the endovascular way, 3 pts with 3 aneurysms were operated on. 3 patients had to be operated upon following insufficient endovascular treatment. Endovascular treatment resulted in 63% total and 27% subtotal occlusions, results being stable in 85%. For our pts as a whole, the grading according to the Glasgow Outcome Scale (GOS) was GOS1 in 4, GOS3 in 8, GOS4 in 7, and GOS5 in 25 cases.

CONCLUSION

Despite a less favourable clinical status of pts pre-treatment, the results of our interdisciplinary concept compare favourably with those of other surgical or interventional groups.

"De novo" formation of intracranial aneurysms: who is at risk?

Although aneurysms are widely considered to be of congenital origin there is still debate as to whether some at least might be formed de novo during life. A review of all 49 reported cases plus one previously unpublished case reveals common clinical features and might aid in the management of this group of patients. Statistical analysis of all 50 cases of de novo aneurysms discloses a more frequent history of smoking (P = 0.0007) and arterial hypertension (P = 0.0026) than in a control cohort. Patients with de novo aneurysms are younger (P < 0.0001); the proportion with multiple aneurysms was 28 %. Of de novo aneurysms 44 % became symptomatic 3-6 years after the first subarachnoid haemorrhage (SAH), and the interval was significantly shorter in hypertensive patients. We suggest that young patients with a history of SAH and arterial hypertension and nicotine abuse should therefore be considered for conventional angiography after a 5-year interval. MRA might not be useful due to clip artefacts from even nonferromagnetic clips. Close control of blood pressure is essential in these patients.

Expression of different extracellular matrix components in human brain tumor and melanoma cells in respect to variant culture conditions

Local tumor invasion into the surrounding brain tissue is a major characteristic of malignant gliomas. These processes critically depend on the interaction of tumor cells with various extracellular matrix (ECM) components. Because only little quantitative information about expression of ECM gene products in general and expression in response to alterations of the surrounding environment is available, the present study was designed. Four human glioblastoma cell lines (U373MG, U138MG, U251MG, GaMG) as well as four human melanoma cell lines (MV3, BLM, 530, IF6) were tested with semiquantitative RT-PCR for their ability to express mRNA of different human ECM components (fibronectin, decorin, tenascin, collagen I, collagen IV, versican). In addition, two human medulloblastoma (MHH-Med 1, MHH-Med 4) and two fibrosarcoma (HT1080, U2OS) cell lines were analyzed. Cells which were grown in DMEM medium containing 10% FCS expressed most of the analyzed protein components. When the same medium, but depleted of ECM proteins by filtrating through a membrane with cut-off at > 100 kD was used, basal mRNA expression of the ECM proteins was changed in most of the examined cell lines. Using serum free conditions, most of the cell lines again showed a variation in the expression pattern of mRNA encoding for the different ECM proteins compared to the other medium conditions. Comparing different cell lines from one tumor entity or different tumor groups, ECM expression was heterogeneous with regard to the different tumor entities as well as within the entities themselves. Migration assays revealed heterogeneous responses between the different cell lines, ECM components and culture conditions, making it difficult to correlate ECM expression patterns and migratory behavior. Our results revealed that all examined cell lines are able to produce ECM proteins in vitro. This suggests that tumor cells can modulate their microenvironment in vitro which has to be taken into consideration for studies related to migration and invasion.

Heterogeneous regional expression patterns of matrix metalloproteinases in human malignant gliomas

The aim of the study was to assess the differential intra- and intertumoral heterogeneity and patterns of matrix metalloproteinase expression in human glioblastomas in vivo. 12 glioblastoma samples were analyzed for MMP expression by semi-quantitative RT-PCR. A total of 56 samples (8 adjoining regions of 6 glioblastoma tumors) were immunohistochemically examined for the expression and regional distribution of gelatinase-A (MMP-2), gelatinase-B (MMP-9), matrilysin (MMP-7) and stromelysin-1 (MMP-3). Gelatinase-A mRNA was detected in all samples, gelatinase-B was found in numerous samples. Correspondingly, strong expression levels of both gelatinase protein was seen in immunohistochemistry. Gelatinase-A was expressed by both tumor cells and endothelium while gelatinase-B was found to be restricted to endothelial cells. Stromelysin-1 protein was not detected in any of the samples. Matrilysin was found around tumor cells of three samples from one patient only. The strong immunoreactivity seen for gelatinase-A around tumor cells and blood vessels suggests a role in both tissue degradation and tumor neoangiogenesis which is in accordance with previously published in vitro data. The marked localization of gelatinase-B to the endothelium and its presence in non-infiltrative benign lesions, however, makes a direct proteolytic role of gelatinase-B on ECM components during glioma invasion appear unlikely. Its close association with vascular structures, however, might indicate a link to neoangiogenesis. The significance of matrilysin which was only seen in tumor cells in three samples remains unclear. Stromelysin-1, though strongly expressed in cell lines, does not appear to play a role in glioblastoma tumors in vivo.

