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Background: The World Health Organization (WHO) Classification of Tumours, also known as WHO Blue Books, represents an international standardised tool in the diagnostic work-up of tumours. This classification system is under continuous revision, and progress in the molecular classification of tumours in the central nervous system (CNS) enforced an update of the WHO 2016 classification, and the fifth edition, WHO CNS5, was published in 2021. The aim of this minireview is to highlight important changes in this new edition relevant for the practicing neurosurgeon. Methods: The sixth volume of the fifth edition of the WHO Blue Books of CNS tumours and related papers formed the basis for this minireview. Results: Major changes encompass standardisation of tumour grading and nomenclature as well as increased incorporation of molecular markers in the classification of CNS tumours. Conclusion: Advances in molecular genetics have resulted in more accurate diagnosis and prognosis of CNS tumours, and this minireview summarises important changes implemented in the last edition of WHO classification of CNS tumours important for the practicing neurosurgeon. [ABSTRACT FROM AUTHOR]

Summary¶Background. A variety of procedures for reconstructing the spine following the removal of spinal cord and cauda equina tumours have been developed to prevent postoperative spinal deformities and nerve entrapment. The purpose of this paper is to introduce a new reconstructive procedure based on rotational laminoplasty and to report preliminary results in a small series. Method. The trough is drilled at the border of the laminae and articular processes and the ligamentum flavum is resected on its cephalocaudal aspect, so the vertebral arch can be separated as a single mass. After tumour resection, the vertebral arch is removed en bloc with the laminae, and is rotated 90 degrees and placed on the articular facets and fixed using suture passing through holes drilled in the bone. Findings. One man and six women underwent rotational laminoplasty following resection of spinal or cauda equina tumours. Operative exposure was good and permitted complete resection. Patients did well postoperatively from both spine-surgical and neurolosurgical points of view. Computed tomography documented a bony union with preservation of widely patent spinal canal. Interpretation. Rotational laminoplasty affords a satisfactory operative exposure for the resection of large, complex lesions. It creates a widely patent, stable spinal canal easily, without the need for special tools. [ABSTRACT FROM AUTHOR]

Summary The aim of this paper is to demonstrate the unusual MR features of thoracic syringomyelia following TB meningitis and to discuss the neurosurgical aspect of the treatment of this rare entity. Four years after a TB meningitis episode, a 30 year-old female patient developed a progressive spastic paraparesis. MR studies revealed multiloculated syrinxes throughout the thoracic cord. She had a syringosubarachnoid shunt with a silastic “T” tube inserted. On the first postoperative day, she showed a dramatic neurological improvement, but unfortunately her paraparesis progressed to the preoperative level within a month despite diminished size of the syrinxes on the control MRI examination. Two and a half years after the operation the patient complained of having a burning type of central pain, and further deterioration in neurological function. Thoracic spinal MRI examination demonstrated enlarged syringomyelic cavities. At the second operation syringo-peritoneal shunt insertion was performed via right T10–11 hemilaminectomy using a “T” tube. At present, 4 months after the second operation, the patient's neurological examination demonstrated decreased spasticity, and improved strength in the legs compared to the preoperative level. MRI is the first choice of investigation in detecting TB related myelopathy as it provides a greater detail of pathological changes within and around the spinal cord such as syrinx formation and arachnoiditis. The MR findings are also helpful in deciding the management and predicting the outcome. Presence of multifocal loculations and arachnoid adhesions is the likely cause of treatment failures and poor prognosis. [ABSTRACT FROM AUTHOR]

Background: The study of the distinct structure and function of the human central nervous system, both in healthy and diseased states, is becoming increasingly significant in the field of neuroscience. Typically, cortical and subcortical tissue is discarded during surgeries for tumors and epilepsy. Yet, there is a strong encouragement to utilize this tissue for clinical and basic research in humans. Here, we describe the technical aspects of the microdissection and immediate handling of viable human cortical access tissue for basic and clinical research, highlighting the measures needed to be taken in the operating room to ensure standardized procedures and optimal experimental results. Methods: In multiple rounds of experiments (n = 36), we developed and refined surgical principles for the removal of cortical access tissue. The specimens were immediately immersed in cold carbogenated N-methyl-D-glucamine-based artificial cerebrospinal fluid for electrophysiology and electron microscopy experiments or specialized hibernation medium for organotypic slice cultures. Results: The surgical principles of brain tissue microdissection were (1) rapid preparation (<1 min), (2) maintenance of the cortical axis, (3) minimization of mechanical trauma to sample, (4) use of pointed scalpel blade, (5) avoidance of cauterization and blunt preparation, (6) constant irrigation, and (7) retrieval of the sample without the use of forceps or suction. After a single round of introduction to these principles, multiple surgeons adopted the technique for samples with a minimal dimension of 5 mm spanning all cortical layers and subcortical white matter. Small samples (5–7 mm) were ideal for acute slice preparation and electrophysiology. No adverse events from sample resection were observed. Conclusion: The microdissection technique of human cortical access tissue is safe and easily adoptable into the routine of neurosurgical procedures. The standardized and reliable surgical extraction of human brain tissue lays the foundation for human-to-human translational research on human brain tissue. [ABSTRACT FROM AUTHOR]

