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Aim: Duplication of 7q34 resulting in generation of BRAF-KIAA1549 fusion transcripts is a characteristic event in pilocytic astrocytoma that may also aid distinction from diffuse astrocytic tumours. As data on BRAF-KIAA1549 fusion transcript status remain mainly limited to children, we aimed to examine the diagnostic value of BRAF-KIAA1549 fusion transcripts across all age groups., Methods: BRAF-KIAA1549 fusion transcript status was examined using reverse transcription polymerase chain reaction on formalin-fixed paraffin-embedded samples of 105 primary pilocytic astrocytomas [median patient age: 17 years (1-74 years)]., Results: Informative results (distinct wildtype BRAF bands detectable) were obtained in 105/124 cases (85%). Fusion transcripts were detected in 53 of cases (51%). They were more often encountered in tumours of infratentorial location [42/67 (63%) vs. 11/38 (29%)] and comprised KIAA1549-Ex16_BRAF-Ex9 (32 cases), KIAA1549-Ex15_BRAF-Ex9 (14 cases) and KIAA1549-Ex16_BRAF-Ex11 (seven cases). Fusion transcripts were present in 79% of tumours diagnosed in the first decade of life, but only in 51% of patients aged 11-20 years, 42% of patients aged 21-30 years, 30% of patients aged 31-40 years and 7% of patients older than 40 years. On multivariate logistic regression analysis, the association of fusion transcript status and age was confirmed adjusting for tumour location (P = 0.006)., Conclusions: The frequency of BRAF-KIAA1549 fusion transcripts is significantly lower in adult patients with pilocytic astrocytoma, weakening the sensitivity of this specific diagnostic marker in that age group., (© 2011 The Authors. Neuropathology and Applied Neurobiology © 2011 British Neuropathological Society.)

Background: This article describes multiple transmissions of rabies via transplanted solid organ from a single infected donor. The empirical Milwaukee treatment regimen was used in the recipients., Methods: Symptomatic patients were treated by deep sedation (ketamine, midazolam, and phenobarbital), ribavirin, interferon, and active and passive vaccination. Viral loads and antibodies were continuously monitored., Results: Recipients of both cornea and liver transplants developed no symptoms. The recipient of the liver transplant had been vaccinated approximately 20 years before transplantation. Two recipients of kidney and lung transplants developed rabies and died within days of symptomatic disease. Another kidney recipient was treated 7 weeks before he died. The cerebrospinal fluid viral load remained at constant low levels (<10,000 copies/mL) for approximately 5 weeks; it increased suddenly by almost 5 orders of magnitude thereafter. After death, no virus was found in peripheral compartments (nerve tissue, heart, liver, or the small intestine) in this patient, in contrast to in patients in the same cohort who died early., Conclusions: Our report includes, to our knowledge, the longest documented treatment course of symptomatic rabies and the first time that the virus concentration was measured over time and in different body compartments. The postmortem virus concentration in the periphery was low, but there was no evidence of a reduction of virus in the brain.

Primary intracerebral manifestation of multiple myeloma is rare and usually arises from the meninges or brain parenchyma. The authors present a case of multiple myeloma primarily manifesting within the lateral ventricle. A 67-year-old man was admitted with headache accompanied by slowly progressing right hemiparesis. Magnetic resonance imaging showed a large homogeneous contrast-enhancing intraventricular midline mass and hydrocephalus. The tumor was completely resected, and histopathological examination revealed plasmacytoma. After postoperative radio- and chemotherapy, vertebral osteolysis was detected as a secondary manifestation of multiple myeloma.

Renal transplantation faces challenges: the organ shortage resulting in extended waiting times and an aging population resulting in death with a functioning graft. The Eurotransplant Senior Program (ESP) allocates kidneys within a narrow geographic area from donors aged >/=65 years to recipients >/=65 years regardless of HLA. This analysis investigates the impact of the ESP on waiting time, graft and patient survival. The ESP group (n = 1406, old to old) was compared to two groups allocated via the Eurotransplant Kidney Allocation System (ETKAS) with either similar donor age (old to any [O/A], donor age >/=65, n = 446) or recipient age (any to old, [A/O], recipient age 60-64, n = 1687). All patients were transplanted between 1999 and 2004. Since initiation of the ESP (1999), availability of elderly donors doubled and waiting time for ESP patients decreased. Local allocation led to shorter cold ischemia time (11.9 vs. >17.0 h, p < 0.001) and less delayed graft function (DGF, ESP 29.7% vs. O/A 36.2%, p = 0.047) but 5-10% higher rejection rates. Graft and patient survival were not negatively affected by the ESP allocation when compared to the standard allocation. The ESP age matching of elderly donors and recipients is an effective allocation system for organs from elderly donors.

Interbody fusion after anterior discectomy may lead to acceleration of degenerative changes at adjacent levels. Although the posterior approach preserves the motion segment, decompression of the nerve root is indirect if "hard disc prolaps" is the main cause. Recently, a technique of microsurgical anterior cervical foraminotomy for the treatment of radiculopathy with preservation of the segment mobility was published. In this study, we present this technique with several modifications.Thirteen patients - 5 men and 8 women with an average age of 49 years - with unilateral radiculopathy resistant to conservative treatment underwent microsurgical anterior foraminotomy via a small keyhole transuncal approach. The base of the uncinate process (UP) was directly drilled in the trajectory to the intervertebral foramen without destroying the disc tissue. The vertebral artery between the transverse process was not exposed. Furthermore, the functional anatomy of the uncovertebral joint remained largely intact. All patients experienced complete relief of radiating pain. A cervical collar was not used. Mean follow-up time was 19 months. The mobility of the operated segment was preserved in each patient. No instability of the cervical spine was seen. The microsurgical anterior foraminotomy via a small keyhole transuncal approach is safe, minimally invasive, and represents an effective method to treat unilateral cervical radiculopathy caused by disc prolaps and/or uncovertebral osteophytes. Additionally, the segment mobility is preserved and prevents the acceleration of degenerative changes at adjacent levels.

