Flow-cytometric DNA analysis of intracranial tumors in children.

The objective of this study was to investigate flow-cytometric DNA values of pediatric intracranial tumors, and to establish DNA analysis as a potential prognostic parameter. Twenty-nine brain tumor specimens from 26 pediatric patients were cryo-preserved within a 3-year period. The DNA content was measured by flow cytometry. Six of the tumor specimens had aneuploid DNA patterns. The median of the proliferation index was lower in the survivor group compared with the non-survivor group (36.4% and 47.5%, respectively). Ten of the 26 patients are still alive, eight were lost to follow up, and eight died. Flow-cytometric DNA analysis may be a helpful tool for examining brain tumors in children.…

A sphenoorbital encephalocele — clinical, radiological, and morphological findings

We report here on congenital sphenoorbital encephalocele which could not be disclosed by computed tomography including contrast medium application or by orbital sonography. Surgery and histological examination were necessary to establish correct the diagnosis.

Magnetic resonance imaging of dysraphic myelodysplasia

The spinal cord in 56 children and adolescents was examined by magnetic resonance imaging (MRI) many years after neonatal surgery on a meningomyelocele (average age 12 years). In a high percentage of cases, the diagnosis "tethered cord" was made. Associated anomalies were found with a frequency of 21%. Typical findings are presented and the impact of these results on therapy planning is discussed.

Bovine pericardium for duraplasty: clinical results in 32 patients.

Bovine pericardium has been widely used for grafts in cardiac surgery and seems to have suitable properties for use as a dural graft. We report on the use of solvent-preserved, gamma-sterilized Tutoplast bovine pericardium for dural grafts in 32 patients undergoing cranial and spinal operations with the objective of clinically assessing this material and technique by a retrospective analysis. All available records were reviewed and information regarding the indication for grafting, complications, and outcome were collected and analyzed for all patients. Indications for grafting included tethered cord myelolysis, closure of lumbosacral myeloceles, Chiari decompression, posterior fossa cranio…

Endo-neuro-sonography: principles and 3-D technique

To evaluate the usefulness of transendoscopic sonography we studied two new sono probes 6 F in diameter in 17 fresh specimens. We saw precise imaging of well-known anatomical structures and also gained an additional dimension in endoscopy, as the sono adds to the endo-view a transverse scan like a mini-CT at the tip of the probe. We also experienced the navigation characteristic of this imaging technique, both in real time and on line. Some 3-D reconstructions of the ventricular system were examined. The equipment has been used in clinical practice and must now be adapted for neurosurgery.

Confluens-sinuum-Obstruktion durch Langerhanszell-Histiozytose

Die Langerhanszell-Histiozytose, bis vor wenigen Jahren als Histiozytose X bezeichnet, umfast 3 verschiedene Syndrome, namlich das eosinophile Granulom, die Hand-Schuller-Christian-Krankheit sowie die Abt-Letterer-Siwe-Krankheit, und gehort zu den seltenen Erkrankungen des Kindesalters. Wir berichten uber einen 10 jahrigen Jungen, der mit einer Schwellung am Hinterkopf und beginnender Hirndrucksymptomatik zur stationaren Aufnahme kam. Klinik, konventionelle radiologische Diagnostik und Computertomographie liesen differentialdiagnostisch ein eosinophiles Granulom als wahrscheinlich erscheinen. MRT und MRT-Angiographie zeigten jedoch die akute Bedrohung des Patienten durch das intrakraniale W…

Orthopedic and neurosurgical treatment of severe kyphosis in myelomeningocele

Kyphosis in myelomeningocele is characterized by a complex pattern of problems during development and therapy. On the one hand, decompensation of upright posture leads to loss of sitting ability and social integration; on the other hand, accompanying malformations and trophic alterations threaten the physical integrity and performance. Neurologic function, cerebrospinal fluid (CSF) circulation, skeletal deformity and the urinary transport system need to be kept in mind and need to be treated with cooperation between the different specialties. Especially during serious surgical interventions such as spinal surgery, neither the nervous system nor the kidneys must be ignored. Sixteen patients …

Magnetic resonance imaging in primary cerebral neuroblastoma

Prevention of deep vein thrombosis in neurosurgical patients: a prospective double-blind comparison of two prophylactic regimen.

