The role of ICP overnight monitoring (ONM) in children with suspected craniostenosis

PURPOSE

Secondary craniostenosis is a relevant problem pediatric neurosurgeons are confronted with and poses challenges regarding reliable diagnosis of raised ICP, especially in case of absent or questionable papilledema. How to identify children with elevated ICP is still controversial and diagnostics vary. We report on our experience with computerized ICP ONM in relation to imaging derived parameters.

METHODS

Thirty-four children with primary or secondary craniostenosis and clinical suspicion of raised ICP were investigated. We compared clinical signs, history, and radiographic assessment with the results of computerized ICP ONM. Differences were significant at a p < 0.05.

RESULTS

Baseline ICP was significantly higher in patients with combined suture synostosis, who also had a higher rate of questionable papilledema. Children with narrowed external CSF spaces in MRI had significantly higher ICP levels during REM sleep. Mean RAP was significantly elevated in patients with multi-suture synostosis, indicating poor intracranial compensatory reserve. Syndromal craniostenosis was associated with elevated ICP, RAP was significantly lower, and skull X-rays showed more impressions (copper beaten skull). RAP increased with more severe impressions only to decline in most severe abnormalities, indicating exhaustion of cerebrovascular reserve at an upper ICP breakpoint of 23.9 mmHg. Headaches correlated to lower ICP and were not associated with more severe X-ray abnormalities.

CONCLUSION

Narrowed external CSF spaces in MRI seem to be associated to elevated ICP. Skull X-rays can help to identify patients at risk for chronically elevated ICP. Severe X-ray changes correlate with exhausted cerebrovascular reserve as indicated by RAP decline. Only ICP monitoring clearly identifies raised ICP and low brain compliance. Thus, in cases with ambiguous imaging, ONM constitutes an effective tool to acquire objective data for identification of surgical candidates.

Avoiding CT scans in children with single-suture craniosynostosis

INTRODUCTION

During the last decades, computed tomography (CT) has become the predominant imaging technique in the diagnosis of craniosynostosis. In most craniofacial centers, at least one three-dimensional (3D) computed tomographic scan is obtained in every case of suspected craniosynostosis. However, with regard to the risk of radiation exposure particularly in young infants, CT scanning and even plain radiography should be indicated extremely carefully.

MATERIAL AND METHODS

Our current diagnostic protocol in the management of single-suture craniosynostosis is mainly based on careful clinical examination with regard to severity and degree of the abnormality and on ophthalmoscopic surveillance. Imaging techniques consist of ultrasound examination in young infants while routine plain radiographs are usually postponed to the date of surgery or the end of the first year. CT and magnetic resonance imaging (MRI) are confined to special diagnostic problems rarely encountered in isolated craniosynostosis. The results of this approach were evaluated retrospectively in 137 infants who were referred to our outpatient clinic for evaluation and/or treatment of suspected single suture craniosynostosis or positional deformity during a 2-year period (2008-2009).

RESULTS

In 133 (97.1%) of the 137 infants, the diagnosis of single-suture craniosynostosis (n = 110) or positional plagiocephaly (n = 27) was achieved through clinical analysis only. Two further cases were classified by ultrasound, while the remaining two cases needed additional digital radiographs. In no case was CT scanning retrospectively considered necessary for establishing the diagnosis. Yet in 17.6% of cases, a cranial CT scan had already been performed elsewhere (n = 16) or had been definitely scheduled (n = 8).

CONCLUSION

CT scanning is rarely necessary for evaluation of single-suture craniosynostosis. Taking into account that there is a quantifiable risk of developing cancer in further lifetime, every single CT scan should be carefully indicated.

Neurosurgery in Würzburg until World War II

The institution of German neurosurgery as an autonomous surgical specialty, starting in Würzburg in 1934, is closely linked to the names of Fritz König and Wilhelm Tönnis. They were acting at a time when the global economic crisis and a consolidating Nazi dictatorship caused a cascade of alarming changes in political and social life. On the one hand it is fascinating to see how the restless work and energy of Tönnis managed to build up the first independent neurosurgical unit in Germany and to tighten efficient international connections all over the world within a few years. On the other hand-from a present-day perspective-it is difficult to understand how his strive towards a specialist's success, in contrast to that of Otfrid Foerster, was barely affected by the threatening political development, until the Second World War stopped his plans and ideas for many years.

