P14.112 Long-term application of TTFields in glioblastoma: a multiple-case study

BACKGROUND

Tumor treating fields (TTFields) is an antimitotic cancer therapy that utilizes low-intensity, intermediate-frequency alternating electrical fields to treat glioblastoma (GBM). Increased compliance with TTFields is independently prognostic for improved survival and was correlated with significantly improved overall and progression-free survival versus temozolomide (TMZ) alone. We present two exemplary cases of primary GBM treated with TTFields on long-term and adjuvant chemotherapy to explore treatment adherence, feasibility and safety issues.

MATERIAL AND METHODS

We present case details of two patients from our comprehensive cancer center, both of whom have primary GBM and are long-term TTFields users. One patient began TTFields at first diagnosis whilst the other had already survived to two years at the time of TTFields commencement. Their histories and disease status under continuous, ongoing TTFields therapy with concomitant, extended chemotherapy are explored.

RESULTS

Patient A is a 52-year-old male with IDH1-wildtype, MGMT promoter-methylated GBM. He began TTFields 24 months after initial diagnosis. Before starting TTFields, he had two resections, one owing to early locoregional progression, and had underwent standard, dual radiochemotherapy and started adjuvant TMZ. He has now completed 931 days of treatment with an average daily usage of 82% and has survived 55 months from first diagnosis. Since beginning TTFields, he has undergone a further two resections and another radiotherapy course. His chemotherapy regime has been modified several times, from standard-dose to dose-intensified TMZ, then later switched to lomustine and irinotecan-containing protocols. Patient B is a 68-year-old male, also with IDH1-wildtype, MGMT promoter-methylated GBM. He began TTFields six months after first diagnosis and after one tumor resection, concomitant radiochemotherapy and initiation of long-term TMZ therapy. He has now undergone 636 days of TTFields treatment with an average daily usage of 74%. In addition, 28 cycles of TMZ have been completed.

CONCLUSION

During a mean treatment duration of 784 days and alongside extended-course adjuvant chemotherapy, TTFields was well tolerated. Both patients are alive and still receiving treatment. Compliance has remained within the target range. Significant adverse events or treatment interruptions have not occurred. The patients have remained symptomatically stable and their quality of life has been maintained.

P14.114 Tumor treating fields in glioblastoma clinical practice guidelines: a European and North American landscape analysis

BACKGROUND

Tumor treating fields (TTFields) are low-intensity alternating electric fields delivered at intermediate frequencies to disrupt cancer cell division and inhibit tumor growth, with significantly longer mean lifetime survival of 1.8 additional years in glioblastoma (GBM). International, national and local clinical practice guidelines have implications for clinical, personal and policy decision-making. Furthermore, they may impact on patients’ decisions to choose treatment at a given institution or even lead to commencement of legal proceedings for withholding therapies recommended by international guidelines. We performed an in-depth landscape analysis of clinical practice guidelines for GBM in Europe and North America to explore variation in treatment recommendations with a specific focus on TTFields.

MATERIAL AND METHODS

A systematic search was conducted of web sites of international guideline developers, relevant cancer agencies and the MEDLINE and Web of Science literature databases. The following information was extracted from each document meeting the inclusion criteria: whether TTFields is discussed and/or recommended in the guideline, the indications for and role of TTFields in the care protocol, the strength of the recommendation and any constraints placed on the situations where this therapy can or may be offered, including on cost grounds, where applicable. Dates of production and validity periods of the guidelines were also noted. In addition, standard operating procedures (SOPs) from several accredited comprehensive cancer centres in Germany, covering GBM care are compared, with a series of clinical vignettes presented.

RESULTS

The guidelines produced by the National Comprehensive Cancer Network (USA), National Institute for Health and Care Excellence (UK), German Society for Neurology, German Society for Haematology and Medical Oncology, European Association for Neuro-Oncology and European Society for Medical Oncology were critically compared. Wide variation in recommendations relating to the TTFields therapy was observed. Many guidelines had not been updated to reflect the results of the EF-14 study.

CONCLUSION

Discrepancy in the adoption of TTFields across clinical practice guidelines and SOPs has potential implications for care practices. This ultimately affects patient outcomes, safety and quality of care. Ideally, guidelines should be updated dynamically when new evidence indicates a need for a substantive change in the guideline based on a priori criteria. An ongoing revision process for guidelines, perhaps with shorter validity periods or a more flexible approach, may facilitate more expedient adoption of novel therapies in clinical practice guidelines and in practice. Meanwhile, therapies significantly improving OS and PFS should be recommended to patients and this should be documented.