Microglial/macrophage expression of interleukin 10 in human glioblastomas

Interleukin 10 (IL-10) expression has been found to be correlated with the extent of malignancy in gliomas. In vitro, IL-10 increases proliferation and migratory capacity in human glioma cell lines. In this study, we localized the site of IL-10 synthesis in gliomas to cells of microglial origin. Biopsy specimens from 11 patients with malignant glioma were processed on native tissues and at early cell culture passages (0-4). IL-10 mRNA was analyzed by RT-PCR and in situ hybridization. Protein was quantitatively assessed by ELISA in cell culture supernatants, and cells expressing IL-10 were determined by a combination of immunohistochemistry for CD68 (specific for microglia/macrophage lineage) and IL-10 in situ hybridization. IL-10 mRNA decreased from passage 0 to 4 in all samples and was undetectable beyond passage 5. Such downregulation of mRNA leads to a steep decrease of IL-10 protein in culture supernatants (below detection level, 0.05 ng/ml, beyond passage 1). The combination of in situ hybridization for IL-10 and CD68 immunostaining revealed that only cells of the microglia/macrophage lineage produced IL-10 mRNA. Our results identify microglia/macrophage cells as the major source of IL-10 expression in gliomas which decreases markedly during early passages of primary cultures of human gliomas due to a progressive reduction of microglia/macrophages present.

Localization and characterization of intracerebral cavernous angiomas by intra-operative high-resolution colour-duplex-sonography

The aim of this prospective study was to evaluate the reliability of high-resolution Colour-Duplex-Sonography (= CDS) in intra-operative localization, guiding and characterization of intracerebral cavernous angiomas (= CA). During a time period from 5/93 to 12/96 a total of 26 patients with 21 supratentorial and 5 infratentorial CA (15 of them deep-seated) were examined intra-operatively by CDS. The study focussed on 1. sonographic characterization, 2. localization in relationship to anatomical landmarks, 3. navigation, 4. correlation of sonographic to magnetic resonance imaging (= MRI), intra-arterial angiography (= DSA) and histological results and 5. control of complete resection. All CA appeared sonographically as hyperechoic lesions without flow-signals in Colour-mode. Imaging of anatomical landmarks as cerebral sulci, brain stem, insular cistern, falx, ventricles and vessels could be used for precise localization and successful guiding to 15 deep-seated lesions. The correlation of the size between MRI and CDS was excellent (1.4 mm mean difference, range from 0 to 5 mm). All 4 associated venous anomalies, as verified by pre-operative DSA, could be visualized and identified by CDS. The completeness of exstirpation was controlled sonographically in 14 cases and confirmed by MRI (= 10) and CT (= 4). This study provides the first comprehensive intra-operative characterization of CAs by CDS and correlation to MRI and DSA. Furthermore it demonstrates the reliability of CDS for intra-operative localization and guiding as well as its potential to control the complete exstirpation.

Expression of matrix metalloproteinases in human glioma cell lines in the presence of IL-10

Matrix metalloproteinases have been implicated to play a vital role in glioma invasion as they degrade extracellular matrix to facilitate the subsequent migration of tumor cells into the surrounding brain tissue. The cytokine Interleukin-10 (IL-10) was detected recently in glial tumors in vivo. Expression of specific IL-10 mRNA as well as blood serum levels of IL-10 in glioma patients increased with malignancy suggesting a functional role of IL-10 in glioma progression. Moreover, glioma cell migration in vitro was enhanced in the presence of IL-10. We therefore investigated the expression of the matrix metalloproteinases (MMPs) stromelysin-1 (MMP-3), 72-kDa collagenase (MMP-2), 92-kDa collagenase (MMP-9), matrilysin (MMP-7) and the human macrophage metalloelastase (MMP-12). In addition, a possible relation between exposure of glioma cells to IL-10 and invasiveness of these cells due to MMP expression was analyzed. Experiments with Matrigel coated Boyden chambers revealed a pronounced dose dependent effect of IL-10 on glioma invasiveness. The synthetic MMP-inhibitor Marimastat markedly reduced cell invasion in the Boyden chambers confirming the significance of MMPs in the process of invasion. Subsequently, the expression level of MMPs and the serine protease uPA was investigated in 7 glioma cell lines (U373, GaMG, U251, GHE, SNB19, U138 and D54) by RT-PCR. In all but one cell line no enhancement of MMP expression by IL-10 was detected. Matrilysin in U373 cells was the only protease found to be upregulated in the presence of IL-10 dependent on cell density. The present data suggest that IL-10 related effects on the invasive properties of the cell lines are not directly mediated by an upregulation of matrix metalloproteinase expression.