Object: Extensive epidural fibrosis after lumbar spine surgery might be an important underlying cause of failed-back syndrome. Based on previously obtained data, the effect of mitomycin C (MMC) in a concentration of 0.1 mg/ml on spinal epidural fibrosis in a rat laminectomy model was investigated in a large series., Methods: Eighty adult Wistar rats underwent lumbar laminectomy. In 40 rats, MMC in a concentration of 0.1 mg/ml was locally applied to the laminectomy sites. No similar treatment was performed in the other 40 rats. At intervals from one to 12 weeks after laminectomy, both macroscopic and histological evaluations were performed. For radiological investigation, 10 rats underwent magnetic resonance (MR) imaging at 6 weeks postoperatively. Furthermore, the concentration of MMC in cerebrospinal fluid (CSF) and serum was determined 12 hours postoperatively in seven rats. Due to ease of absorption, high levels of MMC were rapidly detectable in serum, whereas the values obtained from the CSF were markedly lower. In the majority of MMC-treated laminectomy sites, epidural scarring was significantly reduced and dural adhesions were absent, in comparison with control sites (p < 0.001), as confirmed by MR images. Accordingly, the macroscopic dissection of epidural fibrous tissue to reexpose the dura mater was performed more easily and without severe bleeding in these rats. The healing of skin and the lumbar fascia was not affected, and dural leakage was not observed. All control sites showed dense epidural fibrosis with marked dural adherence., Conclusions: In this experimental model, it was shown that locally applied MMC in a concentration of 0.1 mg/ml effectively reduces epidural fibrosis and dural adherence without side effects in rats that underwent lumbar laminectomy.

In non Mg(2+)-loaded and non malaria-infected rat erythrocytes, mefloquine (100 micromol x l (-1)) stimulated choline/Mg2+ antiport without affecting the Na+/Mg2+ antiport. The stimulation of the choline/Mg2+ antiport by mefloquine, found in this study, and by trifluoperazine and fluvoxamine, reported previously [Ebel et al. Biochim Biophys Acta 2004; 1167: 132-40], was associated with CF3 groups attached to the quinoline or benzene ring. The effect of mefloquine on choline/Mg2+ antiport in vitro was not related to the antimalarial action of mefloquine in vivo. In rat erythrocytes, the choline/Mg2+ antiport can be differentiated from the Na+/Mg2+ antiport through the use of cinchonine that inhibited the choline/Mg2+ antiport [Ebel et al. Biochim Biophys Acta 2002; 1559: 135-44], and mefloquine that stimulated the choline/Mg2+ antiport, whereby the Na+/Mg2+ antiport was not affected by either drug at proper concentrations. The Na+/Mg2+ antiport and choline/Mg2+ antiports behave as different molecular entities.

Total Mg2+ content in plasma and erythrocytes did not significantly differ between WKY and SHR. Mg2+ efflux via Na+/Mg2+ antiport was 10% lower in non Mg(2+)-loaded erythrocytes of SHR than in WKY, and 16% lower in Mg(2+)-loaded erythrocytes of SHR. The activation of Na+/Mg2+ antiport in erythrocytes by Cl-, as tested by substitution of Cl- with SCN-, and the regulation of Na+/Mg2+ antiport by protein kinases, as tested by PMA and staurosporine, showed no differences between WKY and SHR. The reduction of Na+/Mg2+ antiport was explained by a reduction in the number of Na+/Mg2+ antiporter molecules in SHR erythrocytes. Mg2+ efflux in KCl medium by K+/Mg2+ antiport via the unspecific choline exchanger was not significantly reduced in SHR and was equally affected by PMA and staurosporine in WKY and SHR. An explanation for some controversial results, unchanged or reduced concentration of Mg2+ in serum, total Mg2+ and free Mg2+ in erythrocytes of SHR and patients with essential hypertension was proposed. The role of Na+/Mg2+ antiport and [Mg2+]i in the pathogenesis of experimental and clinical hypertension was discussed.

An important class of carbohydrates studied within the field of glycobiology, heparin and heparan sulfate (HS) have been implicated in a diverse array of biological functions. Changes in their sulfation pattern and domain organization have been associated with different pathological situations such as viral infectivity, tumor growth, and metastasis. To obtain structural information about these biomolecules, and the modifications they may undergo during different stages of cell growth and development, a mass spectrometry-based method was developed and used to obtain unambiguous structural information on the glycosaminoglycans (GAGs) that comprise heparin/HS. The method was applied to assay for the heparin substrate specificity of a newly discovered human extracellular endosulfatase, HSulf-2, which has been implicated in tumorigenesis. This new protocol incorporates 12 known heparin disaccharides, including three sets of isomers. A unique response factor (R) is determined for each disaccharide, whereas a multiplexed and data processing method is incorporated for faster data acquisition and quantification purposes. Proof of principle was performed by using various heparin/HS samples isolated from bovine and porcine tissues.

Background: Spinal epidural abscess (SEA) is a rare but potentially devastating disease requiring immediate surgical intervention and appropriate antibiotic treatment. The standard approach to decompress SEA is laminectomy. No report covers comprehensively the indications for the less invasive interlaminar approach, the usefulness of intra-operative ultrasonography and the suspected benefit of inserting a suction-irrigation drainage., Method: A retrospective evaluation of the medical and radiological data was undertaken in 27 consecutive patients with SEA operated on during a period of 10 years by a dorsal approach. Factors influencing outcome were evaluated with special regard to different surgical strategies concerning the invasiveness of the operative approach, the use of intra-operative ultrasound and the use of different drainage systems., Findings: Outcome was mainly determined by the pre-operative neurological condition and the localization of the abscess. Recurrence rate was dependent on the longitudinal extent of the mass and the intra-operative finding of granulation tissue, but not on the administration of a postoperative suction-irrigation drainage. An interlaminar approach was equally matched to a decompression by laminectomy in lumbar SEA concerning the incidence of residual/recurrent abscess formation. In concomitant spondylodiscitis, laminectomy bore the risk of the formation of a postoperative kyphotic deformity. The use of intra-operative ultrasound allowed the visualization of hidden inflammatory masses and, thus, reduced the rate of residual abscess formation., Conclusion: An interlaminar approach should be considered instead of laminectomy in lumbar SEA and in impending anterior column instability due to spondylitis. Intra-operative ultrasound is a beneficial aid for the determination of the extent of decompression during surgery and is practicable even through a narrow interlaminar bony window. The insertion of postoperative suction-irrigation drainage had no beneficial effect on outcome but bore the risk of epidural fluid congestion.

