György I. Csécsei

Fibrin deposition in primary and metastatic human brain tumours

Extravascular, intratumoral fibrin deposition is frequently observed within and around neoplastic tissue and has been implicated in various aspects of tumour growth. This is the first report on the presence and distribution of fibrinogen/fibrin in primary (14 glioblastomas) and metastatic (nine samples of lung cancer origin) human brain tumours detected by immunofluorescent techniques. All tissue samples showed specific staining for fibrinogen/fibrin. In glioblastomas fibrin deposits could be detected within and around tumour foci, while in metastatic brain tumours the tumour cell nodules were surrounded by fibrin deposits localized almost exclusively in the connective tissue compartment of tumours. Double-labelling reactions for von Willebrand factor and fibrinogen/fibrin has revealed that fibrin deposition occurred throughout the tumour stroma independently of tumour vasculature. The overlapping reactions for fibrinogen/fibrin and factor XIII subunit A, as well as the urea-insolubility of the deposits indicate the crosslinked, highly stabilized nature of fibrin both within and around tumours. Staining with Ki M7 monoclonal antibody specific for phagocytosing macrophages showed these cells to be scattered in the nonnecrotic areas in glioblastomas and to be accumulated at the interface of tumorous parenchyma and connective tissue in both primary and metastatic tumours. The close association between fibrin deposition and macrophage accumulation strongly suggests the active participation of tumour associated macrophages in the formation of stabilized intratumoral fibrin network in human brain neoplasms.

Posterior interbody fusion using laminectomy bone and transpedicular screw fixation in the treatment of lumbar spondylolisthesis

BACKGROUND Laminectomy bone is used widely in posterolateral lumbar fusion, but not interbody fusion. No prospective evaluation of interbody fusion using bone grafts from the posterior neural arch in spondylolisthesis has been found in the literature. We prospectively studied series of patients operated on for lumbar spondylolisthesis to evaluate clinical improvement and bony fusion. METHODS Forty-six patients were operated on for lumbar spondylolisthesis using a simplified one-stage posterior procedure. The whole mobile dorsal segment of the vertebral arch was taken out in one piece and the bone was used for interbody fusion. Fixation was performed with transpedicular screws and rods using transverse connectors. RESULTS After an average follow-up time of 27.3 months, 87% of the patients could be considered to have an excellent or good clinical outcome. The rate of successful fusion was 95.7%. No noteworthy complications occurred. CONCLUSION Laminectomy bone seems to be optimal for posterior interbody fusion and together with transpedicular rigid fixation the long-term clinical and radiological results are convincingly good. The method is advisable even for severe spondylolisthesis.

Cefazolin prophylaxis in neurosurgery monitored by capillary electrophoresis

&NA; Prophylactic use of antibiotics to prevent postoperative infections is a routine method in neurosurgery. Little is known about the period of effectiveness of antibiotics applied only for the purposes of operation. The actual concentration of cefazolin was determined in the serum, in the contents of wound drains, and in the cerebrospinal fluid in a 24‐hour postoperative period after the administration of 1 g of cefazolin just prior to skin incision in 8 patients undergoing lumbar discectomy and 11 patients undergoing craniectomy. The concentration of the antibiotic was then compared with the minimal inhibitory concentration values of cefazolin for 10 different bacterial species. For evaluating the concentration of cefazolin, capillary electrophoresis was used, which is a new clinical application of this separation technique. Results showed that the antibiotic was effective against bacterial breeding in the serum and in the drainage up to 12 hours. The drug concentration in the cerebrospinal fluid remained less than the value of the serum, and it exceeded the minimal inhibitory concentration values only for approximately 5 hours.

Assessment of cerebrovascular reserve capacity in asymptomatic and symptomatic hemodynamically significant carotid stenoses and occlusions.

BACKGROUND Cerebrovascular reactivity measurements are believed to be a helpful tool for selecting patients who are at higher risk for hemodynamic strokes. The aim of this study was to compare cerebral vasoreactivity among patients suffering from internal carotid artery stenosis of different severity (asymptomatic stenosis, asymptomatic occlusion, symptomatic stenosis, symptomatic occlusion). METHODS Sixty-two patients with asymptomatic and symptomatic internal carotid artery stenoses and occlusions underwent transcranial Doppler-acetazolamide tests. Absolute velocities of the middle cerebral arteries (MCAV), percent increases of the MCAV at different time points of the test (cerebrovascular reactivity, CVR) and maximal percent increase after administration of acetazolamide (cerebrovascular reserve, CRC) were compared on the affected and non-affected sides. Asymmetry indices (CRC (affected side)/CRC (non-affected side)) were compared between the groups of different severity of obstructive lesion. RESULTS Resting MCAV was similar on both sides in all groups. A significant side-difference of the MCAV values after acetazolamide was observed only in the symptomatic groups. Difference of cerebrovascular reserve capacity between the affected and non-affected side was statistically significant only in the symptomatic groups (CRC symptomatic stenosis 36.6 +/- 20.9% vs. 71.1 +/- 27.9%, CRC symptomatic occlusion: 31.2 +/- 24.6% vs. 64.5 +/- 29.7%). Asymmetry index of the CRC was near to 1 in the asymptomatic stenosis group only, while in all the other groups this index referred to a significant hemispheric asymmetry of the vasoreactivity. CONCLUSIONS Although in general cerebrovascular reserve capacity is compromised in cases of hemodynamically significant carotid lesions, there is a large individual variability within the subgroups. Further randomized studies are needed to clarify whether the clinical efficiency of carotid endarterectomy and extra-intracranial bypass may be improved by selecting the patients using hemodynamic criteria.

