Mohsen Mohadjer

A clinicopathologic and immunomorphologic study of 13 cases of ganglioglioma

The authors present the clinical, histopathologic, and immunomorphologic data of 13 intracranial gangliogliomas. Preoperative computed tomography scans showed a commonly cystic tumor of variable density. Six tumors were completely excised and seven were subtotally resected. After a mean follow‐up of 4.5 ± 2.6 years, 11 patients are asymptomatic or only slightly incapacitated. All tumors were examined with a panel of neuronal and neuroendocrine markers. Immunoreactivity (IR) to anti‐neurofilament polypeptide (clone 2F11) was observed in neuronal processes in ten cases and in neuronal perikarya in five. With anti‐synaptophysin (clone SY38), IR was present along the lining of ganglion cell perikarya and processes in 11 tumors whereas staining of the perinuclear cytoplasm was prominent in two. IR to anti‐chromogranin A (clone LK2H10) was observed within the neuronal perikarya in eight cases. Only one ganglioglioma of the brain stem showed IR for tyrosine‐hydroxylase (clone 2/40/15) and dopamine‐beta‐hydroxylase in some neoplastic ganglion cells. In this study, synaptophysin was the most reliable neuronal marker. For immunocytochemical identification of neoplastic neurons in ganglioglioma as well as other tumors with neuronal differentiation the authors propose a panel of well‐characterized monoclonal antibodies against neurofilament polypeptides, synaptophysin, and chromogranin A to support the histomorphologic diagnoses. Cancer 68:2192–2201, 1991.

Long-term results of stereotaxy in the treatment of essential tremor.

In patients with severe tremor that is resistant to drug therapy, stereotactic coagulation can achieve a satisfactory and lasting reduction of the movement disorders. Very few long-term studies have been conducted following stereotactic operations. From 1964 to 1984, 104 patients with a diagnosis of essential tremor were operated on in the Division of Stereotaxy and Neuronuclear Medicine. After an average follow-up period of 8.6 years, 65 patients were examined. In 80%, the success of the stereotactic operation was still evident. Complete disappearance or substantial reduction of the tremor was determined in 69% and moderate improvement in 11.9% of the patients.

CT-stereotactic fibrinolysis of spontaneous intracerebral hematomas

CT-stereotactic fibrinolysis is an effective alternative to surgical and conservative therapies for intracerebral hematoma. The method consists of stereotactically puncturing and partially evacuating the hematoma. After fibrinolysis using urokinase, the residual hematoma is completely evacuated through a catheter inserted in the cavity of the hematoma. The operation is usually performed under local anesthesia. Stereotactic methods are safer and less invasive than other methods. Since October 1985, a total of 85 patients have been treated with this method in the Department of Stereotaxy and Neuronuclear Medicine at the University of Freiburg Medical School. Although 25 patients died (29.4%) during the mean follow-up period of 20 months, only 16 (18.8%) died in the acute postoperative phase or within the first 60 days after evacuation. Eighteen patients (21.2%) had died six months after the operation. The quality of life of the 60 surviving patients, as measured on the Karnofsky Scale at follow-up, was very good to good in 70% and moderate in 23.3%. Only 6.7% of the patients were so disabled that they required special care and assistance or had to be placed in a nursing home. The long-term results are thus very encouraging.

Hemidystonia due to a contralateral parietooccipital metastasis Disappearance after removal of the mass lesion

A patient presented with left-sided hemidystonia. CT revealed a contralateral parieto-occipital mass lesion compressing the basal ganglia, which were spared by the mass. After microsurgical resection of the tumor, which was verified histologically as a metastasis of a large-cell anaplastic carcinoma, the movement disorder dissolved completely.A patient presented with left-sided hemidystonia. CT revealed a contralateral parieto-occipital mass lesion compressing the basal ganglia, which were spared by the mass. After microsurgical resection of the tumor, which was verified histologically as a metastasis of a large-cell anaplastic carcinoma, the movement disorder dissolved completely.

Large colloid cyst in lateral ventricle simulating brain tumour. Case report.

SummaryThis case report describes a patient presenting with symptoms of increased intracranial pressure, whose computerized tomographic (CT) scan was highly suggestive of a large low-grade glioma invading the basal ganglia. Magnetic resonance imaging (MRI) revealed a well-demarcated space-occupying mass of increased intensity in the left lateral ventricle and adjacent white matter. Following stereotactic biopsy, which yielded a homogeneous jelly-like material, the mass was removed microsurgically and was found to be most like a colloid cyst on histological examination. Discussion focusses on the clinical and differential diagnostic implications of this very unusual combination of findings.

Stereotactic Evacuation and Fibrinolysis of Cerebellar Hematomas

Despite modern diagnostic and operative methods, the mortality and morbidity rates of spontaneous cerebellar hematomas remain very high, i.e., according to a review of the literature as high as 45%. By stereotactic puncture, partial evacuation and fibrinolysis of the remaining hematoma with urokinase, much more favorable results can be achieved. As we could observe in long-term follow-up, only 1 patient out of 15 died within 2 months after operation. The method is effective, easy, exact, without risk and applicable at every age, so that actually there is no comparable alternative way of treatment.

