Benjamin Voellger

Noninvasive assessment of intracranial pressure with venous ophthalmodynamometry. Clinical article.

OBJECT Venous ophthalmodynamometry is a technique used to register the pressure within the central retinal vein. Because the outflow of the central retinal vein is exposed to the intracranial pressure (ICP), the pressure of the central retinal vein may be correlated with the ICP. In the absence of adequate statistical evidence, the authors compared the pressure of the central retinal vein with results of simultaneous invasive monitoring of ICP in neurosurgical patients. METHODS The pressure within the central retinal vein was recorded in 102 patients, in whom invasive continuous monitoring of ICP had become necessary for various reasons, mostly because of suspected hydrocephalus and intracranial hemorrhage. RESULTS A highly significant correlation of the pressure in the central retinal vein and the intracranial cavity was confirmed statistically. An increased pressure of the central retinal vein indicated an elevated ICP, with a probability of 84.2%, whereas a normal pressure of the central retinal vein indicated a normal ICP in 92.8% of patients. Conclusions Venous ophthalmodynamometry is a valuable technique for the noninvasive assessment of ICP.

Evidence-based indications for ICP recording after head injury. A review.

The indication for invasive intracranial pressure (ICP) recording in comatose patients after head injury is a matter of discussion. In this review the evidence-based data are analysed. Monitoring appears useful especially in sedated patients, but there is no study which provides evidence of its overall benefit for the patient. The decision for or against ICP monitoring must therefore be based on weighing the potential benefits versus the risk for the individual patient according to the personal experience and judgement of the attending neurosurgeon.

5-aminolevulinic acid (5-ALA) fluorescence in infectious disease of the brain

Dear Editor, The incidence of malignant glioma with a rate of three cases per 100,000 inhabitants per year [3] is higher than the incidence of brain abscess with 0.8 cases per 100,000 inhabitants per year [4]. Infections may, similar to glioma, lead to a central necrosis, and their radiological features are often indistinguishable from each other. As the surgical treatment of a brain tumor and inflamed brain tissue is not the same, a differentiation prior to resection is important. We report a case of brain infection caused by Listeria monocytogenes mimicking a malignant glioma with 5-aminolevulinic acid (5-ALA) fluorescence of brain tissue. A 74-year-old male presented with intermittent headaches, vertigo, disturbance of speech and confusion. His medical history included ventricular tachycardia, which had led to the implantation of a cardioverter defibrillator (ICD), chronic obstructive pulmonary disease (COPD) treated with inhalative glucocorticoids, and beta-adrenergic agonists. Upon admission, the patient was awake and fully oriented and showed a mild facial palsy and hemiparesis. Other neurological deficits were not found. Axillary body temperature was 35,8 °C. Creactive protein (CRP) serum level was not increased, and white blood cell (WBC) count was elevated to 18.5*109/L. A cranial computerized tomography (CCT) showed a space-occupying irregular enhancing lesion with perifocal edema in the right frontal lobe (Fig. 1, left); magnetic resonance imaging (MRI) was ruled too dangerous with the ICD by the neuroradiologist in cooperation with the cardiologist. As the CCT (Fig. 1, left) had led to suspect a glioma, 5ALA (Gliolan®) was administered prior to the operation to allow for fluorescence-guided resection. A right frontal craniotomy was performed. The cortex of the frontal lobe appeared indurated. After a small cortical incision, the underlying tissue seemed to contain a multitude of small vacuoles with a whitish exudate. The indurated brain tissue was edematous and hardened and exhibited marked 5-ALA fluorescence (Fig. 1, center) without a defined border. Some of the fluorescent tissue was resected, and intraoperative frozen sections confirmed necrosis and invasion with granulocytes. A tumor could not be ruled out at that stage, but an infection appeared more likely. An abscess was not found. After the operation, the patient developed a complete leftsided hemiparalysis and severely reduced vigilance. The definite histological findings confirmed an infection, and microbiological cultivation revealed Listeria monocytogenes as the pathogen. High-dose ampicillin (15 g/d) was administered for 8 weeks. No other site of infection could be identified. Two months later, the patient was in good condition. A slight facial palsy and symptomatic epilepsia, treated with Levetiracetam, remained. The follow-up CCT at 10 months showed no contrast enhancement (Fig. 1, right). 5-ALA-induced fluorescence has become a standard in neurosurgery of gliomas [2, 9], but may also be observed in other neoplastic, inflammatory or infectious diseases [5, 6, 10]. 5-ALA-induced fluorescence is caused by accumulation of protoporphyrin IX. In the presence of infection, an immune response is triggered, leading to an invasion of microglia, neutrophils, macrophages and lymphocytes. Macrophages, activated lymphocytes and neutrophils accumulate increased levels of protoporphyrin IX when incubated with 5-ALA [1, 7, 8]. Surgical reduction of malignant glioma appears to be associated with improved survival [2]. The patient with inflamed brain tissue will benefit from the release of pus from an B. Voellger (*) : J. Klein :R. Firsching Department of Neurosurgery, Otto von Guericke-University Magdeburg, Leipziger Str. 44, 39120 Magdeburg, Germany e-mail: benjamin.voellger@med.ovgu.de