Purpose: Penetrating traumatic brain injury (pTBI) is an acute medical emergency with a high rate of mortality. Patients with survivable injuries face a risk of infection stemming from foreign body transgression into the central nervous system (CNS). There is controversy regarding the utility of antimicrobial prophylaxis in managing such patients, and if so, which antimicrobial agent(s) to use. Methods: We reviewed patients with pTBI at our institution and performed a PRISMA systematic review to assess the impact of prophylactic antibiotics on reducing risk of CNS infection. Results: We identified 21 local patients and 327 cases in the literature. In our local series, 17 local patients received prophylactic antibiotics; four did not. Overall, five of these patients (24%) developed a CNS infection (four and one case of intraparenchymal brain abscess and meningitis, respectively). All four patients who did not receive prophylactic antibiotics developed an infection (three with CNS infections; one superficial wound infection) compared to two of 17 (12%) patients who did receive prophylactic antibiotics. Of the 327 pTBI cases reported in the literature, 216 (66%) received prophylactic antibiotics. Thirty-eight (17%) patients who received antibiotics developed a CNS infection compared to 21 (19%) who did not receive antibiotics (p = 0.76). Conclusions: Although our review of the literature did not reveal any benefit, our institutional series suggested that patients with pTBI may benefit from prophylactic antibiotics. We propose a short antibiotic course with a regimen specific to cases with and without the presence of organic debris. [ABSTRACT FROM AUTHOR]

The author reflects on the pros and cons of permissive hypercapnia in patients with subarachnoid hemorrhage and acute respiratory distress syndrome (ARDS). He states that on one hand it is accepted that hypercapnia should be avoided in brain-damaged patients as it leads to an increase of intracranial blood volume but on the other hand animal studies have demonstrated a beneficial effect of hypercapnia on the central nervous system.

Summary. Glioblastoma of the brain stem is rare and there is no description of such a lesion in patients suffering from acquired immunodeficiency syndrome. The majority of intracerebral mass lesions are due either to toxoplasmosis or primary central nervous system lymphomas so that it is usually not included in the differential diagnosis of enhancing lesions of the central nervous system in these patients. A 31-year-old human immunodeficiency virus (HIV) infected man presented with a four months history of slowly progressive deterioration of brainstem associated symptoms despite antitoxoplasmic therapy. Magnetic resonance imaging revealed a large ring enhancing lesion in the brainstem. Clinical and neuroradiolagical data could not establish a proper diagnosis and a stereotactic serial biopsy was undertaken. Histological examination of the specimen showed a glioblastoma multiforme (GBM) as the first reported case of GBM located in the brainstem in an acquired immunodeficiency syndrome (AIDS) patient. Patient management and effectiveness of stereotactic serial biopsy are discussed. [ABSTRACT FROM AUTHOR]

Background: Circumferential intradural spinal meningiomas are exceptionally rare. They pose several surgical challenges and a complete excision is not easy. The aim of this study is to provide surgical strategies to facilitate a full excision of such tumors. Methods: A fully circumferential intradural meningioma at T9/10 was fully removed via a posterior approach and a structured single procedure, with no intra or perioperative complications. Conclusions: Complete removal of circumferential spinal meningiomas can be achieved with wise preoperative planning, familiarity with techniques needed to transpose the spinal cord, and a structured staged excision of the four components of these tumors. [ABSTRACT FROM AUTHOR]

Background: Surgical treatment of recurrent, posterior cranial fossa epidermoids in multioperated patients carries significant morbidity, mainly due to tumor adhesion to cranial nerves and vessels, and brainstem involvement. Radical resection is often not feasible; therefore surgery should aim to restore cerebrospinal fluid circulation, release engulfed neurovascular structures, and relieve brainstem compression. Intra-axial epidermoids are extremely rare. We present an innovative surgical technique of a cyst-cisternal shunting to treat cystic recurrent, unresectable brainstem epidermoids. Methods: The surgical technique is stepwise described and a case illustration is reported. The pertinent literature has been reviewed. Results: Few cases of brain stem epidermoid tumors have been described to date. The surgical steps of this technique and related intraoperative images are provided. One case illustration regarding the resection of a large recurrent cystic intra-axial brainstem epidermoid is reported to demonstrate the application of the technique in a clinical setting. The patient was followed up for 14 years and did not experience any recurrence, showing a stable disease at the last follow-up control. A systematic review of the competent literature has been provided. Conclusions: Cyst-cisternal shunting in case of recurrent, brainstem epidermoid is a safe and long-term effective technique to relieve mass effect into the brainstem. [ABSTRACT FROM AUTHOR]

The article focuses on atypical granular cell tumour of the sural nerve mimicking. Granular cell tumours are usually found in the skin of head, neck, and tongue and may be multiple. Other less common sites are breast, gastrointestinal tract, vulva, peripheral and central nervous system, spermatic cord, and upper respiratory tract. Granular cell tumours in the upper and lower extremities are mostly located in the skin and subcutaneous tissue. Reports of granular cell tumours of peripheral nerves are extremely rare, and there are only few cases involving the median, radial, ulnar, digital, sciatic, trigeminal, and recurrent laryngeal nerves.