Effect of synthetic matrix-metalloproteinase inhibitors on invasive capacity and proliferation of human malignant gliomas in vitro

Glioma invasion into the surrounding brain tissue is still a major obstacle for any therapeutical approach. As in other solid tumors, matrix-metalloproteases (MMPs) have been suggested as being involved. The aim of this study was to evaluate whether the use of MMP inhibitors to target the protease-mediated invasion process could be a feasible approach. Two human cell lines (U251 and GaMG) and surgical specimens of 6 patients with malignant gliomas were grown as monolayers and spheroid cultures respectively. MMP- and u-PA-mRNA expression was investigated by semi-quantitative RT-PCR. Invasion was studied in Matrigel-coated Boyden chamber transwell assays for monolayers and in confrontation cultures of tumor spheroids with fetal rat brain aggregates in the presence of the synthetic MMP inhibitors batimastat (BB-94) and marimastat (BB-2516). Cytotoxicity/cytostatic effects of high concentrations of both compounds were assessed by growth curves, MTT assays and flow cytometry in human glioma cell lines. Batimastat and marimastat revealed a cytostatic effect at high concentrations (above 1 microM) without cytotoxicity. Both MMP inhibitors effectively reduced glioma invasion in Boyden-chamber assays at low concentrations of 0.3 microM. In confrontation cultures, concentrations of 10 microM and above were necessary to reduce invasion. This effect was observable with inter-individual heterogeneity in the patient's tumor material. MMP inhibitors effectively reduce glioma invasion, although high concentrations were required in 3-dimensional culture systems. At these concentrations, both compounds revealed a cytostatic, but no cytotoxic effect. Thus, high local concentrations of MMP inhibitors could offer a new therapeutic strategy for the treatment of gliomas.

Effect of synthetic matrix-metalloproteinase inhibitors on invasive capacity and proliferation of human malignant gliomas in vitro

Glioma invasion into the surrounding brain tissue is still a major obstacle for any therapeutical approach. As in other solid tumors, matrix-metalloproteases (MMPs) have been suggested as being involved. The aim of this study was to evaluate whether the use of MMP inhibitors to target the protease-mediated invasion process could be a feasible approach. Two human cell lines (U251 and GaMG) and surgical specimens of 6 patients with malignant gliomas were grown as monolayers and spheroid cultures respectively. MMP- and u-PA-mRNA expression was investigated by semi-quantitative RT-PCR. Invasion was studied in Matrigel-coated Boyden chamber transwell assays for monolayers and in confrontation cultures of tumor spheroids with fetal rat brain aggregates in the presence of the synthetic MMP inhibitors batimastat (BB-94) and marimastat (BB-2516). Cytotoxicity/cytostatic effects of high concentrations of both compounds were assessed by growth curves, MTT assays and flow cytometry in human glioma cell lines. Batimastat and marimastat revealed a cytostatic effect at high concentrations (above 1 microM) without cytotoxicity. Both MMP inhibitors effectively reduced glioma invasion in Boyden-chamber assays at low concentrations of 0.3 microM. In confrontation cultures, concentrations of 10 microM and above were necessary to reduce invasion. This effect was observable with inter-individual heterogeneity in the patient's tumor material. MMP inhibitors effectively reduce glioma invasion, although high concentrations were required in 3-dimensional culture systems. At these concentrations, both compounds revealed a cytostatic, but no cytotoxic effect. Thus, high local concentrations of MMP inhibitors could offer a new therapeutic strategy for the treatment of gliomas.