Resveratrol decreases B-cell lymphoma-2 expression and viability in GH3 pituitary adenoma cells of the rat

Objective Resveratrol is a phytoestrogen with various antiproliferative and proapoptotic effects. This in vitro study aimed to analyze the effect of resveratrol on the viability and expression of modulators of apoptosis in GH3 pituitary adenoma cells of the rat. Methods GH3 cells were incubated with resveratrol concentrations from 20 to 100 μM for 48–72 hours. Cell viability was quantified using a hemocytometer. We assessed the ability of resveratrol to kill GH3 cells by an enzyme-linked immunosorbent assay (ELISA) of nucleosome liberation and by DNA degradation (unidimensional gel electrophoresis). Relative messenger RNA (mRNA) expression of survivin, B-cell lymphoma-2 protein (BCL-2) and BCL-2-associated X protein (BAX) normalized to β2 microglobulin was measured using quantitative real-time polymerase chain reaction (qRT-PCR). Results GH3 cell survival significantly decreased with increasing concentrations of resveratrol. In GH3 cells treated with 100 μM resveratrol, ELISA demonstrated a significant rise of nucleosome liberation, which typically occurs during apoptosis. In parallel, gel electrophoresis showed degradation of DNA into random fragments, pointing to a necrotic mode of cell death in most GH3 cells. In GH3 cells treated with 100 μM resveratrol, qRT-PCR detected a significant decrease of BCL-2 mRNA expression and a decrease of survivin mRNA expression, whereas a change of BAX mRNA expression could not be found. The BAX/BCL-2 ratio was significantly increased in GH3 cells after resveratrol treatment. Conclusions Resveratrol reduces GH3 cell viability in a dose-dependent manner by inducing nonapoptotic cell death and apoptosis. Apoptosis in GH3 cells is probably mediated by resveratrol-dependent downregulation of apoptosis inhibitors, namely BCL-2 and possibly survivin. Further investigation of the potential effects of resveratrol on pituitary adenoma cells is warranted.

Survival in granular cell astrocytomas.

BACKGROUND Granular cell astrocytomas (GCAs) are rarely encountered aggressive glial neoplasms. Treatment options comprise surgery, radiotherapy, and chemotherapy. Due to the small number of cases, a standard therapeutic regimen for GCA does not exist. MATERIAL AND METHODS We report on the case of a 64-year-old woman with GCA subjected to tumor biopsy followed by radiochemotherapy with temozolomide. We provide clinical, histopathologic, and magnetic resonance imaging findings as well as a complete follow-up. To assess the relation of age, gender, time of publication, and different treatment options with survival we performed log-rank tests and calculated Cox regression models and hazard ratios in data from all available reports on GCA. RESULTS A significant difference in survival rates in favor of adjuvant therapy (radiotherapy or radiochemotherapy) at 12 months was found. Age > 70 years at the time of diagnosis had a significantly unfavorable impact on survival at 12 months. Although not statistically significant, a tendency toward higher probability of survival at 12 months was found in cases reported after 2002. In surgically treated patients, we could not find a significant impact of extent of resection on survival. A significant impact of gender on survival was not found. CONCLUSION Adjuvant therapy is significantly related to a higher probability of survival at 12 months and may therefore be recommended for patients with a GCA. Further analysis of these rare neoplasms is warranted.

Zusammenarbeit der Neurochirurgie mit der Allgemeinchirurgie: Was muss der Allgemeinchirurg von der Neurochirurgie wissen?

Hintergrund: In der vorliegenden Arbeit werden die haufigsten Beruhrungspunkte bestimmter Erkrankungen bzw. Verletzungen dargestellt, die in die Zustandigkeit der Fachgebiete Neurochirurgie und Allgemeinchirurgie fallen. Methode: Die Dringlichkeiten und die Prognose bezuglich Diagnostik und Therapie des Schadel-Hirn-Traumas, ggf. mit Mehrfachverletzung, der extra- und intraspinalen Tumoren und der Hirnmetastasen werden analysiert. Ergebnisse: Die Dringlichkeit allgemeinchirurgischer und neurochirurgischer Masnahmen folgt keiner gleichbleibenden allgemeingultigen Schablone, sondern ist den Zufalligkeiten des Einzelfalls unterworfen. Schlussfolgerung: Bei der gemeinsamen chirurgischen und neurochirurgischen Behandlung ist die Unterscheidung der lebensnotwendigen von den aufschiebbaren oder im Hinblick auf die Prognose unangemessenen Eingriffen von grundsatzlicher Bedeutung. Die Reihenfolge der neurochirurgischen und allgemeinchirurgischen Masnahmen muss den Erfordernissen des Einzelfalls angepasst werden.