The effect of imipramine on Mg2+ efflux in NaCl medium (Na+/Mg2+ antiport), on Mg2+ efflux in choline.Cl medium (choline/Mg2+ antiport) and on Mg2+ efflux in sucrose medium (Cl- -coupled Mg2+ efflux) was investigated in rat erythrocytes. In non-Mg2+-loaded rat erythrocytes, imipramine stimulated Na+/Mg2+ antiport but inhibited choline/Mg2+ antiport and Cl- -coupled Mg2+ efflux. The same effect could be obtained by several other compounds structurally related to imipramine. These drugs contain a cyclic hydrophobic ring structure to which a four-membered secondary or tertiary amine side chain is attached. At a physiological pH, the amine side chain expresses a cationic choline-like structure. The inhibitory effect on choline/Mg2+ antiport is lost when the amine side chain is modified or abandoned, pointing to competition of the choline-like side chain with choline or another cation at the unspecific choline antiporter or at the Cl- -coupled Mg2+ efflux. Other related drugs either stimulated Na+/Mg2+ antiport and choline/Mg2+ antiport, or they were ineffective. For stimulation of Na+/Mg2+ antiport and choline/Mg2+ antiport, there is no specific common structural motif of the drugs tested. The effects of imipramine on Na+/Mg2+ antiport and choline/Mg2+ antiport are not mediated by PKCalpha but are caused by a direct reaction of imipramine with these transporters. By increasing the intracellular Mg2+ concentration, the stimulation of Na+/Mg2+ antiport at a physiological intracellular Mg2+ concentration changed to an inhibition of Na+/Mg2+ antiport. This effect can be explained by the hypothesis that Mg2+ loading induced an allosteric transition of the Mg2+/Mg2+ exchanger with low Na+/Mg2+ antiport capacity to the Na+/Mg2+ antiporter with high Na+/Mg2+ antiport capacity. Both forms of the Mg2+ exchanger may be differently affected by imipramine.

Background: Chronic allograft nephropathy (CAN) is the most common cause of late graft loss. A beneficial effect of mycophenolate mofetil (MMF) on CAN was observed, although, due to the loss of body weight (BW) under MMF, serum creatinine (sCr) and reciprocal sCr may be unsuitable markers of graft function., Methods: In 17 kidney transplant patients with CAN, azathioprine (Aza) was replaced by MMF. The remaining therapy was not changed; specifically, the cyclosporine (CsA) dose was not decreased. The mean values and regression coefficients of reciprocal sCr, CCr, urinary creatinine excretion (uCr x V), proteinuria, BW, blood pressure (BP), serum cholesterol (sChol), and serum triglycerides (sTG) versus time were analyzed 12 months before and after institution of MMF by a paired-comparison t test., Results: The mean regression coefficient of reciprocal sCr differed significantly before and after conversion to MMF (mean -0.01 +/- 0.01 vs +0.012 +/- 0.029 mg/dL per month), suggesting improved graft function. However, the mean values of BW (74 +/- 15 vs 71 +/- 15 kg, P <.001) and uCr x V (1152 +/- 321 vs 1065 +/- 266 mg per 24 hours, P=.0897) decreased, making the increase in CCr less significant (mean -1.16 +/- 2.69 vs 0.40 +/- 1.79 mL/min per month, P <.05). BP, sChol, sTG, and proteinuria before and after conversion did not differ significantly. Among patients with long-term stable graft function at 36.5 +/- 16.9 months after conversion to MMF there was an almost significant improvement in renal protein excretion., Conclusions: MMF improved graft function, although this effect was overestimated using reciprocal sCr. Other risk factors, such as BP, sChol, and sTG, showed no significant differences, suggesting that MMF accounted for the improvement in CAN. The course of proteinuria under MMF seems to be of prognostic significance.

Background: Although lead exposure has steadily decreased in the last few years, some lead is still used in the metal processing industry, mostly for wall paints and plumbing. Recent studies on children showed neurobehavioral effects of low-level exposure, but little is known about the neurocognitive effects of lead concentrations in the upper reference range on adults., Methods: The neuropsychological effects of lead exposure were examined in 39 adult outpatients at the Unit of Environmental Medicine (UEM), University Hospital, Aachen, Germany. All patients underwent a comprehensive medical examination, including psychiatric. Venous blood and urine samples were collected and tested for heavy metals and selenium. Since the neuropsychological examination was not expected to reveal any severe abnormalities, only specific attentiveness functions were analyzed (alertness, working memory, flexibility, intermodal comparison) since these areas were the likeliest to show objectifiable effects. The tests were conducted using a standardized computerized battery., Results: Lead blood levels ranged from 1 to 65.6 microg/l (mean 27.4 +/- 16.2 microg/l). Although the neuropsychological test results of all patients were within the normal range, there were significant correlations between blood lead levels and the speed of information processing for working memory., Conclusions: The results indicate working memory dysfunctions in adults, the severity of which correlates directly with blood lead levels, supporting the hypothesis that increased blood lead levels can also be associated with measurable neurocognitive abnormalities.

Feasibility of secretin-augmented magnetic resonance (MR) pancreatography and dynamic contrast material-enhanced MR measurements for evaluation of functional status of pancreatic allografts was determined by quantifying the excretion and perfusion of the grafts. Ten patients were included prospectively before pancreatic transplantation. Dynamic T2-weighted sequences after secretin stimulation and dynamic contrast-enhanced T1-weighted gradient-echo sequences were performed. Area under the curve and maximum signal intensity-to-time ratio were determined in selected regions of interest. Biochemical parameters, Doppler ultrasonography, and/or surgery were standards for final diagnosis. Patients with normal outcome (n = 7) produced 236 mL +/- 104 (standard deviation) of pancreatic juice, and patients with dysfunctional grafts (n = 3) produced 42 mL +/- 25. Area under the curve and maximum signal intensity-to-time ratio provided thresholds of 0.5 and 0.3, respectively, for distinction between functional and dysfunctional grafts. Secretin-augmented MR pancreatography combined with MR perfusion measurements may aid in differentiation between patients with and those without graft dysfunction., (Copyright RSNA, 2004)