[Pain and poverty]

BACKGROUND

Poverty is an important problem in Germany. The health effects of poverty can lead to a higher risk of disease and the arising of chronic affections. On the other hand chronic illness may support the development and continuance of poverty. The context of chronic pain and poverty has not been analyzed so far.

OBJECTIVES

We investigated the correlation between chronic pain and poverty.

MATERIALS AND METHODS

In a prospective manner we interviewed 20 patients with pain syndromes during our consultation hour regarding their household income. Further, data from the German Federal Statistical Office were analyzed with respect to the correlation between the incidence of a chronic pain diagnosis and household income.

RESULTS

At 1546 €, the average household income of the patients studied was below the poverty level. The analyzed data showed that women suffered from chronic pain more often than men did and also had a lower income. Another economic inequality was found between Eastern and Western Germany. There was a statistically significant correlation between income and the incidence of the diagnostic codes for chronic pain (R52.1, 2, 9) for men.

CONCLUSION

Our investigation showed the correlation between chronic pain and poverty. A commitment and cooperation of German medical associations and federal politics is necessary to overcome this sociopolitical issue.

[Spinal cord stimulation for thalamic pain: Case report and review of the current literature]

BACKGROUND

Spinal cord stimulation (SCS) is an established procedure for treatment of chronic neuropathic pain of peripheral origin. The efficacy of SCS in case of central poststroke pain (CPSP), especially thalamic pain, has not been adequately proven.

OBJECTIVES

The efficacy of SCS as an extracranial neurostimulation method for the management of central pain syndrome was investigated.

MATERIALS AND METHODS

In this study, relevant pharmacological and nonpharmacological measures for central pain management were reviewed. A case of successful SCS for thalamic pain after ischemic insult is presented. Explanatory approaches of pathophysiological processes and a review of the current literature underline our results.

RESULTS

In the case presented, SCS was found effective in the treatment of thalamic pain.

CONCLUSION

The efficacy of SCS might be caused by segmental and supraspinal processes and collaboration of activating and inhibiting pathways. The integrity of the spinothalamic tract is mandatory. SCS is a treatment option for central pain syndrome, especially thalamic pain. Comparable studies confirm the potency of this technique. In contrast to other neuromodulation procedures spinal cord stimulation is less invasive, has a lower perioperative risk and is often less expensive. Further studies are needed to define its potential and role in the treatment of thalamic pain.

Short Psychological Intervention as a Perioperative Pain Reduction Treatment in Spinal Neurosurgery

STUDY AIMS

The aim of the present pilot study was to test the feasibility of an innovative Short Psychological Intervention (SPI) for back pain patients as part of an acute inpatient neurosurgical treatment. Fear and fear-avoidance beliefs have been shown to influence the functional outcome in chronic back pain (CBP) patients. Therefore, a reduction of fear and fear-avoidance beliefs should improve the functional outcome and reduce pain in the acute neurosurgical setting.

PATIENTS AND METHODS

39 patients were studied in a randomized prospective longitudinal study. The patients had severe degenerative spinal disease and had undergone posterior lumbar interbody fusion.

RESULTS

All patients enrolled in the study were investigated in the immediate preoperative period and 6 weeks postoperatively using a package of standardized questionnaires in which pain intensity, fear-avoidance beliefs, and physical fitness were recorded. In 19 of the patients, the surgical procedure was supplemented by a SPI based on methods to increase self-efficacy by reducing fear-avoidance beliefs. While the intervention group reported a significantly greater reduction in the highest pain intensity and a better physical fitness compared to the control group, we did not find a significant decrease in fear-avoidance beliefs in the intervention group at the second time of assessment, possibly due to the relatively small sample size.

CONCLUSIONS

The study confirmed that psychological interventions can offer significant benefits when used in the acute inpatient setting as the outcome of surgery can be positively influenced. Future studies should focus on cost savings related to improved postoperative recovery and a possible reduction of chronic postoperative pain.

[Space-occupying tumor of the temporal region with facial nerve palsy, vestibular dysfunction and hearing loss]

A 73-year-old female patient complained of right-sided facial pain, progressive loss of hearing, giddiness when changing position, a pre-auricular swelling and lack of facial expression. Clinically there was a right-sided indolent and immovable swelling approximately 7 cm in size and an incomplete ipsilateral acute peripheral facial paralysis. Magnetic resonance tomography revealed a space-occupying lesion approximately 75 mm in diameter right temporal and multilocular metastases in the pelvis, spinal column, clavicle and skull. Histology showed this to be a well to moderately differentiated adenocarcinoma with centers of positive immune response to GCDFP-24 (gross cystic disease fluid protein). The subsequent computed tomography of the thorax and mammography located the approximately 25 mm in size primary tumor in the left breast. After surgery and radiation therapy the TNM classification was a tubular adenocarcinoma of the left breast grade 2, T2N0M1 (OSS multiple osseous, BRA brain) stage IV.

