Albrecht Laun

Prognostic implication of histopathological, immunohistochemical and clinical features of oligodendrogliomas: a study of 89 cases

Abstract Histopathological, immunohistochemical and clinical parameters were correlated with survival in 89 cases of oligodendroglioma (65 patients with grade II and 24 patients with grade III of the WHO classification). Median survival time and 5-year survival rate were 3.5 years and 76% for patients with oligodendroglioma grade II and 0.875 years and 23% for patients with oligodendroglioma grade III. The tumor biopsy specimens were immunohistochemically analyzed for Ki 67 (MIB-1), vimentin, glial fibrillary acidic protein (GFAP), neuron-specific enolase (NSE) and synaptophysin. MIB-1 nuclear labeling index ranged from 0.0% to 33.4%; vimentin-immunoreactive tumor cells were found in 25 cases. MIB-1 nuclear labeling index and vimentin immunoreaction showed a significant statistical correlation to the 5-year survival rate of the patients. Tumors with vimentin expression (n = 25) and/ or high MIB-1 labeling index (n = 26) had a poorer prognosis than tumors lacking vimentin expression (n = 57) and/or displaying a low MIB-1 labeling index (n = 56). The expression of immunoreactivity for GFAP (n = 53), NSE (n = 23) and synaptophysin (n = 15) appeared to be of no prognostic relevance. Patients with gross total tumor resection (n = 47) had a median survival time and 5-year survival rate of 3.3 years and 84% compared to 1.2 years and 42% for patients with subtotal resection (n = 41). The comparison between patients who underwent surgery alone (n = 53) and those who had surgery plus postoperative radiation therapy showed no significant survival benefit from postoperative radiation therapy. In conclusion, tumor grade, MIB-1 labeling index, expression of vimentin and the extent of surgery are shown to be of prognostic relevance for patients with oligodendroglioma.

Intraspinal arachnoid cysts

SummaryEight cases of intraspinal arachnoid cysts are described. The clinical, radiological, intraoperative and histological findings are presented and compared with similar reports in the literature.Opinions in the literature concerning the origin of arachnoid cysts are discussed, and compared with our own case reports. A traumatic or inflammatory origin of the arachnoid cysts is denied if accompanying histological changes are lacking. In such cases the arachnoid cysts are to be viewed as congenital malformations.

Cerebellar infarcts in the area of the supply of the PICA and their surgical treatment.

SummaryThe authors report seven cases of cerebellar infarcts in the distribution of the PICA, of whom six were treated surgically. Only one patient died and he was not operated on. Although of the remaining six patients four were comatose, and two presented obvious signs of midbrain decerebration, all of them subsequently showed a really good quality of survival. In addition to the clinical details of the cases which are set out in tabular form, a survey of the literature is given and the indications for surgical treatment discussed. The exact interpretation of the CT scan and, in this context, particularly of the brain stem and its surrounding cisterns, above all the cisterns of the quadrigeminal plate and of the vein of Galen, gives decisive help in assessing the indications for suboccipital decompressive craniotomy. In view of the small number of cases, expressing the mortality rate in percentages would seem to be pointless. However, it appears appropriate to describe our experiences of the last two years and to recommend surgical treatment.

Cranial nerve lesions following subarachnoid hemorrhage and aneurysm of the circle of Willis

Fifty-eight of 570 patients with an aneurysm and/or subarachnoid hemorrhage displayed palsy of one or several cranial nerves. In 48 patients, this lesion occurred in the context of SAH (total n = 534). The oculomotor nerve was most frequently affected (38 cases), followed by the abducens nerve with the second-highest incidence (18 cases). The highest rate of cranial nerve symptoms occurred in cases of ophthalmic carotid aneurysms (83.3%). Damage to the abducens nerve regressed most rapidly.

Outcome of patients with aneurysmal and presumed aneurysmal bleeding. A hospital study based on 100 consecutive cases in a neurological clinic

One hundred patients with spontaneous subarachnoid hemorrhage due to aneurysm or presumed aneurysm consecutively admitted to a neurological clinic and subjected to CCT during the first 72 hours were examined retrospectively. The outcome after two months as defined by the Glasgow Outcome Scale (GOS) was relatively good: 23% of the patients suffered management mortality (GOS I) (postoperative lethality 8%), 3% showed GOS-Grade II, 14% grade III, 17% grade IV, and 43% grade V. The extent of intracranial hemorrhage correlated well with the initial Hunt-Hess Grade which, in turn, had a strong influence on case fatality and the degree of disability. Lethal factors were: 1. massive subarachnoid hemorrhage together with a massive ventricular hemorrhage (p<0.001),2. massive subarachnoid hemorrhage together with an intracerebral hematoma>20 ml (p<0.05). Case fatality was lower when angiography was negative. In our study rebleeding (12%) and delayed cerebral ischemia (DCI) (18%) were less frequent and the lethality due to acute hydrocephalus (5%) and delayed cerebral ischemia (5%) was less pronounced than in comparable studies. The degree of disability (GOS) was directly related to the amount of intracranial blood, to the development of acute or chronic hydrocephalus, delayed cerebral ischemia and rebleeding. DCI occurred in 60% of patients with marked hydrocephalus. Rebleeding was more frequent in patients with acute hydrocephalus. Hydrocephalus, DCI, and rebleeding were associated with a poorer initial grade on the Hunt and Hess Scale.