In rat erythrocytes, the regulation of Na+/Mg2+ antiport by protein kinases (PKs), protein phosphatases (PPs), intracellular Mg2+, ATP and Cl- was investigated. In untreated erythrocytes, Na+/Mg2+ antiport was slightly inhibited by the PK inhibitor staurosporine, slightly stimulated by the PP inhibitor calyculin A and strongly stimulated by vanadate. PMA stimulated Na+/Mg2+ antiport. This effect was completely inhibited by staurosporine and partially inhibited by the PKC inhibitors Ro-31-8425 and BIM I. Participation of other PKs such as PKA, the MAPK cascade, PTK, CK I, CK II, CAM II-K, PI 3-K, and MLCK was excluded by use of inhibitors. Na+/Mg2+ antiport in rat erythrocytes can thus be stimulated by PKCalpha. In non-Mg2+ -loaded erythrocytes, ATP depletion reduced Mg2+ efflux and PMA stimulation in NaCl medium. A drastic activation of Na+/Mg2+ antiport was induced by Mg2+ loading which was not further stimulated by PMA. Staurosporine, Ro-31-8425, BIM I and calyculin A did not inhibit Na+/Mg2+ antiport of Mg2+ -loaded cells. Obviously, at high [Mg2+]i Na+/Mg2+ antiport is maximally stimulated. PKCalpha or PPs are not involved in stimulation by intracellular Mg2+. ATP depletion of Mg2+ -loaded erythrocytes reduced Mg2+ efflux and the affinity of Mg2+ binding sites of the Na+/Mg2+ antiporter to Mg2+. In non-Mg2+ -loaded erythrocytes Na+/Mg2+ antiport essentially depends on Cl-. Mg2+ -loaded erythrocytes were less sensitive to the activation of Na+/Mg2+ antiport by [Cl-]i.

In a series of 50 consecutive cases in the outpatients' unit of Environmental Medicine (UEM) at the University Hospital of Aachen, Germany, five patients with the diagnosis of schizophrenia presented delusions of being poisoned by environmental factors. This case report illustrates the clinical features of the paranoid type of schizophrenic psychoses. Schizophrenia represents an important differential diagnosis in the interdisciplinary diagnosis and management of health problems attributed to environmental factors.

Background: The initial surgical management of chronic subdural hematoma (CSDH) is still controversial, and a standard therapy does not exist. Because of the advanced age and multiple medical problems of the patients, surgical therapy is frequently associated with complications., Methods: A retrospective study was performed on 172 patients with CSDH, comparing the efficacy of three different primary surgical methods: drainage of hematoma through two different burr-holes without membranectomy (Group A, n = 38); enlarged craniectomy with a size of about 30 mm craniotomy with partial membranectomy and drainage (Group B, n = 121); and extended craniotomy with partial membranectomy and drainage (Group C, n = 13)., Results: Independent of surgical method, the general outcome of the patients was good. The rate of reoperation in the group of burr-hole drainage was 16%, slightly lower than in partial membranectomy with enlarged craniectomy or extended craniotomy with 18% and 23%, respectively. In patients with coagulopathy, the rate of reoperation was 41% (16/43), significantly higher than the rate in noncoagulopathic patients 12% (15/129)., Conclusions: In this study, an extended surgical approach with partial membranectomy has no advantages regarding the rate of reoperation and the outcome. As initial treatment, burr-hole drainage with irrigation of the hematoma cavity and closed-system drainage is recommended. Extended craniotomy with membranectomy is now reserved for instances of acute rebleeding with solid hematoma.

Object: Extensive epidural fibrosis after lumbar surgery may be the underlying cause in most cases of failed-back surgery syndrome. Various materials have been used to prevent epidural fibrosis, but only moderate success has been shown. Mitomycin C, an alkylosing antibiotic substance isolated from Streptomyces caespitosus, potentially supresses fibroblast proliferation after surgery. In this study, the authors investigated the effect of mitomycin C by local application on spinal epidural fibrosis in a rat laminectomy model., Methods: Five Wistar rats underwent laminectomy at cervical, thoracic, and lumbar levels. Based on data obtained from ophthalmological studies, mitomycin C was applied to the laminectomy sites in various concentrations (0.01, 0.05, and 0.1 mg/ml). One laminectomy site in each rat was left untreated and thus served as a control. Evoked potentials were measured pre- and postoperatively, and all rats underwent clinical evaluation. Mobility status and evidence of neurological deficit were recorded. Twelve weeks later, the rats were killed, and the spinal column, including surrounding muscle tissue, was removed en bloc, decalcified, and fixed in formaldehyde. Epidural fibrosis was evaluated histologically. In all mitomycin C-treated laminectomy sites, epidural scarring was significantly reduced compared with control sites. Remarkably, dural adhesions were absent in laminectomy defects treated with mitomycin C concentrations of 0.05 and 0.1 mg/ml. Moderate to marked epidural fibrosis with adhesion to the dura mater was noted at sites receiving 0.01 mg/ml of mitomycin C. All control sites showed dense epidural fibrosis with marked dura adherence., Conclusions: In this experimental model, mitomycin C applied locally at a concentration of 0.1 mg/ml effectively reduced epidural fibrosis, completely avoided dural adherence, and induced no side effects.

We report the case of a 63-year-old patient with sudden onset of an acute syndrome of auditory hallucinations and delusions. Considering the anamnesis, course of the illness, and organopathologic results, we assumed an organic schizophreniform disorder within the scope of pre-existing autoimmune thyroiditis. Under treatment with high-potency neuroleptics, we observed partial regression and, after strumectomy, complete regression of the psychotic symptoms. Apparently, the acute organic schizophreniform disorder was caused by a changed metabolic situation with a transition to hyperthyroidism coinciding with beginning a small dose of antithyroid drugs.

Background: Despite the rapid development in neuro-imaging over the past two decades, ring like contrast-enhancing lesions on CCT or MRI still may pose a diagnostic challenge. The main differential diagnoses of these lesions include metastatic carcinoma, high-grade glioma and brain abscess. Acute demyelination seldom turns out to be the underlying pathology., Method: Retrospective analysis was done on six patients with acute demyelination treated at our neurosurgical department between 1990 and 2001. Clinical, radiological, PET, intra-operative and histological findings were evaluated., Findings: In five patients, the diagnosis of acute demyelination was established by histopathological evaluation of stereotactic biopsy specimen, in the sixth patient following microsurgical extirpation of the lesion. Neuropathology revealed demyelination with the presence of myelin-phagocytosing macrophages. In addition, lymphocytic infiltrates were present. Symptoms and signs improved significantly after high-dose steroid therapy., Conclusions: Despite CNS tissue destruction, necrosis and cyst formation are not usually found in demyelinating disease, being rather more common in young patients with ring-like contrast-enhancing lesions on CCT and MRI. Though an incorrect diagnosis can lead to a potentially fatal therapeutic intervention, histological diagnosis should be made in all cases. Due to minimum morbidity, stereotactic biopsy is the method of choice to obtain representative specimens for histological diagnosis. Open microsurgery of these lesions is not indicated since conservative medical treatment with steroids results in a favourable outcome in most cases.