Background: Selective peripheral denervation (SPD) and deep brain stimulation of the globus pallidus (GPi-DBS) are available surgical options for patients with medically refractory cervical dystonia (CD). There are few data available concerning whether patients who have unsatisfactory treatment effects after primary surgery benefit from a different type of subsequent surgery. The aim of this study was to assess whether combining these surgical procedures (SPD plus GPi-DBS) was effective in patients with unsatisfactory treatment effects after their initial surgery. Methods: Forty-one patients with medically refractory idiopathic CD underwent SPD and/or GPi-DBS. Patients who were dissatisfied with their primary surgery (SPD or GPi DBS) elected to subsequently undergo a different type of surgery. These patients were assessed with the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS). Results: SPD alone and GPi-DBS alone were performed in 16 and 21 patients, respectively. Four patients had unsatisfactory treatment effects after the initial surgery and subsequently underwent another type of surgery. Among them, two patients with persistent dystonia after SPD subsequently underwent GPi-DBS, and two other patients who had insufficient treatment effects following GPi-DBS were subsequently treated with SPD. All of these patients experienced sustained improvement from the combined surgical procedures according to the TWSTRS score during a long-term follow-up of 12-90 months. Conclusions: Patients with unsatisfactory treatment effects after an SPD or GPi-DBS experienced improvement from subsequently undergoing other types of surgery. Therefore, combined surgical procedures are additional surgical options with good outcomes in the treatment of patients with residual symptoms after their initial surgery. [ABSTRACT FROM AUTHOR]

Background: Although histological diagnosis is indispensable in treating primary central nervous system lymphoma (PCNSL), we sometimes face an intractable situation in which tissue can be obtained only from a deep-seated brain lesion. In place of a histological diagnosis, the diagnostic adequacy of the combined use of 18 F-FDG PET and corticosteroid administration for PCNSL located in a deep-seated brain structure is reported. Methods: Patients with a deep-seated tumor were treated as having PCNSL without histological confirmation, based on the following criteria: (1) there was no evidence of systemic malignancy; (2) the tumor showed an extremely high FDG uptake relative to normal gray matter on pretreatment 18 F-FDG PET; (3) the tumor decreased in size 1 week after diagnostic therapy by corticosteroid administration on contrast-enhanced T1-weighted magnetic resonance imaging (MRI). FDG uptake of the lesion was evaluated by the maximum of standardized uptake values (SUVmax) and tumor-to-normal ratio of the SUV (T/N ratio). The extent of the tumor reduction was calculated by volumetric analysis for the treatment response to corticosteroid administration. Results: Ten patients (4 males and 6 females) matched these criteria. On pretreatment 18 F-FDG PET, mean SUVmax in the tumor was 24.8 (8.75-60.75), and mean T/N ratio was 3.24 (2.17-5.12). The extent of tumor volume reduction was shown to be 21 to 68 % 1 week after diagnostic therapy by corticosteroids. Mean total dose and duration of corticosteroids were 719 mg as prednisolone and 6.5 days, respectively. Nine patients achieved complete response and one patient achieved partial response on MRI after standard treatment for PCNSL with high-dose methotrexate and/or whole-brain irradiation. Conclusion: Although the value of biopsy is universal, combining 18 F-FDG PET and corticosteroid administration is an important alternative method that may lead to the diagnosis of deep-seated PCNSLs in cases with intractable histopathological confirmations. [ABSTRACT FROM AUTHOR]

Background: Studies regarding frameless stereotactic brain biopsy mainly report high diagnostic yield (DY) as opposed to relatively low diagnostic accuracy. This discrepancy raises the question of the certainty and precision of obtained diagnoses. This article proposes a DY definition encompassing diagnostic certainty and precision according to the World Health Organization (WHO) central nervous system (CNS) tumour classification system. Furthermore, our eight-year experience with this procedure is reviewed and evaluated. Methods: A consecutive series of 235 frameless biopsy procedures was reviewed. Criteria were set up for categorising obtained diagnoses. All cases were included in a predictive factor analysis of inconclusive biopsy and postoperative complications. Results: According to our predefined DY criteria, the DY was 72.8 %. The inconclusive biopsy outcome measured 21.7 %; the non-diagnostic biopsy outcome was 5.5 %. The only predictive factor found for inconclusive biopsy procedures was age under 30. Predictive factors for postoperative complications, which were found statistically significant after multivariable analysis, were glucose level and intra-operative haemorrhage. The total morbidity rate was 8.5 %, including a mortality rate of 0.9 %. Conclusions: Although frameless stereotactic brain biopsy procedures are considered to be relatively safe, the true DY is significantly less than previously reported, most probably due to the lack of standardised DY criteria. Based on our DY definition and subsequent DY findings, standardisation of DY criteria and definition is paramount for biopsy diagnosis interpretation. [ABSTRACT FROM AUTHOR]