Decerebrate rigidity and vegetative signs in the acute midbrain syndrome with special regard to motor activity and intracranial pressure

SummaryDecerebrate rigidity, intracranial pressure and vegetative signs were studied in 25 patients. Advanced statistical techniques were used to analyse the interrelationships between muscle activity (IEMG), blood pressure (ABP), intracranial pressure (ICP), pulse rate (HR), respiratory rate (RR), and central venous pressure (CVP) occurring during paroxysms of decerebration. The pattern of reaction is influenced by compression or stress imposed on the brain stem at the tentorial incisure and is related to the degree of cisternal obstruction. Significant differences in reaction were disclosed between provoked and spontaneous decerebration posturing.

Rhinorrhea following dopamine agonist therapy of invasive macroprolactinoma.

SummaryWe report on the occurrence of CSF rhinorrhea in a group of 17 patients harbouring macroprolactinomas who were treated with a dopamine agonist (DA, bromocriptine) alone or the combination of DA and transcranial operation. In 2 out of 17 cases shrinkage of tumour remnants during therapy with the oral or injectable form of bromocriptine was responsible for delayed occurrence of rhinorrhea. Operative procedures for successfull closure of the fistulae were mandatory in both cases.

Function tests on the neuroendocrine hypothalamo-pituitary system following acute midbrain syndrome, with special reference to computertomographical and magnetic resonance imaging results

Seventeen patients underwent a neuroendocrinological function test at a mean 6.3 years following a severe craniocerebral trauma (CCT) accompanied by midbrain syndrome. An insulin hypoglycaemia test (IHT) and the combined pituitary anterior lobe test (CPALT) were applied. Whereas the IHT as maximum stimulator of the hypothalamo-pituitary system (HPS) showed an adaequate reserve capacity, the CPALT yielded a partial limitation of the secretion dynamic in the somatotropic, adrenocorticotropic axis as well as a dysfunction in the FSH secretion. Neuroradiological tests could not establish substantial injury in the regio hypothalamica in any patient.

Radiologic Findings in Spinal Angiomas — Plain X-Rays, Myelography, and Spinal Phlebography

Selective spinal angiography is now the procedure of choice for the diagnosis of intradural spinal angiomas. It has largely displaced the other radiologic investigations of the spinal canal. However, the diagnostic significance of straight films and tomography, myelography, and spinal phlebography has not been diminished. With vertebral, extradural, and some intradural angiomas these investigations give characteristic or suggestive findings, or they provide the indication for and supplement the findings of selective angiography. A further and more important reason for discussing them is the fact that such painstaking and specialized angiography is only possible in a few departments, and the classic investigative procedures are still undertaken in most cases. For this reason, they are indispensable in achieving an improvement in early diagnosis and, hence, early treatment.

Acute Direct and Indirect Lesions of the Brain Stem—CT Findings and Their Clinical Evaluation

Since the introduction of computer tomography (CT) (Ambrose 1973, Hounsfield 1973) it has become an essential instrument in the diagnosis of acute intracranial lesions. The precise analysis of the CT and in particular the evaluation of the basal cisterns, yields results which are already wellknown, basically, from post-mortem investigations and clinical findings. However, while these were retrospective analyses and results, serial CT examinations which are free of risk for the patient and can be used in correlation with the clinical neurological findings, allow important assertions intra vitam, as well as a definitely better assessment of the prognosis. In addition to acute supratentorial lesions, acute and subacute infratentorial lesions are analysed and their clinical significance described. In this way, for the first time, the dynamics of the mechanical factors in raised intracranial pressure can be analysed. Important conclusions are drawn for the clinical management of the patients, and even some new indications for operation. Analysis of the acute hyperdense brain stem lesions--pathognomonic for haemorrhages--allows for the first time the diagnosis and continuous observation of traumatic and secondary haemorrhages caused by raised pressure, as well as spontaneous ones. As regards the mortality and morbidity, the results in this large series of traumatic and secondary haemorrhages are in striking contrast to previous analyses based on post mortem findings. Acute hypodense brain stem lesions are not amenable to any definite pathogenetic classification--softening, inflammatory lesions, tumours and oedema must all be considered. With acute lesions we are only dealing with infarcts, which are only incompletely assessable in the computer tomogram, and their diagnosis must still depend on the clinical findings. Secondary ischaemic lesions in acute raised intracranial pressure are identifiable in over 18% as infarcts which involve the entire territory of an artery. These additional space-occupying lesions are only survived by 11% of the patients. Hence the correlation which has been established between the basal cisterns and intracranial pressure is of great clinical significance. From our own research group several reports on different aspects of raised intracranial pressure and lesions of the brain stem have appeared since 1979. Similar analyses of partial aspects of the basal cisterns, have been published only recently, and came essentially to the same conclusions.