To date, relatively little is known about the etiology, pathophysiology, diagnosis, therapy, prevention and prognosis of environment-related syndromes like multiple chemical sensitivity (MCS), idiopathic environmental intolerance (IEI), sick building syndrome (SBS), chronic fatigue syndrome (CFS), candida syndrome (CS) and burnout syndrome (BS). Part of the reason is that these syndromes have not been clearly defined and classified in scientific categories distinct from each other, and that they show clinical similarities to classified somatoform disorders. Furthermore, there are at least three possible explanations for the existence of these syndromes: (1) The syndromes may result from the interaction of environmental factors, individual susceptibility and psychological factors (i.e., how they are perceived and seen by the patient); (2) they may reflect socially and culturally accepted methods of expressing distress; and/or (3) they may be iatrogenic. Despite all the uncertainties in evaluation of environmental syndromes, physicians have the duty to take the affected person's problems seriously. A comprehensive systematic classification which better accounts for these complex clinical manifestations is long overdue. Until these syndromes are well defined, the terms used for them should definitely not be applied to connote a specific disease process.

Mg(2+) efflux from rat erythrocytes was measured in NaCl, NaNO(3), NaSCN and Na gluconate medium. Substitution of extracellular and intracellular Cl(-) with the permeant anions NO(3)(-) and SCN(-) reduced Mg(2+) efflux via Na(+)/Mg(2+) antiport. After substitution of extracellular Cl(-) with the non-permeant anion gluconate, Mg(2+) efflux was not significantly reduced. In Na gluconate medium, an influence of the changed membrane potential and intracellular pH on Mg(2+) efflux could be excluded. The results indicate the existence of Cl(-)-independent Na(+)/Mg(2+) antiport and of Na(+)/Mg(2+) antiport stimulated by intracellular Cl(-). Intracellular Cl(-), as determined by means of (36)Cl(-), was found to stimulate Na(+)/Mg(2+) antiport through a cooperative effect according to a sigmoidal kinetics. The Hill coefficient for intracellular Cl(-) amounted to 1.4-1.8, indicating that two intracellular Cl(-) may be simultaneously active. With respect to specificity, Cl(-) was most effective, followed by Br(-), J(-), and F(-). Stimulation of Na(+)/Mg(2+) antiport by intracellular Cl(-) together with intracellular Mg(2+) may play a role during deoxygenation of erythrocytes and in essential hypertension.

This animal experimental study was designed to examine the effects of TachoComb, a fixed combination of collagen with tissue adhesive, as an interposition membrane on the development of spinal epidural fibrosis in comparison to other hemostyptic materials. In 10 Wistar rats, four laminectomies were performed at lumbar and sacral vertebrae. Alternately, a piece of TachoComb, Spongostan, or Tabotamp was placed into each laminectomy site. One laminectomy site served as an empty control (n = 10). 8 weeks later, the animals were sacrificed, and the spinal column including surrounding muscle tissue was removed en bloc from each rat and fixed in formaldehyde. After decalcification and staining the specimens were graded by a neuropathologist in a blindfold test for severity of epidural fibrosis as "light-moderate" or "marked". Epidural scarring of variable density was seen in all laminectomy sites. Light epidural fibrosis, without any adhesion to dura, as only noted in cases after application of TachoComb (n = 4/10) and Spongostan (n = 1/10). All other slices showed marked epidural fibrosis with dura adherence regardless of the implanted material. Statistical analysis revealed significantly lower epidural fibrosis after application of TachoComb compared to all other groups (p < 0.05). In this series, TachoComb is more effective in reducing the epidural fibrosis than Spongostan, and Tabotamp. However, complete prevention of scar tissue formation was not achieved.

We study agents on a network playing an iterated Prisoner's dilemma against their neighbors. The resulting spatially extended coevolutionary game exhibits stationary states which are Nash equilibria. After perturbation of these equilibria, avalanches of mutations reestablish a stationary state. Scale-free avalanche distributions are observed that are in accordance with calculations from the Nash equilibria and a confined branching process. The transition from subcritical to critical avalanche dynamics can be traced to a change in the degeneracy of the cooperative macrostate and is observed for many variants of this game.

Objective: This study was designed to determine patterns of regional brain activation during emotional stimulation in alexithymics as compared with normal controls., Method: We used 15O-water positron emission tomography and an emotional stimulation paradigm based upon autobiographic recall of either happy, sad or emotionally neutral situations. 10 normal subjects without medical or psychiatrical history were compared with 9 patients with somatoform disorder without any other DSM-IV diagnosis. TAS-20 was used as a measure for alexithymia, depression was measured using BDI., Results: Normal controls showed significantly greater activation than alexithymics in cingulate areas, corpus callosum, and right superior and inferior frontal gyrus. Alexithymics activated significantly more in cuneus and precuneus, thalamus (pulvinar), left medial frontal, right inferior temporal, left superior temporal regions, left precentral gyrus, and the cerebellum., Conclusions: During emotional autobiographic recall, alexithymia, either trait or state, is characterized by utilization of different brain regions when compared to normal controls. The areas activated by alexithymic persons largely comprise of language related regions, leaving out limbic and paralimbic areas.

We study the topology of e-mail networks with e-mail addresses as nodes and e-mails as links using data from server log files. The resulting network exhibits a scale-free link distribution and pronounced small-world behavior, as observed in other social networks. These observations imply that the spreading of e-mail viruses is greatly facilitated in real e-mail networks compared to random architectures.

The Alice in Wonderland syndrome (AIWS), as described by Todd in 1955, denotes a variety of self-experienced paroxysmal body schema disturbances (obligatory core symptoms of the AIWS) which may co-occur with depersonalization, derealization, visual illusions and disorders of the time perception (facultative symptoms of the AIWS). The name comes, of course, from Lewis Carroll's 1865 novel "Alice's Adventures in Wonderland", which is believed to have been inspired by Carroll's own migraine experiences documented as early as 1856. Recent studies of the AIWS occurring as somesthetic migraine aura indicated that the body schema disturbance of macrosomatognosia most frequently affects the head and upper extremities, paralleling the extension of their representation in the human brain. As a misapprehension commonly encountered in the medical literature, it has been suggested to define the AIWS by the presence of visual rather than somesthetic perceptual disturbances, e.g. metamorphopsia and/or visual hallucinations, but this change and broadening of Todd's definition of the AIWS turns it to a both scientifically and clinically useless concept.