[Operative therapy for intraspinal empyema: a retrospective study of 23 patients]

OBJECTIVE

Intraspinal empyema is a rare entity in spinal surgery. This study analyses the results after operating in 23 patients.

MATERIAL AND METHODS

This is a retrospective study of 23 patients suffering from intraspinal empyema treated operatively in our department. The data were obtained by analysing the patient documents including the radiological and microbiological data.

RESULTS

18 patients suffered from different neurological deficits ranging from isolated mild hypaesthesia to paraplegia (n = 3). The operation was done as a one-level (n = 13), two-level (n = 8)or three-level (n = 2) microsurgical fenestration followed by irrigation and drainage of the pus. Staphylococcus aureus was the most frequent triggering organism. After a follow-up of 7 months 1 patient had died because of septic complications. Neurological deficits improved in 14 patients but 3 patients were still disabled in their daily life.

CONCLUSION

Epidural spinal empyema remains a challenge in spine surgery. Persistent neurological deficits and lethal complications make it a severe problem. Management comprises urgent surgical evacuation of the pus followed by targeted antibiotic therapy.

[Operative therapy of bacterial spondylodiscitis: a retrospective study]

OBJECTIVE

Bacterial spondylodiscitis is a rare entity in spinal surgery. This study analyses the postoperative results of 53 patients, focusing on the history, the treatment, and the course of the disease.

MATERIAL AND METHODS

This retrospective study is based on the patients' medical charts, including the laboratory and microbiological data.

RESULTS

Twenty-nine patients suffered from different neurological deficits ranging from isolated mild hypaesthesia (n=1) to complete paraplegia (n=6). Depending on the affected area and the extension of the infection, surgery was done either as simple decompression in 16 cases or as decompression combined with a ventral or dorsoventral stabilization in 37 patients. Staphylococcus aureus was the most important triggering organism (n=23). After a median follow-up of 11.25 months, three patients had died, and 22 patients were still disabled because of persisting pain or neurological disturbances.

CONCLUSION

Because of persistent neurological deficits and possible lethal complications, spondylodiscitis remains a severe problem. Management comprises targeted antibiotic therapy and surgery in selected cases.

Pyogenic infections of the central nervous system secondary to dental affections--a report of six cases

Pyogenic infections of the central nervous system of dental origin are quite uncommon in industrialized countries. We report six cases with intracerebral (n = 4) and intraspinal (n = 2) infections treated in our hospital. The microbial pathogen was successfully isolated in all patients. Fusobacterium nucleatum as well as Streptococcus species were found in three cases. Bacillus species were identified in two patients. Actinomyces was the etiologic agent in one case. All patients suffered from dental pathologies, so that after clinical and radiological exclusion of other sources an oral focus was presumed. Therapeutic management consisted of an operative procedure in order to obtain decompression, as well as evacuation of the pus on the one hand, followed by targeted antibiotics on the other. Clinical improvement was achieved in all patients, with one patient lost to follow-up. On magnetic resonance tomography, the inflammatory changes also disappeared in all cases. We recommend that oral infection with recurrent bacteraemia should always be considered in the pathogenesis of the so-called "cryptic" intracerebral and intraspinal infections.

Outcome after decompressive craniectomy in patients with severe ischemic stroke

Decompressive craniectomy after space occupying infarction of the middle cerebral artery (MCA) tends to decrease mortality and increase functional outcome. The aim of this retrospective study was to evaluate mortality rates and functional outcome in our centre and to identify predictors of prognosis. The charts of 30 consecutive patients (6 women, 24 men, mean age 59.3 +/- 11.0 years) who underwent craniectomy after space occupying MCA-infarction from 1996 to 2002 were analyzed. Functional outcome was assessed by semistructured telephone interview as Barthel-Index, modified Rankin scale and extended Barthel-Index. Five patients (mean age 67.2 +/- 6.1 years) died within 5.2 +/- 2.4 days (range 2-8 days) after the first symptoms due to herniation. Nine patients (mean age 63.1 +/- 7.1 years) died 141.0 +/- 92.5 days (range 40-343) after stroke onset due to internal complications. 16 patients survived (mean surviving time 2.1 +/- 1.5 years, mean age 54.1 +/- 11.4 years). Mortality was related to age and the number of risk factors/comorbidity, and functional outcome was dependent on the number of risk factors/comorbidity. Our small observational, retrospective study suggests that hemicraniectomy in patients with space occupying MCA-infarction decreases mortality rate and increases functional outcome. Further randomized trials may prove useful to better define the indications, timing and prognosis for this procedure.

