High CSF transforming growth factor beta levels after subarachnoid haemorrhage: association with chronic communicating hydrocephalus

BACKGROUND

Chronic communicating hydrocephalus is a common sequela of subarachnoid haemorrhage and develops when the flow and drainage of CSF are impaired after fibrosis in the subarachnoid space. Released by platelets into the CSF after subarachnoid haemorrhage, transforming growth factor (TGF)beta1/beta2 are potent fibrogenic agents that may promote post-haemorrhagic fibrosis and chronic communicating hydrocephalus.

METHODS

Temporal changes in total (latent plus active) TGFbeta1/beta2 CSF levels of post-haemorrhage patients developing acute hydrocephalus were measured using ELISA to discover if titres were higher in patients that subsequently developed chronic communicating hydrocephalus, compared with those that did not.

RESULTS

Mean (SD) CSF levels of total TGFbeta1 were 97 (42) pg/ml and total TGFbeta2 were 395 (39) pg/ml in control patients with (non-haemorrhagic) hydrocephalus. For days 1-5 post-subarachnoid haemorrhage (dph), levels of 1427 (242) pg/ml and 976 (191) pg/ml were seen for total TGFbeta1 and TGFbeta2, respectively. Beyond 5 dph, total TGFbeta1/beta2 levels declined but remained significantly elevated (p<0.01) above control patient values for at least 19 dph. Haemorrhagic patients that went on to develop chronic communicating hydrocephalus had significantly higher levels of total TGFbeta1 (p<0.01) and TGFbeta2 (p<0.05) between 1 and 9 dph, compared with those of haemorrhagic patients that did not.

CONCLUSIONS

Acutely measured levels of TGFbeta1/beta2 in the CSF of patients with subarachnoid haemorrhage are thus potential prognostic biomarkers for the subsequent development of chronic communicating hydrocephalus, indicating likely dependency on CSF shunting.

Transforming growth factor-beta1 in the cerebrospinal fluid of patients with subarachnoid hemorrhage: titers derived from exogenous and endogenous sources

Transforming growth factor-beta1 (TGF-beta1) is a fibrogenic cytokine that is involved in postinjury repair and is implicated in the etiology of postsubarachnoid hemorrhage (SAH) chronic communicating hydrocephalus. TGF-beta1 was measured by enzyme-linked immunosorbant assay (ELISA) in sequential samples of cerebrospinal fluid (CSF) in 11 patients with hydrocephalus after SAH; levels were seen to be biphasically elevated and sources were investigated. TGF-beta1 levels were compared with albumin levels that estimated CSF blood content. Control samples from nonhemorrhagic hydrocephalics were tested similarly. Mean total TGF-beta1 levels were elevated to 4400+/-3435 (+/-SD) pg/mL greater than control levels of 97+/-42 at 1 to 2 days posthemorrhage. Thereafter, levels fell to 714+/-401 by 5 to 6 days posthemorrhage, then rose to a second peak of 1667+/-774 at 9 to 10 days posthemorrhage, remaining significantly increased until 19 days posthemorrhage (P = 0.007). The first peak probably derived from extravasated platelets and correlated with increased albumin levels in the CSF. The second TGF-beta1 peak rose greater than CSF albumin levels that had stabilized at this time, and thus was attributed to a tissue-specific response rather than a re-bleed. TGF-beta1 was detected in the choroid secretory epithelium from controls, but levels were greater in SAH patients at 10 to 12 days posthemorrhage. The authors conclude that the elevated levels of TGF-beta1 in CSF after SAH are derived initially from blood and later from endogenous sources such as the choroid plexus.

Transcranial surgery for pituitary tumors performed by Sir Victor Horsley

OBJECTIVE

To describe the clinical details and the operative method used in pituitary tumors by Sir Victor Horsley (1857-1916), which represent the earliest attempts at pituitary surgery.

METHODS

Horsley's case books and postmortem records, archived at the National Hospital, Queen Square, London, were studied for patients with a primary diagnosis of a pituitary tumor admitted during the period 1886 to 1916 who were treated surgically. Contemporary records of nonpituitary cases were also examined to study aspects of Horsley's operative method.

RESULTS

Four patients (three men and one woman) underwent craniectomy for removal of a pituitary tumor via the subtemporal approach between 1904 and 1907. All four patients experienced significant impairments of visual fields or visual acuity; one patient had severe trigeminal neuralgia. Evidence of acutely raised intracranial pressure was present in one patient. All patients underwent craniectomy under chloroform anesthesia. One patient died on the day of surgery, and the postmortem findings are presented. In the other three patients, neurological morbidity was recorded in the postoperative period in the form of new cranial nerve deficits, monoparesis with dysphasia, and seizures. The patient with trigeminal neuralgia experienced partial relief and was readmitted later for reexploration and Gasserian ganglionectomy via the same route. Four contemporary nonoperative cases of pituitary tumor are also presented.

CONCLUSION

These cases provide insight into the presentation and operative treatment of pituitary tumors during the pre-Halsted era.

Differential binding of anti-CD44 on human gliomas in vitro

Recent studies have shown that the membrane glycoprotein, CD44, is expressed on both normal and neoplastic astrocytes. Moreover, CD44 has been shown to recognise the receptor for hyaluronic acid (HA), an extracellular matrix protein thought to be involved in tumour invasion. The present study has established, by immunocytochemical staining, that CD44 is present on the majority of cells in long and short term cultures derived from astrocytic gliomas. In glioblastoma multiforme, medulloblastoma, ependymoma and dysembryoplastic neuroepithelial tumour, however, staining is either absent or restricted to isolated cells. This differential binding suggests that HA receptor expression may be related to (a) the cell cycle and (b) local invasiveness of brain tumours.