Background: Complications and local extension of dentogenous and paranasal sinus infections most often involve the periorbit and frontal cranium. Because of the widespread use of antibiotics, intracranial extension of maxillofacial sinusitis is rarely seen today. Nevertheless, the clinician must be aware of the potential for these complications, because late recognition of this condition and delay in treatment can increase morbidity and mortality rates., Case Report: A case report of sinogenic intracranial complications is presented, with sinogenic empyema, cerebritis, and subdural empyema. The mechanisms and potential for intracranial spread of infection from the frontal, sphenoid, and ethmoid sinuses are discussed. The management of complications is outlined, including the use of computed tomography and the role of surgical drainage.

How do we make acquaintances? A simple observation from everyday experience is that often one of our acquaintances introduces us to one of his or her acquaintances. Such a simple triangle interaction may be viewed as the basis of the evolution of many social networks. Here, it is demonstrated that this assumption is sufficient to reproduce major nontrivial features of social networks: short path length, high clustering, and scale-free or exponential link distributions.

Two types of Na(+)-independent Mg(2+) efflux exist in erythrocytes: (1) Mg(2+) efflux in sucrose medium and (2) Mg(2+) efflux in high Cl(-) media such as KCl-, LiCl- or choline Cl-medium. The mechanism of Na(+)-independent Mg(2+) efflux in choline Cl medium was investigated in this study. Non-selective transport by the following transport mechanisms has been excluded: K(+),Cl(-)- and Na(+),K(+),Cl(-)-symport, Na(+)/H(+)-, Na(+)/Mg(2+)-, Na(+)/Ca(2+)- and K(+)(Na(+))/H(+) antiport, Ca(2+)-activated K(+) channel and Mg(2+) leak flux. We suggest that, in choline Cl medium, Na(+)-independent Mg(2+) efflux can be performed by non-selective transport via the choline exchanger. This was supported through inhibition of Mg(2+) efflux by hemicholinum-3 (HC-3), dodecyltrimethylammonium bromide (DoTMA) and cinchona alkaloids, which are inhibitors of the choline exchanger. Increasing concentrations of HC-3 inhibited the efflux of choline and efflux of Mg(2+) to the same degree. The K(d) value for inhibition of [(14)C]choline efflux and for inhibition of Mg(2+) efflux by HC-3 were the same within the experimental error. Inhibition of choline efflux and of Mg(2+) efflux in choline medium occurred as follows: quinine>cinchonine>HC-3>DoTMA. Mg(2+) efflux was reduced to the same degree by these inhibitors as was the [(14)C]choline efflux.

The statistical properties of the World Wide Web have attracted considerable attention recently since self-similar regimes were first observed in the scaling of its link structure. One characteristic quantity is the number of (in-)links k that point to a particular web page. Its probability distribution P(k) shows a pronounced power-law scaling P(k) approximately k(-gamma) that is not readily explained by standard random graph theory. Here, we recall a simple and elegant model for scaling phenomena in general copy- and growth-processes as proposed by Simon in 1955. When combined with an experimental measurement of network growth in the World Wide Web, this classical model is able to model the in-link dynamics and predicts the scaling exponent gamma=2.1 in accordance with observation.

The effects of high cervical spinal cord stimulation (cSCS) on regional cerebral blood flow (rCBF) were investigated after experimentally induced subarachnoid haemorrhage (SAH) in rats by the means of (99m)Tc-HMPAO. The experiments were carried out on a total of 24 Wistar rats, divided in three groups [group I: control without SAH, group II: SAH, group III: SAH and cSCS]. (99m)Tc-HMPAO was administered intravenously (group II/group III) 48 hours after induction of SAH. In group III, (99m)Tc-HMPAO was given after 3 hours of cSCS. All animals were sacrificed 30 minutes after application on (99m)Tc-HMPAO. Radioactivities were determined in blood, cerebrum and cerebellum. The ratio cerebrum/blood and cerebellum/blood was calculated to ascertain "extraction rate" in the sample differentially. The following mean values were calculated for the cerebellum/blood ratio: Group I: 1.06, SD: 0.21; Group II: 0.66, SD: 0.21; Group III: 1.00, SD: 0.37. Comparing the mean values a highly significant difference could be found between group II and III (p = 0.007) and between group I and II (p = 0.0019), respectively. Calculations of the cerebrum/blood ratio revealed similar results. After SAH cSCS enhances cerebral and cerebellar blood flow in rats. Possibly, cSCD constitutes a new therapeutic approach in the treatment of disturbed regional cerebral blood flow after SAH.

Concerning the syndromes in environmental medicine, like Multiple Chemical Sensitivities (MCS), Idiopathic Environmental Intolerances (IEI), Sick Building Syndrome (SBS), Chronic Fatigue Syndrome (CFS), Candida Syndrome (CS), and Burnout Syndrome (BS), scientific knowledge in etiology, pathology, pathophysiology, diagnosis, therapy, prevention and prognosis is still lacking until now. A critical comparison shows that it is still impossible to find a scientifically satisfying delimitation. Syndromes in environmental medicine show clinical similarities to somatoform disorders. Furthermore, there are the following possible explanations for the existence of these syndromes: Firstly, they may be a complex interaction of environmental impacts, individual predispositions, psychological influences, as well as processes of mental perception and interpretation. Secondly, they may be an effect of distress influenced by culture and social structures and/or thirdly, they may be an latrogenic determination. A more comprehensive characterisation which better considers the complex clinical manifestations is overdue. Although there are neither scientifically validated procedures for diagnosis or therapy nor prophylactic measures, a hardly comprehensible number of partly unvalidated methods is in practical use. Until the syndromes are not finally defined the terms for the syndromes should not be applied to a certain disease. Despite all uncertainities in the evaluation of syndromes in environmental medicine, physicians have the duty to take the affected persons' problems seriously.