Resolution of a synovial cyst of the lumbar spine without surgical therapy -- a case report

Synovial cysts originating from the facet joint of the lumbar spine are a rare cause of radiculopathy. Surgical resection is considered to be the treatment of choice, although very little is known about the natural history of spinal synovial cysts. Only six cases have been published up to now concerning the spontaneous regression of a cyst without invasive therapy. We present the history of a patient suffering from sciatic pain caused by a synovial cyst at the level of L4/5, and we describe the spontaneous remission of the cyst, discussing the radiological and clinical findings and comparing our findings with respect to the current literature.

CLINICAL PRESENTATION

The patient suffered from sciatic pain for 5 months without neurological deficits. Magnetic resonance tomography revealed a cystic structure adjacent to the facet joint L4/5. Presuming a synovial cyst, we scheduled surgery and at the same time started conservative treatment, including physical therapy and analgesic medication. The patient's condition improved significantly during conservative treatment, so that surgery was cancelled. A second magnetic resonance tomography showed that the cyst had dramatically shrunken, without any narrowing of the spinal canal.

CONCLUSIONS

Up to now, synovial cysts of the lumbar spine have usually been treated operatively, but we and others have shown that spontaneous resolution of the cyst seems possible, so that extensive conservative treatment should always be considered as the first therapeutic option, provided that there are no severe neurological deficits.

High resolution susceptibility weighted MR-imaging of brain tumors during the application of a gaseous agent

PURPOSE

To employ a high resolution blood oxygenation level dependent (BOLD) method called susceptibility weighted imaging (SWI) together with the breathing of carbogen to investigate the response of cerebral tumors to this breathing gas and to assess tumor anatomy at high resolution.

METHODS

Five patients with cerebral tumors (four glioblastoma multiforme, one astrocytoma [WHO grade II]) were studied using a susceptibility weighted 3D gradient echo, first order velocity compensated sequence (TE = 45 ms, TR = 67 ms, alpha = 25 degrees , FOV = 256 x 192 x 64 mm(3), typical matrix = 512 x 192 x 64), on a 1.5 T MR scanner while they were breathing air and carbogen. Signal changes between the two breathing conditions were investigated.

RESULTS

The glioblastomas showed strong but heterogeneous signal changes between carbogen and air breathing, with changes between + 22.4 +/- 4.9 % at the perimeter of the tumors and - 5.0 +/- 0.4 % in peritumoral areas that appeared hyperintense on T (2)-weighted images. The astrocytoma displayed a signal decrease during carbogen breathing (- 4.1 +/- 0.1 % to - 6.8 +/- 0.3 % in peritumoral areas that correspond to hyperintense regions on T (2)-weighted images, and - 3.1 +/- 0.1 % in the tumor-center).

CONCLUSIONS

SWI provides high resolution images of cerebral anatomy and venous vascularization. Combined with hypercapnia it allows for regional assessment of tumor activity.

[Vertebral body replacement system Synex in unstable burst fractures of the thoracic and lumbar spine--a retrospective study with 30 patients]

OBJECTIVES

Retrospective analysis of the vertebral body replacement system Synex in unstable burst fractures of the lumbar and thoracic spine.

PATIENTS AND METHODS

Within 22 months, we treated 30 patients (average age: 45, range: 20- 73 years, 16 females, 14 males) with unstable burst fractures of the thoracolumbar (n=20) and the thoracic (n=2) as well as lumbar (n=8) spine in two stages (primary dorsal transpedicular stabilization with fixateur interne under navigator guidance and intraoperative CT and secondary vertebral body replacement using the Synex). In three patients with osteoporosis we performed additional ventrolateral plate fixation. The complications of the operation were analyzed and the postoperative follow-up results were evaluated regarding stability, bony fusion, loss of correction, pain and neurological status.

RESULTS

There was one postoperative instability, two transient neurological deteriorations and one case with seroma of the pleura. At follow-up examination (mean follow-up 14 months) an average loss of correction of 1.6 degrees was measured. Without osteoporosis a loss of correction of 5 degrees was observed in one case. In four osteoporotic patients without ventrolateral stabilization a mean loss of correction of 10 degrees was present. At the follow-up examinations a bony fusion was documented in 27 and stability in all patients. Most of the patients stated either no or only minor pains at follow-up. Only two patients with pain of medium degree had to take pain medication.