Neurosurgical aspects of childhood hypophosphatasia

OBJECTIVE

Hypophosphatasia (HPP; MIM241510) is a rare inborn error of bone metabolism of recessive inheritance. It is caused by mutations in the gene encoding the tissue-nonspecific alkaline phosphatase. Apart from problems in bone mineralization, growth failure, and premature loss of decidual teeth, the infantile and the childhood types of HPP are associated with premature fusion of cranial sutures.

PATIENTS

We report on seven children affected with infantile and childhood HPP who presented with craniosynostosis.

RESULTS

Neurosurgical intervention was necessary in four of them because of intracranial hypertension. In one of these, severe dural calcification posed an unexpected problem during surgery. Secondary ectopia of the cerebellar tonsils were detected in five of the seven patients and caused hydrosyringomyelia in one of them.

CONCLUSIONS

Since cranial sutures are frequently involved in infantile and childhood HPP, a multidisciplinary approach for the clinical care is necessary, including long-term neurosurgical surveillance.

Morphometric analysis of untreated adult skulls in syndromic and nonsyndromic craniosynostosis

The aim of this study was to perform a morphometric analysis of untreated adult skulls displaying syndromic and nonsyndromic craniosynostosis. We analyzed, in detail, 42 adult craniosynostoses (18 scaphocephaly, 11 anterior plagiocephaly, 2 trigonocephaly, 9 oxycephaly, and 2 brachycephaly) from archeological (three skulls) and pathoanatomical samples (39 skulls). The univariate and bivariate measurements from the pathological skulls were compared with 40 anatomical skulls with normal cranial vault morphology. Bony signs of chronic elevated intracranial pressure (ICP) are (1) diffuse beaten copper pattern, (2) dorsum sellae erosion, (3) suture diastasis, and (4) abnormalities of venous drainage that particularly affect the sigmoid-jugular sinus complex. The mean cranial length was significantly greater in scaphocephaly than in anatomical skulls (20.3 vs 18.0 cm), and the sagittal suture was also longer (14.3 vs 11.8 cm). There were three types of suture course in the bregma region in scaphocephaly: anterior spur (28%), normal configuration (61%), and posterior spur (11%). The plagiocephaly measurements showed nonsignificant differences, and there was no correlation between the length of the anterior and middle skull base (ipsilateral anterior-posterior shortening of the skull) and incomplete or complete suture synostosis. Bony signs of chronic elevated ICP were found in 82% of cases of oxycephaly and brachycephaly. In three such cases of oxycephaly, we found a marked (1.8-2.1 cm) elevation of bregma region. One skull (Saethre-Chotzen syndrome) yielded human DNA sufficient for polymerase chain reaction (PCR)-based amplification procedures. Mutation analyses in the FGFR3 gene revealed nucleotide alterations located in the mutational hot spot at amino acid residue 250 (g.C749). The mean cranial length in adult scaphocephaly was 12% greater than anatomical skulls. A unilateral complete or incomplete coronal synostosis can be found with or without plagiocephalic deformation. Elevation of the bregma region is a bony sign of chronic elevated ICP. These data on adult craniosynostosis could be of interest for physicians dealing with craniosynostotic children.

Contiguous gene deletions involving EFNB1, OPHN1, PJA1 and EDA in patients with craniofrontonasal syndrome

Craniofrontonasal syndrome (CFNS [MIM 304110]) is an X-linked malformation syndrome characterized by craniofrontonasal dysplasia and extracranial manifestations in heterozygous females. In the majority of patients CFNS is caused by mutations in the EFNB1 gene (MIM 300035). We identified three girls with classical CFNS and mild developmental delay harboring de novo deletions of the EFNB1 gene. Applying haplotype analysis, Southern blot hybridization and array-comparative genomic hybridization, deletion of EFNB1 was found to be part of contiguous gene deletions in the patients. In one patient the deletion interval includes the genes for oligophrenin-1 (OPHN1 [MIM 300127]) and praja 1 (PJA1 [MIM 300420]). In the second patient the deletion includes OPHN1, PJA1 and the gene for ectodysplasin A (EDA [MIM 300451]). In the third patient EFNB1 gene deletion may include deletion of regulatory regions 5' of OPHN1. Previously, the OPHN1 gene has been shown to be responsible for recessive X-linked mental retardation. Although it is too early to predict the future cognitive performance of the two infant patients with contiguous gene deletions of OPHN1-EFNB1-PJA1, mild learning disabilities have been recognized in the older, third patient. It is important for genetic counseling to be aware that their male offspring may not only be carriers of CFNS but may also be affected by mental retardation and anhidrotic ectodermal dysplasia.