Background: Neurophysiological monitoring (IOM) consisting of somatosensory (SEPs), muscle (MEPs) and spinal motor evoked (D-wave; spinal MEPs) potentials is used to indicate injury related to surgical treatment of intradural and intramedullary lesions. Combining spinal and muscle MEPs reliably predicts long-term motor deficit. If spinal MEPs recording is not possible, additional markers-e.g. S100B, a serum marker for glial injury-may be a helpful adjunct. Thus, serial serum S100B measurements were related to both the intraoperative IOM recordings and the long-term neurological outcome in patients surgically treated for cervical and thoracic intradural lesions. Methods: In 33 patients (9 men, 24 women, 54 ± 17 years) during intramedullary (8) or intradural (25) cervical or thoracic spinal surgeries significant intraoperative SEP-amplitude decrement >50 % or MEP loss and serial S100B serum concentration (perioperative days 0, 1-3, 5) were related to outcome (>1 year after discharge, grouped into improved and unchanged/altered neurological symptoms). Results: Differences in S100B levels between patients with improved and unchanged/altered neurological outcome were significantly on postoperative days 2 (0.085 ± 0.08 μg/l vs 0.206 ± 0.07 μg/l, p = 0.005) and 3 (0.076 ± 0.03 μg/l vs 0.12 ± 0.05 μg/l, p = 0.007). All patients with permanent altered neurological symptoms developed S100B levels >0.08 μg/l (0.09-0.35 μg/l). Eighty-one percent of patients with improved neurological symptoms presented with S100B levels ≤0.08 μg/l (0.02-0.08 μg/l). Nine out of ten patients (90 %) without changes in EP and S100B had an improved long-term outcome, whereas 9/13 patients (69 %) with changes in EP and S100B had altered neurological symptoms in long-term outcome. Conclusion: Intraoperative stable EPs and S100B ≤0.08 μg/l may be used as a marker to predict long-term neurological improvement, whereas EP-changes and elevated S100B levels on the 3rd postoperative day may be useful as a marker to predict long-term neurological alteration. In summary, the combined use of S100B and EPs might be helpful in the prediction of the severity of adverse spinal cord affection following surgery and guidance of patients. [ABSTRACT FROM AUTHOR]

Background: Melanotic ependymoma (ME) is an extremely rare subset of ependymoma characterized by cytoplasmic and extracellular deposition of melanin, with no case series having been reported to date. The aim of this study was to analyze the clinical manifestations, pathological and radiological features, treatment, and follow-up data, and to discuss the diagnosis, management and prognosis of ME. Methods: We retrospectively reviewed the clinical and imaging data of six patients with primary ME. The diagnosis was based on radiological and pathological criteria. All the patients were treated surgically with gross total resection. The preoperative and postoperative neurological states of the patients were analyzed. All the follow-up data were obtained from office visits, and the long-term outcomes are presented and discussed. Results: Patients presented with nonspecific symptoms. On magnetic resonance imaging (MRI), although a characteristic signal variation could be found reflecting the melanin component, individual appearances varied widely and were related to the content and distribution of melanin in the ME lesions. The characteristic ependymoma-related pathological appearance and specific immunostaining for glial fibrillary acidic protein and antimelanoma monoclonal antibody were revealed. During a mean follow-up period of 46.8 months, no local recurrences or distant metastases were observed. Conclusions: The accurate diagnosis of ME depends on pathology. The histological grading used for ependymoma can be applied. Most MEs have a relatively benign course. Complete surgical resection alone is the treatment of choice for low-grade MEs, and the outcome may be favorable. Postoperative adjuvant radiotherapy can be considered for lesions with histologically anaplastic features. [ABSTRACT FROM AUTHOR]

Background: To investigate characteristic clinical and radiological features of extradural arachnoid cysts (EDACs) in the thoracolumbar region, a retrospective review of medical records and imaging studies was performed. EDACs are well known but relatively rare lesions in the thoracolumbar spinal canal. The most common site is the lower thoracic spine, and it may cause neurological symptoms by compressing the spinal cord or nerve root. In this study, the pathogenesis, symptomatology, diagnostic approach, and surgical management of EDACs will be discussed. Methods: We studied 14 consecutive patients who were surgically treated for EDACs in the thoracolumbar region at our institute between March 2000 and January 2011. The history, clinical presentations, image findings, operative findings, and surgical outcomes of these patients were retrospectively analyzed. The mean follow-up period was 28 months (range: 6-72 months). Results: Progressive motor weakness was the predominant symptom in all patients. Nine patients had radicular leg pain and back pain in the thoracolumbar area. On MRI, the cyst compressed the dural sac and spinal cord posteriorly typically with bilateral foraminal extensions. On radiological study, a communication point with the subarachnoid was hardly observed. The surgical treatment of EDACs included complete resection of the walls and closing the communicating point with the subarachnoid space. All patients showed excellent outcomes according to Odom's criteria without recurrence. One CSF leakage and one postoperative hematoma were noted. Conclusions: Thoracolumbar EDAC patients presented paraparesis and leg pain. Complete excision and closing the communicating point with the subarachnoid space were the choices of treatment, and the outcomes were favorable. [ABSTRACT FROM AUTHOR]