In a prospective, randomized, double-blind investigation of anticoagulant agents for prevention of deep vein thrombosis in patients undergoing operations at the lumbar-vertebral disc, 179 patients were randomly allocated to two groups. 87 patients received a fixed combination of low-molecular weight heparin 1,500 U-aPTT plus dihydroergotamine 0.5 mg (LMWH/DHE) once a day and additionally one injection of placebo per day, 92 patients received a fixed combination of sodium heparin 5,000 U plus dihydroergotamine 0.5 mg (HDHE) twice a day. Treatment was initiated two hours preoperatively in both groups and continued for at least seven days. Deep vein thrombosis (DVT), detected by the 125Iodine-…

Cerebral and spinal MR-findings in patients with postrepair myelomeningocele

In 114 patients with postrepair myelomeningocele MRI of the spine was performed. Tethered cord (89%) and associated malformations (syrinx, lipoma etc.) (33%) were the most important findings. Additional MRI scans of the head (44 patients) revealed numerous further anomalies. Arnold Chiari malformation was found in 76% of the patients (ACM I: 32%, ACM II: 44%). In the ACM II group compression of lower cranial nerves, brain stem, and cerebellum can lead to considerable neurologic symptoms. Therefore in patients with progressive neurologic dysfunction a complete investigation of the whole spine and brain is necessary. MRI proves to be the diagnostic procedure of choice in patients with dysraph…

Development of a Scoring System to Evaluate the Severity of Craniocervical Spinal Cord Compression in Patients with Mucopolysaccharidosis IVA (Morquio A Syndrome).

BackgroundAs spinal cord compression at the craniocervical junction (CCJ) is a life-threatening manifestation in patients with mucopolysaccharidosis (MPS) IVA, surgical decompression should be performed before damage becomes irreversible. We evaluated the diagnostic value of several examinations for determining the need for decompression surgery.MethodsWe retrospectively analysed results of clinical neurological examination, somatosensory evoked potential (SEP) and magnetic resonance imaging (MRI) in 28 MPS IVA patients. A scoring system - based on the severity of findings - was used to compare results of patients with and without indication for decompression surgery. Individual test scores…

URINARY DIVERSION AND ORTHOTOPIC BLADDER SUBSTITUTION IN CHILDREN AND YOUNG ADULTS WITH NEUROGENIC BLADDER: A SAFE OPTION FOR TREATMENT?

Combined pharmacotherapy, clean intermittent catheterization and infection prophylaxis is currently the gold standard of treatment for neurogenic bladder. However, as the adolescent gains independence from parental supervision, the intervals of clean intermittent catheterization compliance with medical treatment and regularity of followup examinations may decrease, and neurological and/or orthopedic status may change. This situation sometimes leads to failure of conservative treatment, resulting in incontinence and/or deterioration of the upper urinary tract. A multidisciplinary team was established at our institution 30 years ago to assess all aspects of care for patients with neurogenic b…

Fine structural features of the cerebral microvasculature in hydrocephalic human infants: correlated clinical observations.

Four of 30 human cerebral cortex biopsies from infants ranging from four days to about ten years treated for hydrocephalus by shunt operations are described paying special attention to the vascular structures. The biopsy specimens were studied in semi-thin and ultrathin sections. Attention is drawn to the role of pinocytotic vesicles found in capillaries and smaller vessels as a possible transcellular route for the hydrocephalic oedema resolution. No intercellular dehiscences or the so called blisters were observed. With the passage of time, the number of membrane bound vesicles increased and arrays of pinocytotic vesicles were discernible both on the abluminal as well as luminal aspect of …

Development of scoliosis in myelomeningocele. Differences in the history caused by idiopathic pattern.

The natural history of scoliosis in the literature concerning the idiopathic and neuromuscular scoliosis in myelomeningocele patients (MMC) are compared to our own results in 12 patients with MMC and 89 patients operated because of an idiopathic scoliosis. According to known experiences the natural history of scoliosis in MMC is progression even after the end of growth. The chance of developing a scoliosis increases with the patients, age and the level of the lesion. The higher the level of paralysis the more common is a spinal deformity. In literature the progression rate of MMC scoliosis is 2.5-3.5 degrees per year, with the idiopathic pattern 0.5-0.65 degrees per year after end of growth…

Antibiotic single-dose prophylaxis of shunt infections.