Management of hydrocephalus in children with plasminogen deficiency

Congenital plasminogen deficiency is an infrequent disorder, which usually becomes symptomatic as ligneous conjunctivitis. However, pseudomembranous lesions in the mucosa of the pharynx, tracheobronchial tree, and the peritoneum may likewise occur. An accompanying hydrocephalus is extremely rare; only 16 cases have been reported to date. The reports indicate that hydrocephalus, even if treated by ventriculoperitoneal (VP) cerebrospinal fluid (CSF) shunting, worsens the prognosis substantially. Thus, VP CSF shunting does not seem to be the optimal therapy for hydrocephalic children with plasminogen deficiency. We add two cases to the literature, and, on the base of our experience, we propose a management strategy for the hydrocephalus. We report the case history of two children with plasminogen deficiency and associated hydrocephalus. Both children initially were treated with VP shunts and had a very similar clinical course with multiple shunt malfunctions due to nonabsorption by the peritoneum. In the first child, the attempt to treat the hydrocephalus with a ventriculoatrial (VA) shunt failed due to catheter thrombosis. Finally, a ventriculocholecystic shunt was placed in both children, which worked well. In patients with plasminogem deficiency and associated hydrocephalus, special care must be taken in the management of hydrocephalus. The absorptive capacity of the peritoneum is reduced by pseudomembrane formation, which results in VP shunt malfunction. The plasminogen deficiency results in early thrombus formation if atrial catheters are used. Therefore, the authors believe that ventriculocholecystic shunting should be considered early on in the course of the disease.

Radiologische Veränderungen bei nichtoperierter isolierter Sagittalnahtsynostose

PURPOSE

To characterize the spontaneous clinical course of isolated sagittal synostosis based on planar skull radiography.

MATERIALS AND METHODS

In this retrospective analysis we evaluated a total of 155 radiographs of 55 children 2 weeks to 9 years old. The sagittal, coronal and lambdoid sutures were evaluated on the basis of pairs of ap and lateral radiographs. The sutures were examined with respect to their boundary, activity, and conspicuity to be visualized (based on a 3-grade score system). Six selected points on the skull X-ray defined eight measured distances, three angles, and a width-length index. To document changes over time, the measurements were correlated to normal values. In addition, a correlation between suture activity and selected parameters was evaluated.

RESULTS

The sagittal suture could be continuously or partially depicted in more then half of all radiographs taken during the first year of life, The measured distances and angles were concordant with results from the literature. With increasing age, the width-length index deviated from standard values while other parameters approximated the norm.

CONCLUSION

In the case of children younger than twelve months, the sagittal suture appears radiologically open in many cases despite clear-cut scaphocephaly. Definite signs of progressive plurisutural fusion were not found in this series. The dolichocephalic deformity remained unchanged while some signs of scaphocephalic appearance actually improved.

Effective NSAID treatment indicates that hyperprostaglandinism is affecting the clinical severity of childhood hypophosphatasia

Background

Hypophosphatasia (HP) is an inborn error of bone metabolism characterized by a genetic defect in the gene encoding the tissue-nonspecific alkaline phosphatase (TNSALP). There is a lack of knowledge as to how the variability and clinical severity of the HP phenotype (especially pain and walking impairment) are related to metabolic disturbances or impairments, subsequent to the molecular defect.

Methods

We analyzed the changes in clinical symptoms and the prostaglandin (PG) metabolism in response to treatment with non-steroidal anti-inflammatory drugs (NSAIDs) in six children affected by childhood HP. In addition, by exposing HP fibroblasts to pyridoxal phosphate and/or calcium pyrophosphate in vitro, we analyzed whether the alterations in PG levels are sequelae related to the metabolic defect.

Results

Childhood HP patients, who often complain about pain in the lower limbs without evident fractures, have systemic hyperprostaglandinism. Symptomatic anti-inflammatory treatment with NSAIDs significantly improved pain-associated physical impairment. Calcium pyrophosphate, but not pyridoxal phosphate, induced cyclooxygenase-2 (COX-2) gene expression and PG production in HP and normal fibroblasts in vitro.

Conclusion

Clinical features of childhood HP related to pain in the lower legs may be, at least in part, sequelae related to elevated PG levels, secondary to the primary metabolic defect. Consequently, NSAID treatment does improve the clinical features of childhood HP.

Cutaneous lesions in occult spinal dysraphism--correlation with intraspinal findings

OBJECTS

This study was conducted to investigate the frequency and type of cutaneous stigmata in different forms of occult spinal dysraphism (OSD) and their correlation to the underlying malformation.