Vascularization of human glioma spheroids implanted into rat cortex is conferred by two distinct mechanisms

Aim of this study was to develop and characterize an applicable in vivo model to investigate angiogenesis of human gliomas. An established glioblastoma spheroid model was used to investigate the neovascularization of a standardized avascular solid tumor mass. Spheroids of two human glioma cell lines were labeled with an in vivo fluorescent dye. Single spheroids were implanted into the cortex of athymic rats. After 1, 3, 7, 14, and 21 days, brain sections containing the spheroid were immunostained for endothelial cells or vascular endothelial growth factor (VEGF). The dye-stained glioma spheroid and the endothelial cells were visualized by confocal microscopy. Two distinct mechanisms of tumor vascularization could be observed. (1) "Classical" angiogenesis with new vessels sprouting from existing host vessels into the spheroid was seen. (2) Individual endothelial cells were found to migrate towards and into the center of the spheroid where they coalesced to form new vessels. This process occurred as early as 24 hr after spheroid implantation. Spheroid vascularization was accompanied by an increase of VEGF expression, which peaked 7 days after implantation and returned to normal patterns by 14-21 days. Besides the "classical" angiogenesis by angiogenic blood vessels, the recruitment of individual endothelial cells seems to be an additional mechanism in early glioma vascularization. Our model proves to be a reliable, reproducible system to study in vivo angiogenesis of human gliomas.

Technical developments in intra-operative monitoring for the preservation of cranial motor nerves and hearing in skull base surgery

Although EMG recordings from mimic muscles have become the standard for intra-operative facial nerve monitoring, few data are available concerning other motor cranial nerves (MCN). Auditory brainstem responses (ABR) are a proven tool for intra-operative hearing preservation, but have their limitations, suggesting the application of supplementary methods. This paper describes new developments of MCN and cochlear nerve monitoring in skull base surgery. Up to 2 x 8 EMG channels were recorded after bipolar stimulation of MCN using concentric coaxial probes. A special software enabled event-dependent registrations of all signals exceeding a definable threshold level. Selective recordings from masticatory muscles (N.V) were obtained using rectangular Teflon-insulated needle electrodes. For oculomotor (Nn.III/ VI) nerve recordings bipolar needle electrodes were precisely placed by orbital ultrasound guidance. Lower cranial nerves were monitored inserting needle electrodes into the soft palate (N.IX), tongue (N.XII) and vocal muscles (N.X) during laryngoscopy using a special applicator. For ABR recordings, click stimuli (95 dB HL) were applied monaurally through insert earphones. Electrocochleography was simultaneously recorded as a near-field potential without averaging after promontory (transtympanic) electrode placement using otomicroscopy. Regarding the ABR biosignal, a characteristic response pattern was detected following bipolar electrical stimulation of the auditory nerve possibly useful for its intra-operative identification.

Expression of matrix metalloproteinases in human glioma cell lines in the presence of IL-10

Matrix metalloproteinases have been implicated to play a vital role in glioma invasion as they degrade extracellular matrix to facilitate the subsequent migration of tumor cells into the surrounding brain tissue. The cytokine Interleukin-10 (IL-10) was detected recently in glial tumors in vivo. Expression of specific IL-10 mRNA as well as blood serum levels of IL-10 in glioma patients increased with malignancy suggesting a functional role of IL-10 in glioma progression. Moreover, glioma cell migration in vitro was enhanced in the presence of IL-10. We therefore investigated the expression of the matrix metalloproteinases (MMPs) stromelysin-1 (MMP-3), 72-kDa collagenase (MMP-2), 92-kDa collagenase (MMP-9), matrilysin (MMP-7) and the human macrophage metalloelastase (MMP-12). In addition, a possible relation between exposure of glioma cells to IL-10 and invasiveness of these cells due to MMP expression was analyzed. Experiments with Matrigel coated Boyden chambers revealed a pronounced dose dependent effect of IL-10 on glioma invasiveness. The synthetic MMP-inhibitor Marimastat markedly reduced cell invasion in the Boyden chambers confirming the significance of MMPs in the process of invasion. Subsequently, the expression level of MMPs and the serine protease uPA was investigated in 7 glioma cell lines (U373, GaMG, U251, GHE, SNB19, U138 and D54) by RT-PCR. In all but one cell line no enhancement of MMP expression by IL-10 was detected. Matrilysin in U373 cells was the only protease found to be upregulated in the presence of IL-10 dependent on cell density. The present data suggest that IL-10 related effects on the invasive properties of the cell lines are not directly mediated by an upregulation of matrix metalloproteinase expression.