Brain abscesses associated with pulmonary arteriovenous malformations

We present three patients with brain abscesses who also had pulmonary arteriovenous malformations (AVMs). All patients had hereditary haemorrhagic telangiectasia (Osler's Disease). It is probable that the lung AVMs contributed to the development of the brain abscesses by allowing bacteria easier access to the systemic circulation through a right to left pulmonary vascular shunt, bypassing the filtering action of the pulmonary capillaries. In addition, one patient required a period of postoperative ventilation using PEEP, which may have exacerbated the shunt through the lung AVM and led to difficulty in weaning her from the ventilator.

Optic canal decompression with dural sheath release; a combined orbito-cranial approach to preserving sight from tumours invading the optic canal

PURPOSE

The purpose of this case series is to describe an orbito-cranial surgical approach for the management of optic nerve compression secondary to tumours extending into the optic canal.

METHOD

We present a retrospective, observational case series of 4 patients who underwent surgery aimed at improving or stabilising vision for tumours invading the optic canal. In all cases tumours were not amenable to complete resection due to their intrinsic relation to important structures including: the internal carotid artery, cavernous sinus, optic and oculomotor nerves. All patients underwent combined orbito-cranial surgery consisting of craniotomy, debulking of the tumour, transcaruncular orbital and optic canal decompression with release of the dural sheath overlying the optic nerve via the craniotomy approach. Visual acuity was the primary outcome measure.

RESULTS

Four patients, aged 42, 44, 61 and 78 years, three with spheno-orbital meningioma and one with cerebral sino-nasal adenocarcinoma were included in the study. Mean postoperative follow-up time was 26, 19 and 15.6 months. The fourth patient died at 2.9 months post-surgery due to high grade aggressive cerebral adenocarcinoma. Postoperative visual acuity improved by greater than 4 lines of Snellen acuity in 2 patients at 26 and 19.1 months. Two patients decreased from counting fingers vision to perception of light at last follow-up.

CONCLUSIONS

In cases of non-resectable meningioma extending into the optic canal with secondary optic nerve compression, a combined surgical approach with optic canal decompression and dural sheath release may help preserve and even improve vision in certain cases.

Prostatic adenocarcinoma presenting with metastatic frontal bone involvement and orbital invasion

We present a rare case of prostatic adenocarcinoma presenting with metastatic frontal bone involvement with subsequent spread to the orbit. Although prostatic adenocarcinoma has a strong tendency to metastasize to bone, particularly axial skeletal bone, frontal bone involvement is rare and subsequent orbital involvement is even more so.

Neuropsychological profiling of ischemic deficit secondary to ruptured dermoid cyst: a case report

This report presents a case of a 39-year-old male with a spontaneously ruptured frontotemporal dermoid cyst. Intraoperatively, during surgical resection of the cyst, significant fat spillage occurred associated with a profound anterior circulation vasospasm. The patient underwent serial neuropsychological evaluation over five months, revealing a profile of initial deterioration, followed by delayed recovery of cognitive function. A review of the literature reveals three other case reports describing ischemic deficit after dermoid rupture, but the cognitive impairment associated with this pathology has never been formally profiled before, and it may be possible to draw analogies to the well-established ischemic deficit post-subarachnoid hemorrhage found in the literature. Neuropsychological profiling additionally informs us about the nature and progression of this entity from a cognitive perspective and whether the etiology of deficit caused by dermoid rupture could be localized, or global, secondary to diffuse fatty dissemination in the CSF.

Hindbrain hernia masquerading as postpartum subarachnoid haemorrhage

A 29-year-old postpartum lady presented with a headache suggestive of subarachnoid haemorrhage. Investigations were negative for sources of haemorrhage, but revealed a hindbrain hernia. Hindbrain hernia should be considered as a cause of headache postpartum, as repeated Valsalva manoeuvres performed during vaginal delivery may further aggravate tonsillar decent.

Nonexpression of CD15 by neoplastic glia: a barrier to metastasis?

Cluster of differentiation 15 (CD15) monoclonal antibodies recognise cell adhesion molecules on the surface of many cells including normal astrocytes and metastatic carcinoma cells. The CD15 epitope (fucosyl-N-acetyl-lactosamine), an adhesive oligosaccharide, functions as a ligand for the selectin family of membrane receptors. These include CD62, a cytokineinducible glycoprotein found in platelets and endothelial cells. CD15 is one of a series of putative adhesion molecules expressed in nervous tissue. Selectin-carbohydrate interactions have been implicated in the metastatic spread of cancer cells. We have immunostained a variety of cultured human brain tumours, three cell lines derived from experimental rat gliomas, two specimens of cultured human foetal astrocytes, two metastatic carcinoma cell lines and human umbilical vein endothelial cells (HUVEC) using two monoclonal antibodies which recognise CD15. While all of the animal glioma cells were positive for CD15, only two human glioma cell lines, derived from an anaplastic astrocytoma and a glioblastoma multiforme, respectively, displayed limited reactivity. Chromium radiolabel binding assays of CD15-positive and -negative cell lines including glioma and carcinoma-derived cells, using HUVEC as an attachment substrate, were carried out in the presence and absence of CD15 monoclonal antibody. The level of adhesion of neoplastic cells to HUVEC not only corresponded to CD 15 expression but application of anti-CD 15 monoclonal antibodies considerably reduced adhesion. We postulate that the absence of CD15 on human glioma cells may explain, to some extent, the general failure of intrinsic brain tumours to metastasis by precluding the adhesion of circulating neoplastic glia to 'target' organ endothelium.