CONCLUSIONS

The vertebral body replacement system Synex is a good technical possibility for a vertebral body replacement in unstable burst fractures of the thoracic and lumbar spine. With osteoporosis an additional anterior stabilization is to be recommended.

Intraoperative computerized tomography for improved accuracy of spinal navigation in pedicle screw placement of the thoracic spine

We report on our experiences with the use of intraoperative CT imaging in surgery of the thoracic spine and on our results of pedicle screw insertion using spinal navigation and implantable fiducial markers. For our operations we used the Tomoscan M-EG and the EasyGuideSpine (Philips Medical Systems). During the operation the patient was positioned on the mobile CT table. Following dorsal preparation, small titanium screws were implanted in the vertebrae so as to serve as fiducial markers. Image data were obtained by performing a spiral CT scan. Ventilation was suspended for the duration of the CT scan. Screw insertion as well as vertebral biopsies were performed using spinal navigation. Intraoperative CT scans were obtained to confirm the position of the implants and to assess the amount of bony decompression as well as the realignment. Since 1998, 112 patients with various disorders of the thoracic spine have been operated on using the described technique. 365 screws were inserted in the area of T1 to T12. There were 23 (6.3%) misplacements of pedicle screws. In 42 cases (11.5%) we observed a minimal lateral perforation (<2 mm) of the pedicle wall. No neurological, cardiovascular, or pulmonary injury occurred. Intraoperative CT imaging influenced surgical decisions as well as the final result of surgery. Despite the use of intraoperative imaging and accurate spinal navigation, pedicle screw placement in the thoracic spine remains extremely challenging.

Neuronavigation in surgery of intracranial and spinal tumors

PURPOSE

To demonstrate the new possibilities and advantages of neuronavigation in the surgery of intracranial and spinal tumors, based on patient populations treated in our hospital.

MATERIALS AND METHODS

An infrared navigation system with integrated microscope guidance was used for frameless intracranial neuronavigation. The biopsies of intracranial tumors were carried out using a frame-based stereotactic technique. Intracranial navigation was, in part, combined with the use of an intraoperative CT scanner and a three-dimensional ultrasound system for data acquisition, correction of brain shifts, and intraoperative quality control. The navigation was also supported by presurgical brain mapping with magnetic source imaging. Navigation in spinal surgery was exclusively performed using an infrared navigation system in combination with an intraoperative CT scanner.

RESULTS

The stereotactic tumor biopsies (n = 57) were carried out with an accuracy of 91.4% as compared with the histological diagnosis. The work flow of stereotactic procedures could be increased by using the intraoperative CT scanner. Fifty-seven patients with intracranial tumors were treated with the aid of neuronavigation between July 1997 and December 1999. These patients showed an improvement from 80% to 86% on the Karnofsky index 8 weeks postoperatively. The majority of intracranial cases were primary brain tumors (n = 30) and metastases (n = 13) in functionally important areas of the brain. In four patients, a significant brain shift was observed during neuronavigation, and could be corrected by an image update using either the intraoperative CT scanner (n = 2) or the three-dimensional ultrasound system (n = 2). The presurgical brain mapping with magnetoencephalography was shown to be reliable in the sensory cortex (n = 25). Eleven patients with a thoracic or lumbar tumor were treated by open surgery or stabilization, using a combination of spinal neuronavigation and the intraoperative CT scanner. Two patients with spinal tumors underwent navigated biopsies. Neither of them showed a reduction in the clinical stage, but the Karnofsky index improved from 63% up to 72% 8 weeks postoperatively.

CONCLUSION

Neuronavigation allows very precise intracranial and spinal surgery. The problem of brain shift during the navigation procedures has been solved by intraoperative image acquisition. The use of neuronavigation was shown to improve the postoperative quality of life of patients suffering from brain and spinal tumors.