METHODS

Fourteen different forms of spinal malformations were identified in 358 operated patients with OSD. Most frequent findings (isolated or in combinations) were spinal lipoma, split cord malformation, pathologic filum terminale, dermal sinus, meningocele manqué, myelocystocele and caudal regression. Stigmata were present in 86.3% of patients, often in various combinations. Using a binary logistic regression analysis, significant correlations with distinct malformations were found for subcutaneous lipomas, skin tags, vascular nevi, pori, hairy patches, hypertrichosis, meningoceles and "cigarette burn" marks.

CONCLUSIONS

Cutaneous markers in a high percentage accompany spinal malformations. Due to the correlations of different stigmata to distinct malformations, they can aid the clinician in further diagnostic and therapeutic work.

Hydrocephalus in craniosynostosis: a review

INTRODUCTION

Ventricular dilatation in the presence of primary craniosynostosis is a unique condition with respect to pathogenesis, clinical significance, and morphological appearance. It is rarely observed in nonsyndromic craniosynostosis, and in these cases usually attributable to coincidental disorders. Conversely, it is a common feature of syndromic craniosynostosis, affecting at least 40% of patients with Crouzon's, Pfeiffer's or the Apert syndrome. Shunt-dependent hydrocephalus is predominantly associated with Crouzon or Pfeiffer syndrome while in the Apert syndrome the usual finding is nonprogressive ventriculomegaly which, however, may also occur in some cases of Crouzon syndrome.

PATHOGENESIS

The pathogenesis of progressive hydrocephalus remains somewhat obscure, a hypoplastic posterior fossa and a venous outlet occlusion at the skull base being the main causative factors discussed in literature. Ventriculomegaly may reflect primary brain maldevelopment or in some cases even a compensated state of increased cerebrospinal fluid (CSF) outflow resistance. CLINICAL EVALUATION: Clinical evaluation is mainly aimed at identifying progressive hydrocephalus, but diagnosis is hampered by the fact that classical clinical signs may be absent, and that ventricular dilatation will often become evident only after decompressive cranial surgery. Moreover, mild ventriculomegaly may in some cases coexist with intracranial hypertension from craniostenosis. Therefore, careful monitoring of intracranial pressure and ventricular size in the pre- and postoperative period is a diagnostic mainstay.

CONCLUSION

In true hydrocephalus ventriculo-peritoneal shunting is currently the single promising mode of treatment.

[Pioneers of neurosurgery: Emil Heymann (4/15/1878-1/11/1936)]

Following Fedor Krause and Otfrid Foerster, pioneers of neurosurgery in Germany, Emil Heymann was one of the outstanding promoters of the young surgical section, before it emerged as an independent specialty. As successor to Fedor Krause at the Augusta-Hospital, Berlin, he consistently improved techniques of investigation and operative treatment of intracranial and spinal tumors. Because of his Jewish parents he was persecuted by the Nazi regime, who nearly succeeded that his name fall into oblivion.

Immunolocalization of urokinase and its receptor in prematurely fused cranial sutures of infants

In cranial sutural samples derived from five children with premature cranial suture fusion we have performed immunostaining for the urokinase plasminogen activator (uPA) and urokinase receptor (uPAR). We have found a strong reactivity for cell- or matrix-bound uPA and uPAR in the sutural connective tissue and associated with the osteoblasts and osteocytes lining the calvarial bone. The sutural tissue itself showed a banding with different intensity of urokinase and uPAR staining concerning connective tissue. It is proposed that the components of the plasminogen activating system are involved in tissue turnover of sutural tissue and in sutural growth.

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.

Clustering of FGFR2 gene mutations inpatients with Pfeiffer and Crouzon syndromes (FGFR2-associated craniosynostoses)

A cohort of 36 unrelated German patients with craniosynostosis syndromes of the Crouzon and Pfeiffer type were analyzed for FGFR mutations. Mutations in FGFR2 were identified in 25 Crouzon and 5 Pfeiffer syndrome patients, whereas no sequence alterations were found in the remaining patients, even after screening of the relevant parts of FGFR1, FGFR3, and TWIST. Mutations in FGFR2 clustered at two critical cysteine residues, 278 and 342, which were involved in 18 of 30 cases (60%). These two mutational hot spots, therefore, are prime targets for an efficient mutation-screening strategy. The spectrum of mutations overlapped the two syndromes and thus reflected the phenotypic similarities observed in both patient groups. In 21 families, the origin of the mutation could be traced by analyzing parents and relatives. Eleven mutations arose de novo, indicating a high mutation rate for FGFR2. In the 10 familial cases, the clinical presentation varied considerably within the pedigree, but both syndromes "bred true," i.e., a Pfeiffer syndrome phenotype was never observed in a Crouzon syndrome family and vice versa.

