R. Martínez

Cavernomas of the central nervous system: Clinical syndromes, CT scan diagnosis, and prognosis after surgical treatment in 25 cases

SummaryWe present our clinical experience and the results of surgical management with 25 cavernomas of the CNS, treated in our hospital in the last 10 years. The location of the lesion assessed by clinical and CT scan examinations, proved to be the most significative factor determining the prognosis of cavernomas of the CNS, after surgical removal.The symptoms started in most of the cases in the third decade of life. 19 cases were located in the cerebral hemispheres and produced three well defined clinical syndromes:1)Irritative syndrome (seizures) present in 70% of the cases.2)Space-occupying lesion syndrome (20%) and3)haemorrhagic syndrome (10%). The remaining six cases were located within the basal ganglia, brainstem, pineal region, cerebellum and spinal cord, showing a progressive course.CT scan studies were performed on 24 cases. The characteristic image of a cavernoma is represented by a moderately hyperdense nodule with discreet contrast uptake. Calcification was observed in and around the lesions in 33% of the cases. Perilesional hypodensities suggestive of brain tissue atrophy were noted in 22% of the CT scans. On the other hand, 12% of cerebral hemisphere cavernomas showed atypical CT scan images that suggested an erroneous diagnosis of cystic gliomas.Radical surgical removal was performed in all cases. The postoperative results varied according to the location of the lesions. Complete recovery was obtained with cerebral hemisphere cavernomas presenting with a progressive history suggesting tumour or a haemorrhagic syndrome. 85% of the cases presenting with seizures, were symptom-free and taking no anticonvulsants 1 year after surgery. In deeply placed cavernomas (basal ganglia and brainstem) the surgical results were poor. In the latter cases surgery has to be carefully evaluated when a mode of treatment is to be considered in patients whose CT scan data strongly suggest a diagnosis of cavernoma.

Effect of fibrin glue on postlaminectomy scar formation

SummaryAn experimental study in rats has been carried out with the aim of studying the scar formation over the spinal dura in the presence of fibrin glue. Although the main action of fibrin glue is the enhancement of wound healing by increasing the fibrous tissue, our present data suggest that this re-absorbable biomaterial diminishes the epidural scar formation, at least the first two weeks after laminectomy. This finding leads us to consider the use of fibrin glue over spinal duramater when it is likely that reoperation may become necessary in a short period of time after a laminectomy.

Neurosurgical experience with tumours of the pineal region at Clinica Puerta de Hierro

SummaryThe clinicopathological experience with 50 cases of pineal region tumours at Clinica Puerta de Hierro is presented. In this series, 88% of the patients were evaluated by CT-scan. Pineal region tumours make up approximately 0.7% of the intracranial expansive processes in the Spanish population. The largest group of lesions appearing in this localization is that of the germinomas (38%), followed by nontumoural lesions (20%) and tumours generally considered to be of the vicinity, such as meningiomas, gliomas and metastases (18%), tumours of the pineal parenchyma (14%), and non-germinoma germinal tumours (10%).In our series, in addition to an intracranial hypertension syndrome, an ophthalmological and, to a minor degree, an endocrinological syndrome predominate in germ-cell tumours, with a cerebellar syndrome appearing in gliomas of the pineal region.All the patients in the series diagnosed as having a germinoma and treated by irradiation are alive, and free of disease, after follow-up ranging from 2 to 20 years (mean: 8 years). The experience obtained with the present series supports the opinion that, in radiosensitive tumours, surgical resection adds no therapeutic benefit to treatment with radiotherapy alone.We suggest that when dealing with a tumour of the pineal region, CT-scan and clinical assessment now permit an initial selection of patients susceptible to surgery as a first therapeutic option, indicating those patients who, because they are considered to have either a “probable germinoma” or a “tumour of uncertain diagnosis”, should undergo stereotaxic biopsy or trial radiotherapy and, only when this has proved a failure, should be subjected to open surgery.

Intratumoural injection of autologous lymphocytes plus human lymphoblastoid interferon for the treatment of glioblastoma.

SummaryPreliminary experience with a clinical trial of immunotherapy for glioblastoma, by means of intratumoural injection of autologous lymphocytes (AL) mixed with low doses of human lymphoblastoid interferon (HLI) is presented.In two of twelve patients, a transient reduction of tumoural volume was obtained. Morphological studies showed that injected lymphocytes remain within the tumour, and suggest tumoural lysis due to activity of natural killer (NK) cells.Clinically no significant prolongation of survival time could be achieved and, as in other series, patients with additional radiation therapy survived longer. But the morphological findings suggest that immunotherapy carrying NK-cells to contact with tumoural cells might be useful in some patients with glioblastoma. Actually no explanation can be given why only two of our cases responded positively. Regarding the otherwise poor prognosis it seems justified to continue these studies.