Background and purpose: We describe the rationale and safety of concurrent decompression of Chiari type 1 malformation (CM1) and untethering of the spinal cord. Spinal cord traction is considered one of the pathogenic mechanisms involved in the development of CM, and 14% of patients with CM1 have tethered cord syndrome (Milhorat et al., Surg Neurol 7:20-35, ; Roth, Neuroradiology 21:133-138, ; Royo-Salvador, Rev Neurol 24:937-959, ; Royo-Salvador et al., Acta Neurochir 147:515-523, ). Therefore, intraspinal anomalies that require intervention are commonly treated before surgical decompression of Chiari malformation (Cheng et al., Neurologist 8:357-362, ; Menezes, Pediatr Neurosurg 23:260-269, ; Milhorat et al., Surg Neurol 7:20-35, ; Royo-Salvador et al., Acta Neurochir 147:515-523, ; Schijman and Steinbok, Childs Nerv Syst 20:341-348, ; Yamada et al., Neurol Res 26:719-721, ). However, in the interval between the spinal cord untethering and the decompression surgery, patients may continue to suffer from the untreated symptoms of CM. In a series of four patients with concurrent severe and progressive symptoms referable to both conditions, we performed both surgeries simultaneously. Methods: Charts of four patients who underwent concurrent Chiari decompression and spinal cord untethering were reviewed. Results: All patients tolerated the procedures well without complication. They reported significant or complete early postsurgical resolution of headaches and ambulating difficulties. On average, patients started to walk on postoperative day 3 (3 ± 1 days) and were discharged on hospital day 6 (6 ± 1 days). No patient experienced a persistent subcutaneous or transcutaneous cerebrospinal fluid leak. Subsequent postoperative courses were uneventful. Conclusion: Concurrent Chiari decompression and untethering of the spinal cord is a feasible option and in some patients may be preferred in lieu of staged procedures. [ABSTRACT FROM AUTHOR]

Superficial siderosis of the central nervous system is a rare disorder with hemosiderin deposition in the spinal and cranial leptomeninges and subpial layer, mostly from repetitive subarachnoid hemorrhage. Progressive sensorineural deafness, cerebellar ataxia, and pyramidal signs comprise the typical clinical presentation. We describe a 47-year-old patient, who showed initial 2-year improvement after successful occlusion of an intradural bleeding source at T4. Secondary progression of symptoms without further bleedings was noted thereafter, with a clinical picture of amyotrophic lateral sclerosis. This case illustrates that the disease may progress secondarily even without re-bleedings, and that secondary progression might be due to a similar pathomechanism as in amyotrophic lateral sclerosis. [ABSTRACT FROM AUTHOR]

Radiation-induced brain injury (RBI) is an insidious side-effect of radiotherapy mediated by vascular alterations, inflammation and ischaemia. In previous studies we had shown potential increases in loco-regional blood flow and glucose metabolism in brain tumours by using electrical cervical spinal cord stimulation (SCS). In this preliminary report we demonstrate the effect of cervical SCS on RBI-tissue metabolism, as assessed using [18F]fluorodeoxyglucose-positron emission tomography (FDG-PET). SCS devices were inserted in eight patients with diagnosis of potential RBI in previously irradiated areas. While the SCS device was deactivated, each patient underwent an initial FDG-PET study to evaluate the clinical status. A second FDG-PET study was performed later the same day while the SCS device was activated in order to evaluate the effect of cervical SCS on glucose metabolism. Basal glucose metabolism in RBI areas was 31% lower than peri-RBI areas ( p = 0.009) and 32% lower than healthy contra-lateral areas ( p = 0.020). There was a significant increase in glucose uptake during SCS in both the RBI ( p = 0.005) and the peri-RBI ( p = 0.004) areas, with measured increases of 38 and 42%, respectively. The estimated potential maximal residual activity of the first FDG dose’s contribution to the activity on the second scan was ≤14.3 ± 4.6%. In this study using PET, SCS increased glucose metabolism in RBI and peri-RBI areas. These results warrant further clinical investigation to elucidate more fully the clinical usefulness of SCS in these patients. [ABSTRACT FROM AUTHOR]

Previous studies have shown that axonal outgrowth in the damaged central nervous system is closely related to the local microenvironment. Transplantation of bone marrow stromal cells (BMSC) or BMSC with some biomaterials has been used to treat various central nervous system diseases with some success. In the current study, we investigated if BMSC on denuded human amniotic membrane (DhAM) as a composite matrix could stimulate axonal outgrowth or not. After completely removing the cells on the amniotic membrane with a tryptic and mechanical approach, we seeded BMSC on it. The MTS was applied to test the cytotoxicity of DhAM compared with PLGA and PLL. The morphology of the BMSC was observed by light, electronic and laser confocal microscopy. We also used four kinds of substance (PLL, DhAM, BMSC + PLL, BMSC + DhAM) to coculturing with the cortical neurons. Finally, the lengths of axons in each group were studied using the positive axon-specific marker NF–H. The DhAM was devoid of cellular components and only its intact basement membrane was left. BMSC grew on the substrate and proliferated with a flat to fusiform morphology. In the MTS test, the results indicated that BMSC cultured in DhAM extract had a high survival rate (> 80%). Moreover, the cortical neural axons in the experimental group (BMSC + DhAM) were longer (287.37 ± 12.72 μm) than in the other groups ( P < 0.01). This study demonstrates that the DhAM was a good carrier to support growth of BMSC and BMSC on DhAM was an effective composite matrix to support the outgrowth of the axons of rat cortical neurons in vitro. Future studies of the use of the composite matrix in disorders are planned. [ABSTRACT FROM AUTHOR]