An unusual FGFR1 mutation (fibroblast growth factor receptor 1 mutation) in a girl with non-syndromic trigonocephaly

Non-syndromic trigonocephaly is a heterogeneous entity; in most cases the origin is unknown. Rare cases with autosomal dominant and recessive inheritance exist. Here the mutational screening of ten patients in the FGFR1, 2, and 3 genes and the TWIST gene causative of autosomal dominant craniosynostosis syndromes was reported. In one girl an unusual FGFR1 mutation was found.

Standardized evaluation and documentation of findings in patients with craniosynostosis

Surgical correction of craniosynostosis is usually performed according to standard procedures. However, a standard for clinical examination and report of findings for patients with craniosynostosis does not exist as yet. To compare findings from different hospitals, a documentation system was developed by a national craniosynostosis group. This system comprises a two-page document, clinical photographs, radiographs, CT scans, anthropometric measurements and molecular genetic findings. Data from craniosynostosis patients collected from participating hospitals are stored in a database, which facilitates online access. The documentation system was developed in cooperation with the group during 3 years since 1996. It was evaluated as being practicable and reliable and enables a comparability of findings reported in different hospitals. Molecular genetic analysis was found to support the investigation of patients with craniosynostosis and should therefore be integrated in the clinical evaluation.

[Long-term outcome after corrective surgery of the neuro- and viscerocranium of patients with simple and syndrome-related premature craniosynostosis]

A retrospective and partly prospective study was conducted to analyse both clinically and cephalometrically the craniofacial growth pattern of patients with isolated and syndrome-related premature craniosynostosis after standardized fronto-orbital and midface advancement. The file data of 293 children with fronto-orbital advancement were evaluated over an average period of 4.4 years. In addition, lateral teleradiographies of 117 patients from this group were cephalometrically analysed. Moreover, late results of 36 children and 8 adults with midface-advancement with an average follow-up period of 4.5 years were assessed. In contrast to linear craniectomy and so-called lateral canthal advancement, in only 8.2% of cases (24 out of 293 patients) were relapses requiring reoperation found in this study after fronto-orbital advancement. The evaluations indicate that with simple forms of craniosynostosis such as trigonocephaly and plagiocephaly predominantly very good or good growth can be observed. Cephalometric evaluation confirmed the limited potential of growth in the area of the anterior skull base and in the midface in the presence of syndrome-related faciocraniosynostoses. In such cases the cephalometrically confirmed maxillary hypoplasia, which increases in severity in the following order of syndromes 'Saethre-Chotzen-Crouzon-Apert-Pfeiffer', could be influenced only to a limited degree by fronto-orbital advancement. For this reason midface advancement is of secondary importance in children with very severe anomalies. In the present evaluation, a high rate of relapse of midfacial hypoplasia was to be found in children and adolescents after this operation in accordance with other references. Therefore, the indication for Le Fort III osteotomy in the growth period should be limited.

A novel mutation (a886g) in exon 5 of FGFR2 in members of a family with Crouzon phenotype and plagiocephaly

We identified a novel mutation in members of a family with signs of Crouzon syndrome and plagiocephaly. In affected members of the family an A-->G transition was found at position 886 in exon 5 of the fibroblast growth factor receptor 2 (FGFR2) gene. The base change results in the replacement of a lysine by glutamic acid in Ig-like loop III of FGFR2. The unusual finding of plagiocephaly in these Crouzon patients may either be the result of the type of mutation or because of genetic and environmental factors that affect the phenotype in addition to the mutated FGF receptor.