Molecular size distribution of somatostatin-like immunoreactivity in the cerebroventricular fluid of neurosurgical patients

The molecular size distribution of somatostatin-like immunoreactivity (SLI) in the cerebroventricular fluid of patients with Parkinsons disease, dystonic syndromes, multiple sclerosis, basal and midline tumors, epilepsy and pain syndromes was investigated by separation with a Sephadex G-50f column and subsequent radioimmunoassay of the eluate. Marked heterogeneity of SLI was observed in most of the pools investigated. The most conspicuous feature of the elution profiles was the preponderance of the peak coeluting with synthetic somatostatin-14, whereas the peaks comigrating with synthetic somatostatin-28 and attributable to precursor-like SLI represented only minor or trace amounts of total immunoreactivity. These findings are consistent with the greater biological activity of somatostatin-14 in the human central nervous system, whereas somatostatin-28 appears to represent the more active form in the pituitary and in the intestinal mucosa. Solely in the case of brain tumor patients, some differences could be seen, resulting in an approximately equal distribution of somatostatin-14 and somatostatin-28 in two pools of ventricular fluid and by the detection of a degradation product of somatostatin-14 in another one. These observations could be explained by a lowered barrier function as a consequence of increased intracranial pressure in case of brain tumors, which is well in accordance with a markedly elevated total protein content being a sign of a lowered barrier function.

A new safety device to prevent bleeding complications during stereotactic biopsy - the «stereotactic» doppler sonography. Technical note

SummaryTo further reduce the incidence of haemorrhagic complications during stereotactic biopsy, the use of a microvascular Doppler system is proposed. The microprobes are fitted into the biopsy cannula to detect vessels in the neighbourhood of the target point. The first clinical results are promising.

Sympathetic contribution to pain – need for clarification

Certain patients with a possible contribution of the sympathetic system to pain may not fit the definition of complex regional pain syndromes (CRPS), which raises the question of terminology for those patients. To further clarify the relationship between the sympathetic system and pain, apart from the need for placebo studies, there remains an urgent need for a satisfactory definition of the criteria for a complete sympathetic block. It also remains uncertain whether a change in the discharge pattern of sympathetic fibres underlies the changes in sympathetic organ function, often found in patients with CRPS.