Shunt infections after implantation or revision of a shunt for CSF drainage in hydrocephalic patients are serious complications. In view of their frequency, this study investigated the efficacy of prophylactic administration of a single dose of the antibiotic cefazedone in reducing in the post-operative infection rate. Fifty children of up to 14 years of age suffering from hydrocephalus of various etiologies were treated prophylactically and compared with a similar untreated group. The diagnosis of infection was based mainly on microbiological and clinical observations and investigations. Classical infection parameters were also recorded and evaluated, but played only a secondary role in es…

Primary myelomeningocele closure and consequences

Myelomeningocele, the most frequently occurring open neural tube defect, requires lifelong care of the patient by medical professionals and by relatives. A basic understanding of the neurosurgical measures that have to be taken in the newborn, the infant, the child and the adult is important also for physicians of other disciplines involved in the treatment of patients with myelomeningocele.The most recent topic broadly discussed in this context is the role of foetal neurosurgery for closure of the neural tube defect. There is ongoing debate as to whether the beneficial postnatal effects of a prenatal operation in the unborn foetus outweighs the possible complications for the mother as well…

Dreidimensionale Rekonstruktionen von computertomographischen Untersuchungen des knöchernen Schädels bei kraniofazialen Dysplasien und Frakturen

Eine Routineuntersuchung am CT gilt in der Regel nach Anfertigen der zweidimensionalen Querschnittbilder als beendet. Nahezu alle Computertomographen sind heute jedoch technisch dazu in der Lage, aus den Daten zweidimensionaler CT-Bilder ein dreidimensionales Oberflachenbild zu berechnen. Ein diagnostischer Nutzen dieser Sekundarrekonstruktionen wird oft angezweifelt, da im Vergleich zu den Querschnittbildern keine zusatzliche Information gewonnen werden kann [1, 3, 6, 15]. Unabhangig von dieser Tatsache zeigen jedoch diejenigen Chirurgen ein zunehmendes Interesse fur 3-D-Darstellungen, die in komplexen anatomischen Gebieten arbeiten und sich praoperativ eine optimale raumliche Vorstellung …

Assessment of brainstem function in Chiari II malformation utilizing brainstem auditory evoked potentials (BAEP), blink reflex and masseter reflex

Brainstem dysfunction was evaluated in 67 patients with myelomeningocele and Chiari II malformation using brainstem auditory evoked potentials (BAEP), blink reflex (BR) and masseter reflex (MR). Signs and symptoms related to Chiari II malformation were observed in 18 patients while 49 patients had normal brainstem findings. BAEP and BR showed a higher sensitivity of brainstem involvement than MR (BAEP=1.0, BR=0.83, MR=0.50). BR, and in particular, MR were of higher accuracy (BR=0.52, MR=0.72) than BAEP (0.39) in separating patients with brainstem signs and symptoms related to Chiari II malformation. We feel that this is due to anatomic and physiologic peculiarities of the brainstem structur…

Arachnoid cysts: does surgery improve epileptic seizures and headaches?

During the period from 1985 to 1992 we treated 43 patients with intracranial arachnoid cysts (ACs). In this retrospective study we assessed the outcome of these patients with regard to non-specific symptoms such as headaches and epileptic seizures. Twelve patients had headaches of obscure origin and a mostly temporal located AC. Six of these 12 underwent surgery. After the operation 4 patients (4/6) had no further headaches, two remained unchanged. The other 6 conservatively treated patients (6/12) had further headaches. Ten of the 43 patients had epileptic seizures. One patient dropped out of the survey. Six of the 9 remaining patients had a temporal AC. Four of these 6 underwent surgery; …

Cerebral spinal fluid flow, venous drainage and spinal cord compression in achondroplastic children: impact of magnetic resonance findings for decompressive surgery at the cranio-cervical junction

In order to investigate the diagnostic properties of MRI of the brain and spine in achondroplastic children with regard to decompressive surgery, 25 patients were examined by conventional morphological and by "functional" imaging of CSF flow and magnetic resonance angiography (MRA) of the veins and sinuses at the cranial base following a special protocol. The results were compared to those from age-matched controls and were correlated with each other and retrospectively with the neurological findings. Measurements of distances and angulations at the cranio-cervical junction (CCJ) from MR scans showed similar values to those from conventional radiographs and CTs and thus can be used without …

Clinical aspects and prognosis of ependymoma in infants and children

Thirty-two patients (22 boys and 10 girls) with a histologically confirmed diagnosis of ependymoma were treated between 1972 and 1999. A total macroscopic resection was achieved in 16 of these patients, whereas 15 resections were classified by the surgeon as subtotal. In 1 patient a ventriculostomy was created as part of a palliative strategy. All children over 3 years old were treated with postoperative radiotherapy. Chemotherapy consisted of procarbazine, ifosfamide, etoposide, methotrexate, cisplatin and cytosine arabinoside. There was 1 perioperative death. Twenty children developed a relapse of disease within 2 months to 13 years and 1 month after the initial therapy. A maximal number …