Craniofacial growth characteristics after bilateral fronto-orbital advancement in children with premature craniosynostosis

The standardized bilateral fronto-orbital advanced method of osteotomy established at the University of Wuerzburg is applied in all forms of craniosynostosis except scaphocephalus. The intention behind early operation is to halt progression of the disorder and to institute the physiological direction that growth should take. The preoperative severity of the disorder, the particular symptoms of the various malformations concerned, and the postoperative course of growth were analyzed and assessed both clinically and cephalometrically using the retrospective evaluations of the file data of 131 children with various forms of craniosynostosis. In contrast to linear craniectomy and so-called lateral canthal advancement, which have sometimes been thought to lead to undesirable postoperative growth development, only 11 relapses requiring renewed operation were found postoperatively in our own study of 131 children. It became evident that the greater the severity of the malformation, the more probable it was that a relapse would occur. Fronto-orbital advancement can only affect the pathological growth pattern to a limited degree, especially when craniosynostosis is related to a syndrome. Cephalometric evaluation confirmed the limited potential for growth in the area of the anterior skull base and in the mid-face in the presence of syndrome-related brachycephaly and severe facio-craniosynostoses. In such clinical cases, compensatory growth of maxillary hypoplasia cannot be expected after fronto-orbital advancement.

Consensus: trigonocephaly

Trigonocephaly mostly occurs in isolated synostosis of the metopic suture, but 10-20% of patients are affected by complex syndromes, and in 2-5% the condition is familial. Intracranial hypertension has been observed in a minority of cases, but is never severe. Surgery is performed mainly for cosmetic reasons, following the standard principles of craniofacial surgery. Complications are rare and satisfactory cosmetic results are generally obtained. There is little likelihood for recurrent deformity.

Recurrent bacterial meningitis

To characterize recurrent bacterial meningitis in children, we reviewed the charts of all patients treated for more than one episode of bacterial meningitis at the Würzburg University Children's Hospital from 1980 to June 1995. Twenty-five children suffered 2-13 episodes of bacterial meningitis. Most patients were referred from other hospitals to our paediatric neurosurgical service. No immunodeficiency was found. In all patients, the cause of recurrent meningitis was an anatomical lesion with 13 intracranial defects including encephaloceles, skull fractures, Mondini dysplasias, neurenteric cyst, fibrous dysplasia, persistent craniopharyngeal duct, and 12 lumboscral defects with a dermoid cyst within the lumbosacral spine. A first episode of meningitis at school age did not exclude a congenital defect. In total, 84 episodes of meningitis were treated, a pathogen was isolated in 77%. The most common pathogen was Streptococcus pneumoniae, followed by Escherichia coli, Staphylococci and others. The pathogen isolated often gave a clue to the location of the defect. Personal history was often unrewarding and in some cases the search for the anatomical lesion required repeated imaging and explorative surgery. In 24 of 25 cases, final treatment of recurrent meningitis was by surgical intervention.

CONCLUSION

In recurrent bacterial meningitis, excessive diagnostic and therapeutic procedures are indicated. An anatomical defect is a very probable cause.

Functional and anatomic aspects of the orbitotomy in craniofacial surgery

The orbitotomy has a central importance in craniofacial surgery. It is indicated for premature craniosynostoses, malformations and tumor surgery. The aim of the treatment is to correct functional disturbances and aesthetic impairments. Anatomical structures must be respected. Functional and anatomical aspects of the orbitotomy in craniofacial surgery are described.

[Intervertebral disk prolapse in childhood]

Four girls and one boy aged 11 to 16 years presented with lumbar disc disease. The main aspects of the disorder in children and its differences to adults are emphasized. The prognosis following surgical treatment is favourable.

Hydrocephalus in craniosynostosis

Routine CT scanning in 221 patients with craniosynostosis revealed ventricular dilation in 40. In 5 hydrocephalus was obviously unrelated to the craniostenosis. The remaining 35 cases were associated almost exclusively with syndromic craniosynostosis. Ventricular dilation was mild in 22, moderate in 9, and marked in 4 patients. Clinical and radiological findings strongly suggest that three different mechanisms are involved in the pathogenesis of hydrocephalus: primary cerebral maldevelopment, brain atrophy, and CSF outflow obstruction. In the diagnosis of hydrostatic hydrocephalus with craniosynostosis, head circumference is no indicator of progressive hydrocephalus, and intracranial hypertension may be due either to CSF accumulation or to craniostenosis. The present study indicates that shunt treatment prior to correction of synostosis should be restricted to a few cases of rapidly progressing hydrocephalus. Secondary shunting of hydrocephalus may be considered if intracranial pressure remains high despite adequate cranial decompression. Shunting is not an appropriate treatment for craniostenosis--even in cases of concurrent ventricular dilation.

Bilateral lesions of the putamina

13 cases of bilateral necrosis of the putamina in children and adults are reported. CT shows similar parenchymal defects, though clinical data reveal different histories, causes and circumstances of the damage. The relationship between CT findings and clinical symptoms is investigated, and the neurological dysfunctions resulting from symmetrical areas of necrosis in each putamen are discussed.