Anteposition of the internal carotid artery for surgical treatment of kinking

BACKGROUND Kinking of the extracranial portion of the internal carotid artery (ICA) requires surgical reconstruction when it causes neurological symptoms. We suggest a simple surgical reconstruction without arteriotomy. METHOD Anteposition of the ICA ventral to the digastric muscle has been performed in three patients. Kinks in the ICAs, proved by angiography, were thought to be responsible for clinical signs and symptoms. RESULTS The operations resulted in improvement, both clinically and radiologically. CONCLUSION The complications of arteriotomy can be avoided using the technique of ICA antepositioning described in this paper.

Somatosensory and Motor Evoked Potentials in Patients with Tumours in the Spinal Canal

Summary Motor and sensory evoked potentials were recorded in 27 patients with expanding spinal tumour. The patients were divided into 2 groups: I. tumours at the level of the spinal cord [18] and II. at the level of the cauda equina [9]. On the basis of the localization of the tumour, midline and lateral subgroups were distinguished. The latencies of motor evoked potentials were prolonged in most of the patients, even those without paresis, in both groups. The motor evoked potentials detected subclinical motor lesions in 7 patients. All patients but one manifested sensory deficits, which could not be shown with the somatosensory evoked potentials. Significantly more prolonged cortical motor latencies were found in most of the patients with a laterally located tumour on the tumour side than contralaterally, whereas in somatosensory evoked potentials this difference was not apparent. On the basis of these observations, we concluded that motor evoked potentials, 1. could more reliably detect the neural deficit than somatosensory evoked potentials; 2. could show the side where the tumour was located; 3. proved useful in the detection of subclinical motor lesions. The general conclusion may be drawn that this electrophysiological method can provide useful information for the surgeon.

Spinal extradural arachnoid cyst causing cord compression in a 15-year-old girl: a case report

The authors describe the case of a fifteen-year-old girl with progressive paraparesis of the lower limbs that was caused by an intraspinal extradural dorsal arachnoid cyst at the level of Th 3-6. Diagnosis was established with MRI and MRI myelography. The latter revealed the CSF-like content of the cyst. The patient underwent laminotomy and en bloc resection of the cyst. Ligation of the pedicle of the cyst was done with laminoplasty. Quick and complete recovery was observed after surgery.

Quantitative determination of hyaluronan content in cerebral aneurysms by digital densitometry

OBJECT Hyaluronan (HA) is a highly hydrated macromolecule; it is one of the essential components of the extracellular matrix (ECM) of the arteries and plays an important role in maintaining the biomechanical features of blood vessels. Although the potential contribution of HA in aneurysms of different vessels has been studied intensively, no data are available about the alteration of the HA content in the extracellular matrix of intracranial aneurysms. The aim of the study was to determine the hyaluronan content in the wall of human cerebral arteries. METHODS A biotinylated aggrecan fragment that binds specifically to HA was used to stain samples from cerebral aneurysms (n = 11) to compare the HA content to non-aneurysmal arteries of patients who had intracranial aneurysm (n = 11), and to histologically normal arteries of patients who had expired from non-vascular diseases (n = 14). Digital microscopic densitometry was used for the quantitative analysis of the hyaluronan content in these samples. RESULTS The highest level (169.5 +/- 7.9) was detected in aneurysms, while the HA-level of non-aneurysmal vessels was lower (130.2 +/- 16.8). Both vessel groups contained significantly higher HA than the normal cerebral arteries (32.9 +/- 2.1). CONCLUSIONS Results suggest that an elevated hyaluronan level in the extracellular matrix may affect the cerebral arterial wall architecture. It is reasonable to suppose that the increased hyaluronan content creates a viscoelastic ECM which might improve the biomechanical resistance of the thinned vessel wall.

Transtracheal electrical stimulation of the spinal cord for intraoperative monitoring of the motor pathway

Because of the suppressant effects of anesthetic drugs and muscle relaxants on motor responses elicited by either magnetic or electrical transcranial stimulation, intraoperative monitoring of the motor system, and especially monitoring of lower limb function, presents many difficulties.The upper part of the spinal cord was stimulated in 14 anesthetized and relaxed dogs with a cathode attached to the intratracheal tube and an anode fixed above the upper cervical spinous processes. Action potentials evoked by single and serial stimuli were recorded from the exposed right femoral nerve and quadriceps muscle Averaging was necessary for serial stimulations.Reproducible early and late responses to both single and serial stimulations were recorded during regular anesthesia. The origin of the different responses is discussed.Transtracheal stimulation of the spinal cord is easy to perform and the responses recorded from the peripheral nerve or limb muscle are well reproducible in regular anesthesia. The method seems to be appropriate for intraoperative monitoring of the thoracolumbar spine.

Neurosurgery in Hungary. A historical overview and the present state.

The ®rst data of cranial trephinations in Hungary go back to the period of the great migration of peoples. Some craniocerebral injuries were surgically treated even at the time of the Hungarian Conquest. Material evidence on display at the National Museum of Budapest testify to the fact that some of the patients survived the operation. Three periods in the development of modern neurosurgery in Hungary can be sharply separated by two dates, viz. 1945 and 1990.