Trigeminusneuralgie—wie erleben die Patienten ihre Krankheit

INTRODUCTION Effective treatment of patients with trigeminal neuralgia is often a long and complicated procedure. The symptoms of trigeminal neuralgia are clearly defined in most cases. Sudden and brief episodes of severe and stabbing pain (tic douloureux) occur, with pain usually starting from a trigger point. Recent reports suggest 80-90% suppression of pain with various treatment regimens, which seems to indicate that the diagnosis and successful treatment of the disorder are no longer a major problem. In fact, however, the intense suffering of patients and isolated reports in the literature suggest that there are still considerable diagnostic difficulties. Patients are referred from one specialist to another, in most cases without the necessary interdisciplinary cooperation, and countless interventions and attempts at therapy not only remain unsuccessful, but may cause serious adverse effects. METHODS The records of 120 trigeminal neuralgia patients in two different areas of Germany were analysed retrospectively. In addition, the course of the disorder from the initial symptoms up to the institution of effective therapy was documented by means of information obtained from the general practitioner or other physicians. The patients themselves were also interviewed about their history. RESULTS After a so-called pain career of 51/2 years, each patient had taken an average of 4,000 pills or capsules, 2,500-3,000 of which were carbamazine, lost 1-2 healthy teeth in attempts to treat the painful condition, undergone three or four maxillofacial or ENT operations, or been subjected to exeresis. The result is prolongation and exacerbation of suffering and an apparently hopeless situation. The financial burden on the patients and the health insurance companies is enormous. DISCUSSION Apparently there is a considerable need for more information about the clinical symptoms, cause, diagnosis and therapy of trigeminal neuralgia, especially as the symptoms are often no longer typical because they have become chronic or are the result of previous treatment. This is needed by all specialists involved, including dentists and general practitioners. In patients in whom clinical criteria suggest the diagnosis of trigeminal neuralgia, drug treatment should be initiated immediately in consultation with the neurologist or neurosurgeon. For cases in which drug treatment fails or resistance to the drug develops surgical treatments are available, such as non-destructive microvascular decompression or thermocoagulation of the gasserian ganglion.IntroductionEffective treatment of patients with trigeminal neuralgia is often a long and complicated procedure. The symptoms of trigeminal neuralgia are clearly defined in most cases. Sudden and brief episodes of severe and stabbing pain (tic douloureux) occur, with pain usually starting from a trigger point.Recent reports suggest 80–90% suppression of pain with various treatment regimens, which seems to indicate that the diagnosis and successful treatment of the disorder are no longer a major problem. In fact, however, the intense suffering of patients and isolated reports in the literature suggest that there are still considerable diagnostic difficulties. Patients are referred from one specialist to another, in most cases without the necessary interdisciplinary cooperation, and countless interventions and attempts at therapy not only remain unsuccessful, but may cause serious adverse effects.MethodsThe records of 120 trigeminal neuralgia patients in two different areas of Germany were analysed retrospectively. In addition, the course of the disorder from the initial symptoms up to the institution of effective therapy was documented by means of information obtained from the general practitioner or other physicians. The patients themselves were also interviewed about their history.ResultsAfter a so-called pain career of 51/2 years, each patient had taken an average of 4,000 pills or capsules, 2,500–3,000 of which were carbamazine, lost 1–2 healthy teeth in attempts to treat the painful condition, undergone three or four maxillofacial or ENT operations, or been subjected to exeresis. The result is prolongation and exacerbation of suffering and an apparently hopeless situation. The financial burden on the patients and the health insurance companies is enormous.DiscussionApparently there is a considerable need for more information about the clinical symptoms, cause, diagnosis and therapy of trigeminal neuralgia, especially as the symptoms are often no longer typical because they have become chronic or are the result of previous treatment. This is needed by all specialists involved, including dentists and general practitioners. In patients in whom clinical criteria suggest the diagnosis of trigeminal neuralgia, drug treatment should be initiated immediately in consultation with the neurologist or neurosurgeon. For cases in which drug treatment fails or resistance to the drug develops surgical treatments are available, such as non-destructive microvascular decompression or thermocoagulation of the gasserian ganglion.ZusammenfassungDie Behandlungswege bei Patienten mit einer Trigeminusneuralgie sind oft lang und kompliziert. Es vergehen Jahre, bis die Betrofferen zumindest zum Teil von ihrem Leid befreit werden. Die Gründe dafür sind schwer verständlich. Die Krankheit kann durch ihre klar definierten und charakteristischen Symptome meist sicher diagnostiziert werden. Die bekannte Trias, blitzartig einschießende kurze Schmerzattacken, ihre segmentale Zuordnung sowie das Vorhandensein eines Triggermechanismus wird immer wieder betont. Nachdem mit unterschiedlichen Behandlungsmethoden eine fast 80–90%ige Schmerzlinderung erreicht wird, sollten die Diagnose und die erfolgreiche Therapie der Erkrankung keine großen Probleme darstellen. Aber die praktischen Erfahrungen, die genauen Angaben und Klagen der von uns betreuten Patienten sowie vereinzelte Hinweise in der Literatur deuten eher auf das Weiterbestehen der problematischen Auseinandersetzung mit der Erkrankung hin. Anders können der relativ lange Leidensweg der Patienten mit qualvollem Marsch durch die verschiedenen medizinischen Fachdisziplinen—meist ohne interdisziplinäre Zusammenarbeit-, zahlreiche Fehleingriffe und Behandlungsversuche nicht hinreichend erklärt werden.Gegenstand der vorliegenden Arbeit ist die Aufzeichnung des diagnostischen und therapeutischen Weges der Patienten vom Beginn der ersten Symptome bis zur erfolgten effektiven Therapie. Zu diesem Zweck wurden die Unterlagen von insgesamt 120 Patienten mit Trigeminusneuralgie aus zwei weit voneinander entfernt liegenden Einzugsgebieten großer medizinischer Kliniken retrospektive analysiert und mit Angaben der Patienten sowie deren behandelnden Ärzte zusammengetragen. Nach 51/2 Jahren wurde nur bei 70% der Patienten eine akzeptable Schmerzlinderung bzw. Schmerzbefreiung erreicht. Während dieser Zeit hatte, statistisch gesehen, jeder Leidtragende im Durchschnitt etwa 4000 Tabletten oder Kapseln eingenommen—darunter 2500 Tabletten Carbamazepin. Er verlor 11/2 gesunde Zähne bei zahnärztlichen Behandlungsversuchen und wurde 3–4mal HNO- und/oder zahn-kieferorthopädisch operiert und mußte einige Exhairesen ertragen. Damit wird das Leid der Patienten nicht nur verlängert, sondern noch vertieft, und sie werden nicht selten in eine scheinbar aussichtslose Lage manövriert, in der sie meist mit ihren Beschwerden allein bleiben.Anscheinend besteht ein erheblicher Nachholbedarf an weiterer Aufklärung bezüglich Klinik, Pathogenese sowie adäquater Therapie der Trigeminusneuralgie. Dieser Nachholbedarf besteht in allen beteiligten Disziplinen einschließlich der praktizierenden Allgemeinärzte. Besonders die Rolle, Bedeutung und Möglichkeit einer echten interdisziplinären Zusammenarbeit bei der Behandlung der Schmerzpatienten—auch derjenigen mit Gesichtsschmerzen-, sollte prinzipiell in den Vordergrund gestellt werden.