CT of the postoperative lumbar spine: the value of intravenous contrast

Sixty-five patients with recurrent radicular complaints after operation for lumbar disc herniation underwent CT examination before and after intravenous contrast application (volume: 1.5-2.0 ml/kg body weight; flow rate: 0.35 ml/s). Postsurgical hypertrophic scar tissue showed definite contrast enhancement, whereas disc herniation remained unenhanced. Intravenous contrast application is recommended in patients previously operated upon for disc herniation.

Supratentorial intraventricular tumors in childhood

We report on a series of 21 infants and children with tumors of the supratentorial ventricular system, all of whom were assessed by computed tomography and underwent operation using microsurgical techniques. In 7 cases the tumor was found in the 3rd ventricle, whereas the lateral ventricles were involved in the others. Surgical access to the lateral ventricles and the anterior portion of the 3rd ventricle was gained by standard intergyral cortical incision in the precentral or postcentral regions and via the foramen of Monro. The posterior portions of the lateral ventricle of the dominant hemisphere as well as the posterior part of the 3rd ventricle were exposed with minimal risk, using the occipital midsagittal supratentorial route. Following this technique, total removal of the tumors was possible in all cases without substantial postoperative morbidity. After a follow-up period of 6 months to 9 years all patients are in good or excellent neurological condition. Tumor recurrences were not encountered, although a definitive statement cannot be made in some patients with malignant lesions.

[Current aspects of pseudomonas meningitis]

The article reports on the incidence, the conditions of occurrence, possibilities and successes of treatment with certain (combinations of) antibiotics, in dealing with cases of pseudomonas meningitis. The various possible substances used for treatment are discussed. Rates of penetration and CSF concentrations of azlocillin and cefsulodin are stated. Alternative possibilities for treatment are pointed out.

Congenital hydrocephalus revealed in the inbred rat, LEW/Jms

We studied the development of congenital hydrocephalus found in a colony of an inbred strain of Wistar-Lewis rats (LEW/Jms) at various intervals after birth. The disorder was transmitted as a simple recessive mendelian character. Hydrocephalic neonates were recognized 2 days after birth by stretching of the skin over the head. Death usually occurred between 10 and 20 days of age. The findings suggested the possibility of a disturbance of cerebrospinal fluid circulation resulting from primary occlusion of the 3rd or lateral ventricles during embryological development. In later phases, the hydrocephalus was aggravated by obliteration of the subarachnoid space and by stenosis of the aqueduct occurring secondary to compression of these structures from increased pressure within the brain. In some animals, external hydrocephalus occurred as a result of rupture of the occipital pole and the establishment of a direct communication between the lateral ventricles and the subdural space. We looked for antibodies against viruses that have been known to produce hydrocephalus in experimental animals and obtained entirely negative results.

[Cefsulodin in the treatment of Pseudomonas meningitis]

Three patients with meningitis due to Pseudomonas aeruginosa (in one patient following a neurosurgical procedure and in two patients following severe head trauma with multiple skull bone fractures and liquorrhea) were treated with cefsulodin in combination with other antibiotics (aminoglycosides/acylureido penicillins). All of the patients were cured. Two patients received intraventricular administrations of aminoglycosides in addition to systemically applied antibiotics. After recurrence of pseudomonas meningitis in one patient in spite of the intraventricular application of an aminoglycoside, definite cure could only be obtained by additional intraventricular application of cefsulodin. The third patient was cured by systemic administration of cefsulodin and amikacin. The value of cefsulodin is discussed with reference to obtainable ventricular and lumbar CSF concentrations.

Netilmicin in human CSF after parenteral administration in patients with slightly and severely impaired blood CSF barrier

After administration of 150 mg netilmicin samples of CSF and blood were obtained. In one group of nine patients with no or only slight impairment of the blood-CSF-barrier 29 samples of CSF were assayed for netilmicin concentrations. All samples, obtained after the first dose, failed to reveal detectable drug levels. Drug levels up to 0.18 mg/l were detected in samples of CSF of three patients after 3 to 22 doses. Only the lumbar CSF of one patient contained netilmicin concentrations higher than 1.0 mg/l. In comparison 19 samples of CSF, obtained from patients with meningitis after more than one dose of netilmicin, had levels of 0.27-5.0 mg/l. Three CSF samples from patients out of this group, collected after the first dose of netilmicin failed to show any drug activity.