Source localization and possible causes of interictal epileptic activity in tumor-associated epilepsy

Electrophysiological studies in gliomas have demonstrated action potentials in neoplastic cells. These "spiking tumor cells" are, however, an enigma. In attempt to find evidences for spikes within tumoral borders, 21 patients with different intracerebral tumors were preoperatively screened for the occurrence of epileptogenic discharges using multichannel MEG and EEG. A correlation between histopathology and the distance between dipole and tumor border could be found. Glioma patients showed epileptic activities closer to the border than those with mixed glioneuronal neoplasms and metastases. Four glioma patients demonstrated epileptic activity within the tumor boundary, however, not in the deep center of the tumor. Patch-clamping of cells from acute glioma slices did not yield a correlation between the presence of voltage-gated sodium channels in tumor cells and the MEG/EEG data. Our results demonstrate that the zone with the highest epileptogenic potential is different in gliomas and other brain tumors. However, our data do not strongly suggest that glioma cells are directly involved in the generation of tumor-associated epilepsy in vivo via their capability to generate action potentials.

May 1999--16 year old male with an unexpected MRI finding

Four years after resection of a supratentorial pilocytic astrocytoma this 16-year-old boy displayed widespread leptomeningeal seeding. Although the primary tumor lacked contrast enhancement, the multiple metastatic nodules were markedly contrast enhancing. Both the initial and disseminated tumor were consistent with a pilocytic astrocytoma. He was treated with vincristin and carboplatinum and the tumor was stable up to Dec. 1998. Dissemination of low-grade intracranial astrocytoma in children occurs in only 4%. It is not a sign of malignancy. The present case is similar to previously published cases. The prognosis of these patients might be quite favorable when treated with radiotherapy and/or chemotherapy.

Functional thrombin receptor PAR1 in primary cultures of human glioblastoma cells

In this study we investigated primary cultures obtained from two glioblastomas surgically removed from a 64-year-old man and a 50-year-old woman, respectively. The presence of the tethered ligand thrombin receptor PAR1 (protease-activated receptor 1) in these cells was demonstrated at the level of receptor binding by using immunofluorescence studies with the monoclonal anti-PAR1 antibody Mab 31-2. Stimulation of human glioblastoma cells both with alpha-thrombin and the thrombin receptor activating peptide TRAP-6 resulted in a series of [Ca+]i spikes as shown by confocal laser fluorescence microscopy with fluo-3 as calcium sensitive fluorescence indicator. This effect was completely blocked with the thrombin receptor antagonist peptide T1. Our results demonstrate functional thrombin receptors (PAR1) in primary cultures of human glioblastomas for the first time.

GABA binding sites: their density, their affinity to muscimol and their behaviour against neuroactive steroids in human gliomas of different degrees of malignancy

The aim of the present investigation was to answer the question if there exists a relation between the equipment of human gliomas with GABA binding sites and the degree of malignancy of these tumours diagnostically characterized according to WHO classification. The following parameters were assessed: the density, the affinity and the sensitivity to the modulating steroids 3 alpha-hydroxy-5 alpha-pregnane-20-one (3 alpha OH-DHP) and 3 alpha,21 dihydroxy-5 alpha-pregnane-20-one (THDOC). Scatchard analysis and non linear computerization revealed that the occurrence of GABA sites was directly related to the degree of tumour malignancy: GABA sites were only detectable in lower malignant gliomas of WHO grade II but not in the very malignant glioblastomas. However, irrespective of the individual density to be detected all glioma GABA sites were sensitive to 3 alpha-hydroxy-5 alpha-pregnane-20-one (3 alpha OH-DHP) and 3 alpha,21 dihydroxy-5 alpha-pregnane-20-one (THDOC) without exception. The effects of THDOC were due to increases in the number of binding sites whereas in the presence of 3 alpha OH-DHP a decrease in affinity was noted, additionally. These findings support the view of a normal functional integrity of GABA receptors in gliomas.

[The scar tissue protective effect of free autologous fatty tissue transplants. An animal experiment on spinal surgery]

All spinal operations can be followed by the formation of extensive epidural scar tissue. The development of fibrous adhesions around the nerve roots is known to be the main cause of recurrent symptoms after lumbar discectomy. In the past many materials have been used to prevent or to reduce postlaminectomy membrane, with very different results. They have to be implanted onto the dura at the end of the operation. Therefore, we carried out the following controlled experimental study in dogs to compare the materials that seemed to be most suitable. In 30 adult beagles three lumbar laminectomies were performed. For each level a different material was used--free autologous fat graft, cellulose mesh, gel foam, triamcinolone suspension. Animals were sacrificed after 7 days and 1, 3, and 6 months. The lumbar vertebral columns were prepared for further histological examination. We found that free autologous fat grafts reduce epidural scarring in a high percentage, especially after 3 and 6 months. Only in this group good or excellent results were found at all lumbar levels (n = 18). To compare the results with each other we used a newly developed classification scheme (I-IV). The consistency and extent of scar tissue, the kind of cellular infiltrations, and adhesions to the surrounding structures were estimated separately. Cellulose mesh yielded the worst results. We conclude that free autologous fat is superior to other materials, because of: (1) simple and uncomplicated operative handling, (2) good compatibility and (3) effective prevention of postlaminectomy membrane.