It could be demonstrated that cervical spinal cord stimulation increases cerebral blood flow. The effects of electrical stimulation of the trigeminal ganglion in the acute phase of SAH in pigs were investigated. The experiments were carried out on 11 domestic pigs divided in two groups (group I: SAH [n = 5]; group II: SAH and trigeminal stimulation [n = 6]). In all animals a native SPECT was performed. The Gasserian ganglion was exposed for inserting the stimulation electrode. SAH was induced by injecting 10 ml autologous blood through a catheter placed in the suprasellar cistern. 30 minutes after SAH-induction electrical stimulation was started for two hours in group II (2.8-4.5 V, 50 Hz, 300 microseconds). 99mTc-HMPAO (400-540 MBq) was injected intravenously 110 minutes later. In group I 99mTc-HMPAO was applied after the same time interval. 80 minutes later SPECT was performed. Data were processed to calculate the uptake of radioactivity (%/kg tissue weight). The mean values were calculated for the different groups: native animal examination (%/kg tissue weight): 0.6343; group I: 0.468; group II: 0.6533. Comparing the mean values a highly significant difference between group I and group II (p < 0.01) and between native examination and group I (p < 0.01) could be found. No statistical significance could be detected on comparing the left/right-ratio in any ROI. The electrical stimulation of the Gasserian ganglion leads to a significantly increased uptake of 99mTc-HMPAO after induced SAH. Maybe the stimulation of the Gasserian ganglion constitutes a new therapeutic modality treating disturbed rCBF after SAH.

28 patients with a mean age of 43.6 years were operated on for a cerebral neoplasm situated in close proximity to an eloquent area (24 speech area, 4 motor cortex) from 1996 to 1999. Preoperatively, all patients had undergone a detailed neuropsychological examination. In 10 patients aphasic disturbances could be detected. All patients underwent preoperative PET studies (methionine and (15)O-labeled water with activation during speech or finger tapping). These were performed and co-registered with MRI data to demonstrate the topographical relationship between motor or language function and the tumor borders. Anesthesia was induced with i.v. administration of propofol (150-250 mg/h). Craniotomy was performed under local infiltration anesthesia. After opening of the dura, sedation was stopped and operation was continued with the patient being alert and co-operative. With close clinical observation during electrical cortex stimulation, a speech arrest could be triggered or avoided. The motor cortex was identified by recording the phase reversal of the contralateral SEP of the median nerve and by direct cortical stimulation. As soon as aphasic or motor disturbances appeared, the tumor removal was continued with the goal of avoiding these specific regions. In 27 patients, preexisting neuropsychological and neurological deficits did not worsen. Only one patient was left postoperatively with a major permanent aphasic deficit that was present preoperatively to a minor degree. The use of local anesthesia in craniotomy for surgery of intrinsic cerebral neoplasms in eloquent areas allows for a continuous and repetitive monitoring of speech and motor function during the removal of even those tumors that were previously considered inoperable.

The rigid fixation of bone fragments in the repair of depressed skull fractures can be a problem, especially if not all fragments are replaceable. Usually, in these cases mini- or microplates are used. The Craniofix titanium clamp (Aesculap, Germany) was developed for the fixation of bone flaps after osteoplastic craniotomy. It consists of a screw holding together two 10-mm diameter metallic disks with concaved teeth pressing bone flap and cranium between the two disks. We used this system for the operative treatment of two patients with depressed skull fracture. A rigid fixation of the bone fragments was achieved in both cases. The postoperative three-dimensional CT scan showed a good fragment alignment. From the report of two cases we show that this system is a useful tool in the fixation of bone fragments in the repair of depressed skull fractures.

Two patients with paranoid schizophrenia had delusions involving the internet. Additionally, one of them experienced computer databases as being distributed to other people in a phenomenologically similar way to that encountered in thought broadcasting. The presented cases illustrate the historical association of the contents of delusions in schizophrenia.

Deafferentation pain syndromes developing after peripheral nerve lesions are difficult to treat. According to the follow-up (mean: 39.5 months) of 6 patients suffering from causalgic pain we will present our method of augmentative therapy in chronic neuropathic pain caused by peripheral nerve lesions, i.e., peripheral nerve stimulation (PNS), spinal cord stimulation (SCS) and chronic intrathecal opioid infusion. None of the patients showed intraoperative or follow-up complications. Evaluated by visual analogue scales all patients reported a good to excellent pain relief (75-100%). (1) Regarding the favourable long-term results of PNS, this method should be considered in cases of mononeuropathic pain syndromes. (2) Neuropathic pain syndromes which are not assignable to a singular nerve lesion, can often be managed effectively by SCS. (3) In contrast to the widespread opinion, deafferentation pain syndromes of central or peripheral origin can be treated satisfactorily by intrathecal opiate administration.

Background: Postoperative infections are common and potentially fatal complications in neurosurgical intensive care medicine. An impairment of immune function has been described after central nervous system surgery and in patients harboring malignant brain tumors. The aim of our study was to investigate whether differences in cell-mediated immunity can be found in patients undergoing craniotomy for surgery of glioblastoma or clipping of an intracerebral aneurysm., Methods: In order to determine the influence of the underlying disease on the immune system, we measured changes in cytokine concentrations (IL-6, IL-10, TGF-beta1) and lymphocyte-subsets (CD3+, CD3+HLA-DR+, CD4+, CD8+, CD19+, and CD16+56+) in 8 patients with glioblastoma and in 8 patients with an intracerebral aneurysm before, during and after the neurosurgical procedure., Results: In the comparison of glioblastoma and aneurysm patients, we could show that IL-6 plasma levels were pre- and intraoperatively higher in the aneurysm-group (P<0.05), and the plasma concentrations of IL-10 and TGF-beta were significantly elevated in the glioma-group. The lymphocyte-subsets showed a significantly lower percentage of NK-cells and activated T-cells in the glioma-group., Conclusion: Our results document a significant dysregulation of immune response in glioma patients. This may be induced by elevated plasma concentrations of immunoinhibiting cytokines IL-10 and transforming growth factor-beta 1.

Given the diagnostic ambiguity of physically unexplained complaints we wanted to study whether the clinically and symptomatically characterized groups, all of them defined according to DSM-III-R criteria, could be reclassified using selected empirical and theoretical variables of operationally defined parameters. Patients with conversion (N = 75), somatization or undifferentiated somatoform disorders (N = 74) and major depression (N = 70) according to DSM-III-R underwent multidimensional work-up including psychopathological, personality-psychological, illness, behavioral and coping assessment. The clinically characterized groups should be statistically reclassified by discriminant analytic techniques. The existing diagnostic categories according to DSM-III-R could be widely confirmed by the statistical reconstitution of the clinical groups. Conversion, somatization and depressive disorder presented as distinct clinical categories. A classification relying widely on symptoms still seems to be too superficial and does not represent the complexity of these patients. Thus, the modern classification systems with their purely phenomenological criteria should be added with further dimensions.