Cefotaxime levels in ventricular cerebrospinal fluid, determined by bioassay and by high-performance liquid chromatography

Five series of cerebrospinal fluid (CSF) samples, obtained from external ventricular drains (EVD) of 4 neurosurgical patients with cefotaxime treatment were tested simultaneously by high-performance liquid chromatography (HPLC) and microbioassay using E. coli V 6311/65 as test organism. Higher cefotaxime (CTX) concentrations in CSF were measured by the microbioassay method in 4 of the 5 series, reflecting the microbioassay being influenced by increasing amounts of desacetyl-cefotaxime (DAC) during the post-application interval. Decrease of CTX levels in CSF was consistently faster in tests performed by HPLC than those using microbioassay. The clinical efficacy in gram-negative bacillary meningitis is to be explained by levels of the parent compound CTX in CSF which are several times higher than the minimal inhibitory concentrations (MICs) of most enterobacteriaceae.

[CSF levels of amikacin following systemic application in patients with slightly and severely impaired blood cerebrospinal barrier (author's transl)]

Levels of amikacin after systemic application of 350 mg were determined by the agar well diffusion method in 12 samples of CSF and serum of 7 patients with bacterial meningitis and in 2 samples of 2 patients with viral meningitis. Only in 2 samples of CSF drawn after the first systemic application of 350 mg i.m. no antibiotic activity was detectable. In 7 specimens of CSF levels of amikacin were greater than or equal to 3 microgram/ml. In 12 tests of CSF of neurosurgical patients with only slight impairment of the blood-CSF-barrier, taken for comparison reasons, only in 6 samples antibiotic activity was found. Only one test revealed CSF-concentration of amikacin higher then 3 microgram/ml.

Cefotaxime in treatment of meningitis and ventriculitis? Evaluation of drug concentrations in human cerebrospinal fluid

In three groups of patients levels of cefotaxime in serumand cerebrospinal fluid were determined. Therapeutic value and efficacy are discussed in meningitis patients. Nine concentrations of cefotaxime in lumbar and ventricular CSF out of 19 in a group of seven neurosurgical patients with mild to moderate impairment of the blood-CSF-barrier were higher than 0.5 micrograms/ml. In seven determinations in a second group of six patients with no or very little dysfunction of the blood-cerebrospinal-fluid barrier only twice cefotaxime was not detectable in lumbar CSF. Concentrations of cefotaxime in 25 determinations of lumbar or ventricular CSF in six patients with bacterial meningitis ranged from 1.1 micrograms/ml to 19.2 micrograms/ml. Treatment with cefotaxime alone was successful in a patient with E. coli meningitis and ventriculitis after infection of a ventriculo-atrial shunt and in another patient with pneumococcal meningitis and penicillin allergy. The other four patients with bacterial meningitis were treated successfully by antibiotics including cefotaxime.

Tobramycin levels in cerebrospinal fluid of patients with slightly and severely impaired blood-cerebrospinal barrier

Concentrations of tobramycin in cerebrospinal fluid (CSF) and serum of neurosurgical and of meningitis patients were determined following systemic application of 80-mg doses. Tobramycin was detectable only in 8 tests out of 17 in CSF of 11 neurosurgical patients. The highest drug amount in CSF in these tests was 0.47 microgram/ml. In CSF of 7 meningitis patients with CSF cell counts ranging from 173/3 to 20,500/3 cells, tobramycin was detectable in all 11 determinations. However, the tobramycin level was above 1.0 microgram/ml in only one CSF sample. These results also confirm the poor penetrability of aminoglycosides through the blood-CSF barrier for tobramycin. In proven gram-negative bacillary meningitis and tobramycin treatment, additional intraventricular aminoglycoside application is necessary to obtain effective levels in CSF. An exception may be treatment of neonatal meningitis.

[Quantitative determination of human bone marrow proliferation kinetics during three culture days]

In order to obtaon of human bone marrow cells, fresh bioptic material was homogenized and the cell suspensions were incubated for 72 hs in a fluid medium. After 24, 48 and 72 hs of incubation the total cell number of the culture was determined. At the same time differential counts of stained smears were performed. Both, erythrocytopoiesis and granulocytopoiesis showed regeneration, maturation, and an absolute increase of the number of precursors and of mature cells. The quantitative data obtained in vitro during 24 hs correspond with our data of kinetics obtained by observed mitotic duration and cell differential countings in vivo. However, after a longer cultivation time we found a diminution of divisible precursors, and an increase of mature erythroblasts as well as an excessibe survival of the PMNs.