Object. To assess whether nimustine (ACNU), a drug that can cross the blood brain barrier, combined with radiotherapy, improved the survival of patients with primary central nervous system lymphoma (PCNSL). Clinical materials and methods. Between 1995 and 2005, we treated 63 immunocompetent PCNSL patients with combination therapy consisting of intra-arterial ACNU (100 mg/m2) and whole brain radiotherapy (36–50 Gy). Their median age was 60 years (range 28–81). The median follow-up was 24 months. Findings. With this regimen we achieved a complete response rate of 75% (43 of 57 patients). Kaplan–Meier estimates for median progression-free survival and median overall survival were 26 and 39 months, respectively. The 3- and 5-year survival rates were 51% (95% confidence interval [CI], 36–65%) and 32% (95% CI, 17–47%), respectively. By multivariate analysis, age (<60 vs. ≥60 years) was the only statistically significant prognostic factor; the WBRT dose, sex, and number of tumors were not significant prognostic factors in this study. Myelosuppression was the most frequent side effect, 60% of patients experienced grade 3–4 leukopenia. Late neurotoxicity as a result of treatment was observed in 14 of 43 patients (34%) and higher age (>60) was associated with a high risk of neurotoxicity. Conclusion. The intra-arterial administration of ACNU combined with radiation therapy yielded a high response rate at acceptable toxicity levels in younger patients with PCNSL. However, late neurotoxicity was a serious complication in patients above 60 years of age. [ABSTRACT FROM AUTHOR]

Background. The purpose of this article is to report experience gained over three years of the use of a protocol for patient selection and timing of operation for acute thoracic and lumbar fractures. Method. At admission, all patients underwent neurological and imaging exams. All patients with a spinal cord lesion scored as ASIA A at any level inferior to T10 and as ASIA B, C or D at any level, were categorized as emergency and operated on within eight hours from trauma. ASIA A cases in the T1–T10 tract and ASIA E cases at any level were treated in the ordinary operative work schedule. Findings. Ninety-four patients with surgically treated lumbar or thoracic fractures took part in this study. On the imaging studies, 12 patients were classified as A, 50 as B and 32 as C following the AO classification. At the neurological exam, 39 patients were scored as ASIA A, nine as B, six as C, two as D and 38 as E. At follow-up, of the 39 patients scored as ASIA A, 13 (33%) improved at least one grade and of the 17 scored as ASIA B, C or D, 11 (64.7%) improved. None of the 38 patients scored as ASIA E deteriorated. Conclusions. The findings show that the strategy in the protocol was safe and followed by satisfactory rates of neurological outcome. Larger prospective studies, preferably randomized, are needed to establish definitively its place in the management of patients with spinal injury. [ABSTRACT FROM AUTHOR]

Background. The pathogenesis of idiopathic normal pressure hydrocephalus (INPH) is unknown, and the syndrome of INPH remains a diagnostic and therapeutic challenge. The present study investigated the disease-specific proteins that aid in the diagnosis and treatment of INPH and thus to study their role in the disease process. Methods. A comparative proteomic analysis was used for clinical screening of cerebrospinal fluid (CSF) proteins in 15 patients with INPH and compared with 12 normal subjects. Furthermore, enzyme linked immunosorbent assay (ELISA) was performed for comparison with CSF proteins between individual INPH patients and controls. Results. Seven proteins and their isoforms, including leucine-rich α-2-glycoprotein (LRG), α1-antichymotrypsin, apolipoprotein D, apolipoprotein J, haptoglobin α1, serum albumin, and α-1-microglobulin/bikunin precursor showed significant changes in CSF of INPH patients compared with controls by proteomic analysis. And significant higher CSF levels of LRG in INPH patients compared with controls were found by ELISA. Conclusions. These results indicate that there are significant differences in the expression of certain proteins in the CSF of patients with INPH and normal subjects. In particular, the CSF level assay of LRG suggests that LRG is a specific biomarker for INPH and has potential use in the diagnosis and indication for CSF shunting. [ABSTRACT FROM AUTHOR]

Superficial siderosis (SS) of the central nervous system is an insidious, progressive, irreversible and debilitating neurological disorder caused by recurrent haemorrhage within the subarachnoid space. The subsequent deposition of haemorrhagic breakdown products in the spinal cord and nervous tissues leads to the loss of neurones and myelin, and to the development of a neurological deficit. In a small number of patients, the source of haemorrhage is related to traumatic cervical nerve root avulsion occurring several years prior to the onset of symptoms. Surgical ablation of the source has been shown to halt the progression of the disease, at least in the short term. We review the literature on SS secondary to cervical nerve root avulsion and report a further case in which surgical management was successful in halting disease progression. We emphasize that early detection and recognition of the initial non-progressive symptoms related to this poorly known disease, coupled with timely surgical management, minimizes the degree of neurological disability. [ABSTRACT FROM AUTHOR]