[Prognostic factors in acute traumatic epi- and subdural hematoma]

The results of a retrospective study on the outcome of 147 patients with acute traumatic epidural and subdural haematomas are presented. It is shown that several factors have a significant influence on the outcome of these patients (e.g. type of haematoma, injuries of other organ systems, and findings on admission. Our conclusions: 1. Epidural haematomas have a far better prognosis than subdural haematomas. 2. For both types of haematoma the initial findings and duration of coma seem to be the main predictors of outcome. 3. The patient's age does not significantly influence outcome. 4. As for subdural haematomas, concomitant brain injuries are of greater importance to the outcome than the effects of the haematoma itself.

[Radicular paralysis with reference to lumbar root compression syndromes. Incidence, extent and follow-up in a neurosurgical patient sample]

This is a retrospective study of 170 patients which were operated on for lumbar intervertebral disc herniation. The mean follow-up was 8 weeks. All patients showed muscular weakness before operation. Incidence, severity, and natural history of motor deficit following lumbar discectomy are reported. Moreover it was of special interest to analyze the effect of sex, age, severity and duration of muscular weakness, and timing of surgery on changes in radicular function.

Operative spondylodesis in injuries of the lower cervical spine

In view of the high incidence of late instability during conservative treatment of cervical spine fractures, operative stabilization should be performed as soon as possible. Besides immediate decompression of the spinal cord, rapid mobilisation of the patient without external fixation is possible. We report on the results of operative treatment in 97 patients with injuries of the lower cervical spine. The indication for spondylodesis as well as the surgical methods and their complications are discussed.

Comparative experimental biomechanical study of different types of stabilization methods of the lower cervical spine

In a comparative experimental biodynamic study using thirty-two human cervical spines of cadavers the primary stabilization effect of different types of spondylodesis was examined. Whereas in flexion stress all methods showed a sufficient stability, the rotation tests proved, that in case of a dorsal instability of the lower cervical spine, posterior interlaminar wiring or anterior plate stabilization showed no reliable stabilization effect. However, the compression clamps by ROOSEN and TRAUSCHEL as well as the hook-plates by MAGERL are suitable dorsal stabilization methods with excellent rotation stability. In case of dorsal instability of the lower cervical spine a posterior spondylodesis is necessary and sufficient.

Subarachnoid hemorrhage of unknown origin. Longterm prognosis

Patients suffering subarachnoid hemorrhage in whom angiography does not initially show vascular malformation and CT scan rules out an intracranial tumor, have, reportedly, a good prognosis with a rate of recurrent hemorrhage of about 2-10% within a follow-up time of up to 15 years. Most authors denied indication for control angiography. In order to study the benefit of control angiography performed after 4-6 weeks, four-hundred eighty-three patients with SAH but without ICH were reveiwed, and the longterm clinical course of 98 patients with SAH of unknown origin treated in our department between 1976 and 1988 was investigated. Among 183 patients who underwent control angiography, a second angiography showed an aneurysm in 143. The third angiography was positive in a further 18 patients. Recurrent SAH occurred early only in patients who had undergone only one angiography. One patient died from intracerebral hemorrhage of unknown origin two years following SAH. These data support the need for control angiography in cases of SAH.

Spontaneous intracerebral hemorrhage

We report on 146 patients with spontaneous intracerebral hemorrhage treated in the period between 1984 and 1988. The aim of this retrospective study was to point out factors for operative respectively conservative treatment. Looking for etiology, age, unconsciousness, localization and extension of hematoma as well as bleeding into the ventricles our results showed that patients over 70 years of age and/or in coma III and IV (Brussels Coma Scale) have a bad prognosis as well as patients with intraventricular bleeding. Patients seem to benefit from operation if hematoma is located in the hemisphere or cerebellar and the extension ranges from 3 to 5 cm.