Bipolar electrocoagulation is one of the most important procedures in modern neurosurgery. However, there are still many practical problems, especially tissue adherence to the tips of the coagulating forceps and the difficulty removing carbonized clots from the tips. Both make the process less accurate and more time-consuming. To prevent formation of coagulum, recently, irrigation with a saline solution and coating of the forceps tips with a special metal have been tried. In this work, we compare a new bipolar electrocoagulator with automatic output control in relation to tissue impedance (Auto Suture - Valleylab NS 2000 with INSTANT RESPONSE technology) with a high-frequency coagulator (Erbotom ICC 350, Erbe). The femoral arteries and nerves of Wistar rats, weighing on average 360 g, were prepared and coagulation was carried out with variable power settings during a constant time (3 seconds). Sections were stained with haematoxylin-eosin, van Gieson and Luxol-Fast-Blue for histological examination. Coagulation with Erbotom ICC 350 resulted in tissue sticking to the tips of the forceps in all cases, regardless of the power chosen. With the new electrocoagulator, tissue adherence to the forceps tips was not seen. With the new system, effective coagulation was also achieved at comparably lower power settings.

Non-Mg(2+)-loaded rat erythrocytes with a physiological level of Mg(2+)(i) exhibited Mg(2+) efflux when incubated in nominally Mg(2+)-free media. Two types of Mg(2+) efflux were shown: (1) An Na(+)-dependent Mg(2+) efflux in NaCl and Na gluconate medium, which was inhibited by amiloride and quinidine, as was Na(2+)/Mg(2+) antiport in Mg(2+)-loaded rat erythrocytes; and (2) an Na(+)-independent Mg(2+) efflux in sucrose medium and choline Cl medium, which may be differentiated into SITS-sensitive Mg(2+) efflux at low Cl(-)(o) (in sucrose) and into SITS-insensitive Mg(2+) efflux at high Cl(-)(o) (in 150 mmol/l choline Cl).

Previous studies with animal models of supratentorial ICP elevation have demonstrated a pressure gradient between the supratentorial and the infratentorial compartments. The present study was designed to investigate the possible presence of such a gradient in the case of infratentorial ICP elevation. An inflatable infratentorial balloon catheter was implanted in seven domestic pigs. The infratentorial ICP (ICPi) was measured in the left cerebellar hemisphere, and the supratentorial ICP (ICPs) was measured in the left cerebral hemisphere. The corresponding pulse amplitudes (ICPi-PA, ICPs-PA) were recorded in both compartments, and the cerebral perfusion pressure (CPP) was calculated. ICPi and ICPs values prior to balloon inflation were 4.4 (SD 2.2) and 4.1 (SD 2.3) mm Hg, respectively, and increased to 63.1 (SD 32.6) and 62.3 (SD 28.1) mmHg after balloon inflation. ICPi-PA rose from 3.1 (SD 0.43) to 12.8 (SD 8.0) mmHg, and ICPs-PA rose from 3.2 (SD 0.63) to 13.0 (SD 7.1) mmHg. CPP decreased from 86.1 (SD 12.0) to 55.4 (SD 14.6) mm Hg. The paired difference between ICPi and ICPs values was 0.44 (SD 1.96) mmHg, and the paired difference of ICP amplitudes was 0.03 (SD 1.19) mmHg. All these differences in infratentorial and supratentorial values were statistically not significant. In conclusion, infratentorial ICP elevation in the presented pig model leads to a uniform ICP elevation in the intracranial space without development of a considerable pressure gradient below and above the tentorium. In the low pressure part of the ICP curve, cerebrospinal fluid connects the compartments and contributes to the pressure equilibrium. The early obstruction of the foramen magnum by intruding cerebellar tissue seems to isolate the infratentorial from the spinal compartment. In the high-pressure part of the curve, the upwards cerebellar transtentorial herniation takes over the pressure transfer, and the whole intracranial space can be considered as a single compartment in the pig.

Patients with health problems attributed to environmental factors such as chemical pollutants and electromagnetic fields often do not present evidence of an environmental aetiology of their symptoms. It has been postulated, that their problems are due to disorders diagnosed by other medical disciplines, especially allergology and psychiatry. Our study was designed to subject these patients to a comprehensive diagnostic program involving several medical disciplines in order to achieve diagnoses appropriate to explain the patients' symptoms. Fifty patients consecutively referred to the department of environmental medicine in the university hospital of Aachen, Germany, were submitted to the following examinations: (i) environmental medicine (history, clinical examination, biological and/or ambient monitoring for environmental agents); (ii) allergological examination (history, clinical examination, skin tests); (iii) psychiatric examination (psychopathological examination, psychometric and neuropsychological testing). In addition, the patients were examined in other hospital departments according to the symptoms presented. The findings were discussed in case conferences attended by the physicians involved in order to achieve individual diagnoses. The numbers of patients to whom diagnoses were given by different medical disciplines are as follows: psychiatry (32 patients), dermatology (4), allergology (2), neurology (2), rheumatology (2), gynaecology (1), haematology (1). The most frequent mental disorders diagnosed by the psychiatrists were somatoform disorders (19), followed by schizophreniform and delusion disorders (7). In spite of extensive diagnostic efforts, patients with health problems attributed to the environment usually do not present sufficient evidence of an environmental aetiology of their symptoms. On the other hand the symptoms often meet the diagnostic criteria of other diseases, especially of mental disorders.

Herpes simplex virus is the most common cause of acute viral encephalitis in children. Due to the variety of possible clinical manifestations the diagnosis is often overlooked in the early stages of the disease. Anti-viral therapy with acyclovir should be started whenever HSE is suspected. When there is further deterioration under virostatic therapy, a brain biopsy should be performed to verify the diagnosis. But even when the adequate medical therapy is established, massive brain edema and brain shift resulting in tentorial herniation can develop. Up to now the reported mortality of these patients is still around 30%. Here we report on a child with severe necrotizing herpes simplex encephalitis who developed severe tentorial herniation due to a right-sided mass lesion. The patient's status markedly improved after decompressive anterior temporal lobe resection. To our knowledge a similar case has not yet been reported in the literature. We suggest that anterior temporal lobe resection and decompressive craniotomy is of benefit in selected cases with tentorial herniation because both decompression and reduction of infectious material can be achieved.