Summary ¶Objective. Meningeal melanocytoma generally occurs in the posterior fossa. Orbital manifestation is rarely encountered. Methods. A thirty-five year-old man presented with progressive proptosis of his right eye. Computed tomography (CT) and Magnetic Resonance Imaging (MRI) of the brain showed an expansive intraconal mass lesion occupying the superior orbital compartment, the entire orbital apex, and the optic foramen. Histological analysis and Immunohistochical staining for S-100 and HMB-45 monoclonal antibodies confirmed melanocytoma. Findings. Microsurgical removal was accomplished through a fronto-orbital craniotomy. Chemotherapy and irradiation followed the initial intervention. The patient returned for follow up two years after surgery, complaining of headache and right visual loss. A subfrontal tumor with massive edema was found on follow up CT scan. Interpretation. Meningeal melanocytomas are rare benign pigmented tumors of the central nervous system. They are predominant in the posterior fossa and spinal cord and frequently mistaken for melanomas, especially on frozen sections. Orbital presentation is rare. The natural history is poorly defined. [ABSTRACT FROM AUTHOR]

Summary¶We present the unusual occurrence of multiple systemic and two central nervous system tuberculomas in an immunecompetent young patient. A large left frontal epidural tuberculoma with transcalvarian extension was removed surgically and chemotherapy was initiated. The patient remained on a chemotherapy with INH, RMP, and EMB and was followed clinically and with MRI scans for 24 months. Findings. The clinical presentation and neuroimaging studies initially suggested malignant disease. Surgical resection of the left frontal lesion was required to relive the mass effect. The histological evaluation showed a granulomatous inflammation with epitheloid and Langhans giant cells, but no acid-fast bacilli. Cultures of the specimens yielded a mixed infection with Corynebacterium species and Staphylococcus epidermidis. Based on the histological findings, chemotherapy for tuberculosis was initiated. Subsequently, Mycobacterium tuberculosis was cultured from the surgical specimen and sputum. Interpretation. Parenchymal CNS tuberculosis with or without extracerebral manifestations may present as a space-occupying lesion. Because a tuberculoma is rarely suspected especially if there is atypical morphology, biopsy is required to establish the diagnosis and expedite specific treatment. [ABSTRACT FROM AUTHOR]

Summary Object. Brain check-up is very important for detecting the incidence and prevalence of aneurysms in the population and to get the definite strategy for the treatment of intracranial aneurysms. Methods. This is a retrospective study of 116 aneurysms detected by brain check-up between 1998–1999 which were treated either by clipping or endovascular coiling. In some cases the aneurysmal wall was resected for histopathological examination and compared with five normal autopsy cases. Conclusions. Direct surgery is the primary option for a patient with an aneurysm in the anterior circulation especially in young patients. Intravascular therapy is suitable for aneurysms in the posterior circulation and in intracavernous site. [ABSTRACT FROM AUTHOR]

Summary We report one case of spontaneous thoracic spinal cord herniation presenting with a progressive spastic paraparesis for 4 years in a 55 years old man. From preoperative MRI, showing a ventrally displaced atrophic spinal cord at T2–T3 level, a dorsal intradural arachnoid cyst was suspected. At operation, after a 3 level laminectomy, no arachnoid cyst was found and spinal cord herniation into a meningeal diverticulum was confirmed. The herniated myelon was replaced intradurally and the lumen of the diverticulum was filled with Teflon® settled with fibrin glue to prevent recurrence. Postoperatively some neurological recovery was achieved. The literature was reviewed, regarding clinical and epidemiological features, proposed pathophysiological mechanisms, treatment options and outcome. Only 32 surgically proved cases of thoracic spinal cord herniation with no past history of spine trauma, injury or surgery were found. [ABSTRACT FROM AUTHOR]

Summary Background. The basic mechanism of delayed cerebral vasospasm following subarachnoid haemorrhage (SAH) has been intensively investigated. It is thought that nitric oxide (NO) is a basic mediator of the cerebral vasodilator mechanism. Previous clinical and experimental studies have shown a cerebral vasodilator effect of high cervical spinal cord stimulation (SCS) however, the mechanism of this effect is still controversial. We investigated the contribution of the vasodilator effect of NO to this mechanism in an experimental SAH model using rabbits. Method. Four experimental groups, were designated: Group 1. Cerebral blood flow (CBF) was evaluated by transcranial Doppler ultrasonography (TDU) in 8 rabbits. Group 2. In 4 animals, intracisternal saline injection and cervical epidural electrode placement without SCS were performed before TDU. Group 3. TDU was performed before and after SCS on the fourth day of SAH in 8 rabbits. Group 4. In 8 animals, N-Nitro-L-Arginine Methyl Esther (L-NAME) was administered intracisternally on the fourth day of SAH, at a dose of 0.6 mg/kg, 45 minutes before SCS. CBF parameters, obtained via measurements or calculations from TDU data, were compared. Findings. The occurrence of vasospasm after SAH was demonstrated with significant changes in TDU parameters (high peak systolic velocity and positive values of the degree of stenosis). In all SAH animals, SCS resulted in significant vasodilation. Even after the injection of L-NAME, SCS still had a significant vasodilatory effect in SAH animals, but there was also a significant difference in CBF parameters in the SCS-only group when compared with the L-NAME treatment before SCS group. Interpretation. The mechanism of the cerebral vasodilatory effect of SCS remains controversial. Our results revealed the contribution of a neurohumoral effect which can be partially prevented by use of an NO synthase inhibitor. [ABSTRACT FROM AUTHOR]