Tissue characterization of benign brain tumors: Use of NMR-tissue parameters

Abstract To evaluate the potentials of NMR tissue parameters for tissue characterization we investigated 68 patients with benign brain tumors. Tissue parameters were accurately measured by a recently developed interlaced triple sequence. Each individual tumor was characterized by a set of three numbers (relaxation times T 1 and T 2 and proton density Rho). Different tumors exhibited significant overlaps of the three tissue parameters. Therefore a reliable prediction of the histological diagnosis based on the quantitative analysis of tissue parameters alone was not possible. T 2 -prolongation correlated well with water content and “regressive changes” in meningiomas and neuromas.

Somatosensory evoked potentials in Arnold-Chiari malformation.

Abstract Nearly all patients with repaired myelomeningoceles have an Arnold–Chiari (AC) malformation and about 20% of these patients develop clinical signs of brainstem dysfunction. The management of symptomatic AC malformation is still controversial and techniques are needed to provide an objective assessment of brainstem function. We recorded somatosensory evoked potentials (SEPs) in 52 patients aged between 8 months and 20 years (median 7.3 years) with AC malformation, to determine whether the SEPs discriminate patients with symptomatic AC malformation from those without symptoms. The subcortical far-field components P13, P14 and N18, which are generated within the brainstem, were record…

Arterio-venous malformations in childhood: Clinical presentation, results after operative treatment and long-term follow-up

In a series of 182 arterio-venous malformations (AVM) recently published [8] we found 33 children aged 1 to 16 years. In 28 cases, the admitting condition was hemorrhage. For 31 AVMs total excision was possible. We observed one postoperative death accounting for a mortality of 3%. All children but two were followed-up by personal examination. Two were not able to work due to severe neurological deficits and seven had not been able to get into their intended occupation.

Hypertonic saline solution and decompressive craniectomy for treatment of intracranial hypertension in pediatric severe traumatic brain injury.

Experimental data 8 –11 and first clinical results in adults 12,13 suggest that hypertonic saline ( 1.0) may be highly effective in lowering ICP even when mannitol has lost its therapeutic potential after prolonged and repeated use. In children, only limited experience exists with the use of hypertonic saline solutions: a randomized prospective study in children with severe head injury compared the effects on ICP (increased to 15–20 mm Hg) of isotonic (0.9% NaCl) and hypertonic (3% NaCl) saline injections, demonstrating a beneficial effect of the hypertonic solution. 14 Another prospective randomized trial compared the effects of continuous infusion of either lactated Ringer’s solution (277…

Magnetic resonance imaging of postrepair-myelomeningocele — findings in 31 children and adolescents

Magnetic resonance imaging has clearly demonstrated its efficacy in the diagnosis of pathological processes in the C.N.S. We examined 31 children who had undergone plastic closure of myelomeningocele a few days post partum. We could show that a high percentage of the patients (89%) presented the pathological anatomy of a tethered spinal cord; clinical symptoms of the tethered spinal cord syndrome, i.e. progressive neurological symptoms, however, are rarely observed. Possible revision of neurosurgical treatment of MMC is discussed.

Masseter reflex and blink reflex abnormalities in Chiari II malformation.

Masseter reflex and blink reflex were evaluated in 64 patients with a myelomeningocele and Chiari II malformation. In 46 patients, no brainstem signs or symptoms were present. Brainstem dysfunction related to Chiari II malformation occurred in 18 patients. The masseter reflex was more frequently abnormal in the symptomatic than asymptomatic patients (P = 0.02). Although the blink reflex was similarly affected in the two groups of patients (P > 0.1), it was very sensitive, being abnormal in 83% of symptomatic and 65% of asymptomatic patients. Concomitant abnormality of masseter reflex and the late contralateral blink reflex component (R2c) was almost exclusively found in symptomatic patients…

Cerebral angiomas: Influence of morphological aspects such as size and site on their clinical behavior with special reference to the mode of bleeding

The following paper presents analysis of 182 cases of arteriovenous malformations treated surgically at the Neurosurgical Department of the Johannes Gutenberg-Universität Mainz, FRG. Although the behavior of AVMs remains unpredictable, morphological features of AVMs have an important bearing on their clinical presentation, especially the mode of bleeding.