Biomechanics of fixation systems to the cervical spine

The biomechanical evaluation of a cervical spine implant must include flexural and torsional testing if it is used for stabilizing a traumatic unstable motion segment. A cadaveric model is presented that allows flexural and torsional testing of a cervical spine motion segment, measuring the tilting angle, the translation, and the torsional angle. After measuring the intact segments, in the first series, a so-called posterior instability was created and stabilized posteriorly with the hook-plate and sublaminar wiring; anteriorly with the H-plate; and with combinations of these implants. In a second series, their stabilizing effect after complete discoligamentous instability was tested. With isolated posterior instability, it was found that the flexural stability is preserved, whereas torsional stability is markedly reduced. In cases of isolated posterior instability, only hook plating alone or its combination with anterior H-plating seemed to bring about a higher torsional stability than the intact specimen. In cases of complete discoligamentous instability, only anterior H-plate and posterior hook plate procedures combined or the hook plate alone was able to guarantee both torsional and flexural stability higher than the intact spine. Exclusive posterior wiring without postoperative external immobilization in complete discoligamentous instability may result in permanent subluxation of the functional unit. Exclusive anterior H-plate fixation in complete discoligamentous instability requires additional external immobilization in the postoperative phase to prevent flexion and torsion.

[Complications of ventral fusion operations in degenerative intervertebral disk diseases]

1112 anterior cervical fusion operations were performed on 951 patients according to the method described for the first time by Grote in 1970. The neurogenic, mechanical and inflammatory complications arising with this method are described. The typical complications are demonstrated by means of case reports and their possible causes are discussed. The incidence rate of the individual complications is compared with that reported in the literature for a total of 8366 fusions performed on 6384 patients.

[Posttraumatic headache : Observations in a pain clinic.]

Following head trauma many different forms of headache can develop. Complaints in the early post-traumatic period appear to be organic in most cases. Later in the course post-traumatic headache frequently shows a psychogenic picture. Describing the causative factors and discussing the therapeutic guidelines, the authors explain how psychological influences can form chronic pain syndromes.

[Intracranial complications of inflammatory ear diseases]

Acute and chronic ear infection can lead to intracranial complications, brain abscess and meningitis being the most serious. The clinical picture, diagnosis and therapeutic guidelines are discussed. The important role of interdisciplinary management is emphasised by a case report.

Clinical outcome after head injury in children

For at least 1 year we have done a follow-up on 178 children under the age of 18 years with head injuries treated between 1981 and 1987. The Brussel Coma Scale and the Glasgow Outcome Score were used to determine neurological deficits and patient outcome. In children with coma, there was good recovery or moderate disability in 71.4%, severe disability in 6.1%, and death in 22.5%. When all head injuries were taken into consideration, a satisfactory outcome was found in 84.3%, severe disability in 3.3%, and death in 12.4%. The outcome mainly depended on the initial coma grade, but the duration of coma or advanced age were also negative factors for outcome. In 14.8%, intracranial mass lesions showed no significant correlation with outcome. In contrast to adults, diffuse brain swelling had a satisfactory outcome in 85.1%.

Computerized tomography after internal fixation of the spine

32 patients with internal fixation of the spine were postoperatively examined by computerized tomography. Details of metallic osteosynthetic material were demonstrated in all our cases. Bony structures were well defined in 27 patients, whereas soft tissue imaging was degraded by scattering artifacts in 14 of 20 examinations. Application of intrathecal contrast medium, however, was helpful for the evaluation of intraspinal soft tissues. Involvement of extraspinal soft tissues could be interpreted on the basis extent of vertebral osseous destruction.

Spinal metastasis of pilocytic astrocytoma of the chiasma opticum

We report a case of spinal seeding of a pilocytic astrocytoma of the chiasma opticum. Microscopic examination of the optic nerve tumor and the spinal tumor showed the same pathological patterns, without any signs of anaplastic transformation. The clinical course demonstrates the low growth rate of this kind of tumor, but spinal metastasis has not yet been described. We discuss different pathophysiological explanations of this atypical biological behavior with reference to the literature.

[Thromboembolism as a complication of Pudenz-Heyer drainage with cardiac shunt]

We report the case of a 2.7 year old boy with ventriculoatrial Pudenz Heyer shunt for hydrocephalus internus presenting with symptoms suggestive of shunt infection. 2D-echocardiography showed a pedunculated right atrial thrombus that prolapsed through the tricuspid valve in diastole. Scintigraphy of the lungs showed multiple defects suggestive of embolism. The thrombus was excised after exploratory surgery with cardiopulmonary bypass. No organisms could be isolated from the thrombus. In ventriculo-atrial Pudenz Heyer shunt thrombi and embolism are possible complications. The regular use of 2D-echocardiography in order to detect these thrombi at a very early stage is discussed.

[Granular cell tumor of the orbit]

The authors report on the rare case of the intraorbital localisation of a granular cell tumour. Nature, histogenesis and biological behaviour of this lesion are discussed. The therapeutical consequences are presented.