Summary Background. The wide variety of intraspinal cystic lesions necessitates different elaborate diagnostic procedures to choose the right therapeutic management in symptomatic patients. Based on the case reports of seven patients with symptomatic spinal arachnoid cysts we discuss the aetiology, diagnostic procedures and therapeutic management of extra- and intradural spinal cysts. Method. All patients underwent MRI, Myelography and CT-Myelography during diagnostic evaluation. During surgery the cyst was resected and the communication between the cyst and the subarachnoid space was closed. Findings. Two patients were identified with intradural, five with extradural spinal arachnoid cysts. Postoperative outcome was favourable in those patients without preoperative cord damage. Interpretation. MRI is the diagnostic procedure of first choice because of its potential to demonstrate the exact localisation, extent and relationship of the arachnoid cyst to the spinal cord. Cord atrophy secondary to compression can be visualised and used for prediction of neurological outcome. Myelography and CT-Myelography (CTM) are still of diagnostic value since they might demonstrate the communication between the subarachnoid space and the cyst, which is important for surgical planning. The aim of surgical treatment is neural decompression and prevention of refilling of the cyst which is best accomplished by complete resection of the cyst and closure of the communication between cyst and subarachnoid space. [ABSTRACT FROM AUTHOR]

Summary¶ The potential role of Iloprost, a stable analogue of prostocyclin, in treating spinal cord ischemia was investigated in rabbits subjected to aortic occlusion for 15 minutes. Ten adult rabbits weighing 2–2.5 kg received an intravenous infusion of saline (SF) as a control group and 14 rabbits received an intravenous infusion of Iloprost, 25 μg/kg/h. Iloprost infusion was started immediately after clamping of the aorta and continued 60 minutes thereafter. Cortical somatosensorial evoked potentials (CSEP) were recorded during the pre-ischemic period as a baseline and post-ischemic readings were taken at 15, 30 and 60 minutes. There was no statistically significant difference between CSEP of the saline and Iloprost treated groups (p<0.05). All animals were examined neurologically by using a modification of Tarlov scale and all subjects were then deeply anesthetized and their spinal cords were removed for light and electron microscopic examinations at 24 h after spinal cord ischemia. In order to obtain an accurate comparison of ultrastructural changes between saline treated and Iloprost treated groups, a grading scale was performed. The light microscopic and ultrastructural analysis of the Iloprost treated group revealed that there was moderate protection of the myelin and axons and edema was attenuated. Findings of this study suggest that Iloprost exerts a protective effect on spinal cord ischemia. However, further studies are needed to reveal possible mechanisms of protection provided by Iloprost. [ABSTRACT FROM AUTHOR]

Summary Background. This retrospective study evaluated the neurological outcome of 26 patients with spontaneous and non-spontaneous spinal epidural haematoma (SEH) who underwent microsurgical clot removal. It was the objective of the present study to investigate whether the aetiology of the SEH has an influence on the neurological outcome. Methods. The medical records and radiological investigations of 26 patients with SEH were re-examined, and the latency between symptom onset and operation, and the size of the haematoma were determined. Motor and sensory function had been evaluated before surgery and 90 days after discharge. Findings. Fourteen patients with non-spontaneous SEH and 12 patients with spontaneous SEH were identified. After surgery, neurological deficits improved in 9 of the patients with spontaneous (75%) and in 13 of the patients with non-spontaneous SEH (93%). In cases of spontaneous SEH, the median latency between symptom onset and operation was longer (72 hrs vs 7 hrs) and the median extent of the haematoma was larger (3.5 vs 2 spinal segments), than in the non-spontaneous cases. Interpretation. Neurological outcome seems to be related to the aetiology of the SEH. Better outcome was observed in patients with surgically treated non-spontaneous SEH. Two explanations for this finding are worth considering. First, patients with non-spontaneous SEH usually are already under medical surveillance and can undergo medullary decompression more rapidly. Second, the compression of the spinal cord is possibly less severe in non-spontaneous SEH because of their smaller size. [ABSTRACT FROM AUTHOR]

Summary¶ We report five cases of ganglioglioma in various locations. The tumours were removed with gross total resection in most cases without any further neurological deterioration. Without any additional treatment, no evidence of recurrence or regrowth of tumours was observed in the mean follow-up period of 4.1 years. We suggest that intramedullary spinal cord gangliogliomas be resected totally due to the high risk of recurrence and regrowth rate of the tumours with subtotal resection in the long term considering especially that these tumours affect predominantly young patients. [ABSTRACT FROM AUTHOR]

Objective and importance. Spinal epidural haematoma (SEH) following implantation of an epidural spinal cord electrode is a very rare complication but one that must not be overlooked. This case is unusual because of the almost “holocord” extension of the haematoma and the excellent recovery obtained by prompt surgical treatment.Clinical presentation. A 69 years old man with normal serum coagulation parameters was submitted to spinal cord stimulation (SCS) for chronic pain syndrome. After a minimal L1 laminotomy the patient developed paraplegia due to a large haematoma at D4-L2.Intervention. Surgical removal of the entire clot by a D4-L2 laminectomy was performed immediately.Conclusion. Large epidural haematoma can result from SCS and this complication may be cured by appropriate and prompt surgery. [ABSTRACT FROM AUTHOR]