Immunohistochemical study of IOT-10 natural killer cells in brain metastases

SummaryThe presence of NK-cells in a series of 40 metastatic brain tumours has been studied by means of the monoclonal antibody IOT-10. There appeared IOT-10 NK-cells in all tumours studied, but in most cases these cells represented less than 10% of the tumour infiltrating lymphocytes (TIL). In the present series, the obtained data suggest that the number of NK-cells in brain metastases can be influenced by other factors than the mere quantity of TIL.

Intrathecal injection of autologous leucocytes in glioblastoma: circulatory dynamics within the subarachnoid space and clinical results.

SummaryIn Part I of this report, the CSF circulatory dynamics of autologous leucocytes labelled with indium-111 and injected in the subarachnoid space, in patients operated on for glioblastoma, were studied. In the Part II, a series of 11 patients with recurrent glioblastoma was studied for evaluating the efficacy of intrathecal injection of autologous leucocytes. Six patients previously had radiotherapy.The results in Part I show that after intrathecal injection of autologous leucocytes, these cells follow throughout the subarachnoid space and pass to the systemic blood circulation, showing no evidence of colonization of the tumour or deposit in the tumoural region.The mean survival of the patients studied in Part II was 8 months. Those six patients who received radiotherapy had a mean survival of 11.4 months, and those five who received only intrathecal injection of autologous leucocytes after surgery, had a mean survival of 4 months.This results seem to demonstrate that immunotherapy, as used in this study, is ineffective in patients with glioblastoma.

Immunotherapy of glioblastoma with intratumoural administration of autologous lymphocytes and human lymphoblastoid interferon. A further clinical study.

SummaryA clinical trial of an immunotherapy which consisted of intra-tumoural injections of autologous lymphocytes with human lymphoblastoid interferon was evaluated in 31 patients with intracranial glioblastoma. Immunotherapy was performed after stereotactic biopsy or surgical resection. The treatment was tolerated well by all patients. Three patients showed positive response to immunotherapy as documented by transient regression or stabilization of the tumour size on computed tomography. Nevertheless, there is no significant difference in the survival time of the patients treated with immunotherapy and those not treated. We conclude that this immunotherapeutic regimen is not beneficial in patients with glioblastoma when used as single treatment after tumoural biopsy or resection.

Image-directed functional neurosurgery with the Cosman-Roberts-Wells stereotactic instrument

SummaryAn isocentered system for functional stereotactic procedures with the Cosman-Roberts-Wells frame and a CT localizer that allows extrapolation of target data directly from the CT slice is presented. Based on anatomical landmarks and on the scaled corresponding transverse plates of the Schaltenbrand and Wahren atlas, we delineate the thalamic and cerebellar nuclei. Twenty three image-directed functional procedures were performed in one year on 18 patients (7 with Parkinsons disease, 4 with dystonia, 3 persons with essential tremor, 2 patients with choreo-athetosis and 2 with de-afferentiation pain). The 23 procedures included 19 thalamotomies, two dentatotomies and two stereotactic implantations of deep seated brain electrodes. Successful targeting was verified by intra-operative electrical stimulation and postoperative CT scan. Complete reduction of symptoms was observed in 4 persons with Parkinsons disease and in 2 patients with essential tremor with significant improvement observed in the rest of the patients with the exception of the individual with choreo-athetosis. There were no operation-related complications. The reported technique is safer and less distressing for patients than previous radiological procedures and it makes image-directed stereotactic functional neurosurgery available to many units with the CRW frame.

Intratumoural and intraventricular human lymphoblastoid alpha interferon (HLBI) for treatment of glioblastoma multiforme

SummaryA series often patients with glioblastoma multiforme were treated with human lymphoblastoid alpha interferon (HLBI) as a single therapy after partial surgical resection (5 cases) or stereotactic biopsy (5 cases). Treatment consisted of intratumoural administration of HLBI (15 × 166IU) every month (8 cases) or in the continuous intraventricular infusion of HLBI (1.8 × 106IU daily) in 15-day cycles (2 cases) until rapid growing of the tumour and important neurological deterioration. The treatments were well tolerated. As judged from data from control groups, the patients demonstrated no improvement in mean survival time and follow-up CT-scan showed rapid progression of the tumour in all cases.

Precocious puberty and hypothalamic hamartoma. Report on a new case with ultrastructural data.

SummaryA new case of hypothalamic hamartoma associated with precocious puberty is presented. After reviewing the literature, 23 other cases appeared. The ultrastructural study of the present case revealed common features with other hamartomatous lesions of the central nervous system and with the gangliogliomas. The data suggest that these lesions are morphologically organized in a very similar manner despite their very different growing potential.