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Maligant gliomas occur at an incidence from 2 to 10/100,000 (Japan vs. Sweden) constituting up 50% of all patients suffering from brain tumours. Despite all therapeutic approaches the median survival for glioblastomas is 15 months and for anaplastic gliomas Grade III are 30 months. Surgery is the first step in the therapeutic cascade of the patients. There is still debate about the surgical extent of resection and whether a most radical resection is more beneficial than an extended resection. Image-guided neurosurgery has become the gold standard for interventions in the brain and helps to define the radiographic limits of the tumour to maximize safety and the extent of resection whilst minimizing damage to eloquent brain tissue. Tumour removal in eloquent areas such as speech area will be performed in local anaesthesia as an awake operation. A precise presurgical examination is therefore mandatory. This includes all information gathered from functional diagnostics (fMRI, fibretracking and 3D reconstruction) and metabolic information from FET/FDG PET. Age, Karnofsky performance and histology as well as radical removal have significant influence on overall survival. Adjuvant radiotherapy and chemotherapy with Temozolemide have further improved the outcome significantly. The 2-year survival has reached 28% in most recent studies. Experimental surgical therapies are in clinical trials and will be introduced to general clinical practice in the near future. These include intratumoural convection-enhanced instillation of immuntoxins and radiopeptids, photodynamic therapy and direct instillation of new formulations of chemotherapeutic drugs. These new developments in the treatment of malignant brain tumours allow designing an individual neuro-oncological treatment concept to enhance overall survival and quality of life.

4 patients with recurrent gynecological malignancy were treated photodynamically, 4 d after sensitisation with intravenous meso-tetra(hydroxyphenyl)-chlorin (m-THPC) at a dose of 0.15 mg/kg bodyweight (total dose ranged from 12-15 mg). Light at 652 nm was derived from a KTP-Dye laser (Diasonic) and delivered superficially at a total light dose of 20 J/cm2 (power density of 100 mW/sec). Within 24 h necrosis occurred which was restricted to the tumor area. There was serious bleeding occurred in 1 patient. All tumors responded to PDT, however woundhealing was significantly delayed and survival times were disappointingly short.

Supratentorial primitive neuroectodermal tumours (sPNET) are rare tumours in adults. Five-years survival remains below 50%. We present a case report of a 38-year-old female with metastases of a supratentorial primitive neuroectodermal tumour. Treatment was radical surgical resection, followed by chemotherapy according to the HIT 2000 protocol. Twelve months after the first diagnosis, a relapse was diagnosed which was again surgically removed followed by radiotherapy and concomitant Temozolemide. Because of severe thrombocytopenia the chemotherapy was shifted to Gleevec therapy resulting in a stable disease until now.

Meta-tetrahydroxyphenylchlorin (m-THPC) and 5-aminolaevulinic acid (5-ALA) are two second-generation photosensitizers which are currently under investigation for photodynamic therapy (PDT) and photodynamic diagnosis (PDD). So far, the experience with these photosensitizers for use within brain tumours is limited. We examined the distribution and retention of 14C-labelled m-THPC and [14C]5-ALA in the rat C6 glioma brain tumour model. After intraperitoneal injection of m-THPC (71,909 d.p.m. microl(-1); 0.16 mg ml(-1) m-THPC; 0.3 mg kg(-1)), the following activities were found after 36 h: brain tumour 223,664 d.p.m. g(-1), brain contralateral to the tumour side 2567 d.p.m. g(-1), liver 369,959 d.p.m. g(-1) and skin 55,197 d.p.m. g(-1); 100,000 d.p.m. corresponding to 0.22 microg of m-THPC. After 7 days, the concentration of m-THPC decreased to 76,277 d.p.m. g(-1) in tumour and 635 d.p.m. g(-1) in brain. The radioactivity after intravenous administration of [14C]5-ALA (23,079 d.p.m. microl(-1); 40 mg ml(-1); 120 mg kg(-1)) increased within 15 min (59,634 d.p.m. g(-1) in tumour, 17,427 d.p.m. g(-1) in brain); after 8 h only a small amount (3653 d.p.m. g(-1) in tumour) remained. Brain adjacent to the tumour was also found to have a higher uptake of 5-ALA. This study provides basic information for the use of m-THPC and 5-ALA in brain tumours. Because of the different pharmacokinetic and toxicological profile, we recommend m-THPC for PDT and 5-ALA for PDD. Clinical trials now have to prove the superior phototoxic properties of these second-generation photosensitizers.

Patients with recurrent gynaecological carcinomas have a poor prognosis, with a survival of a few months. Three patients with a recurrent vulva carcinoma, one patient with a recurrent cervical carcinoma, one patient with a recurrent endometrial carcinoma, and one patient with a recurrent breast carcinoma underwent PDT after parenteral or topical sensitisation with Photosan 3. From these patients, two of them showed a complete response with no evidence of disease for 32 and 29 months. One patient responded partially with two recurrences, which were treated twice after tropical sensitisation, living now 21 months. The remaining three patients showed partial response and died 3 to 8 months after PDT. The energy applied was derived from an argon-dye-laser ranging between 225 and 750 joule/cm2. Photosan 3 was given intravenously at a dose of 2.5 mg/kg body weight and was tolerated without any allergic reaction. The response rate in three of six patients in recurrent gynaecological malignancies encourages us to pursue PDT in gynaecological disease.

Synthesis of the multifunctional cytokine basic fibroblast growth factor (FGF-2) is up-regulated after sciatic nerve lesion. In this study, the effects of low and high molecular weight FGF-2 isoforms on axonal elongation and branching of dissociated rat sensory neurons derived from adult lumbar dorsal root ganglia were investigated. These neurons express FGF receptor (FGFR) type I in the cytoplasmic/membrane compartment and in nuclear speckles. FGF-2 isoforms increase the number of axonal branches in cultures obtained from control rats, but do not promote axonal elongation. In response to a preconditioning lesion, i.e. transection of the sciatic nerve 1 week before culture, the axonal length of ipsilateral lumbar sensory neurons increases two-fold when compared with non-lesioned control rats, and this response is significantly enhanced by FGF-2 isoforms but not by nerve growth factor (NGF). Neurons dissociated from ganglia located contralaterally to the lesion exhibit a smaller increase in axon elongation (30%). The stimulating effects of FGF-2 isoforms on axon growth are fully blocked, and the enhanced regeneration of prelesioned neurons is reduced by the FGFR inhibitor SU5402 suggesting an involvement of endogenous FGF signaling in response to a lesion. The present data support a direct neurotrophic role of the 18 kD and 23 kD FGF-2 isoforms on adult axonal regeneration which may be of therapeutic value in the treatment of peripheral nerve lesions. Furthermore, evidence is provided for an enhanced regenerative capacity not only of preaxotomized neurons but also of homonymous non-axotomized neurons.

Patients with recurrent gynaecological carcinomas have a poor prognosis, with a survival of a few months. Three patients with a recurrent vulva carcinoma, one patient with a recurrent cervical carcinoma, one patient with a recurrent endometrial carcinoma, and one patient with a recurrent breast carcinoma underwent PDT after parenteral or topical sensitisation with Photosan 3. From these patients, two of them showed a complete response with no evidence of disease for 32 and 29 months. One patient responded partially with two recurrences, which were treated twice after tropical sensitisation, living now 21 months. The remaining three patients showed partial response and died 3 to 8 months after PDT. The energy applied was derived from an argon-dye-laser ranging between 225 and 750 joule/cm2. Photosan 3 was given intravenously at a dose of 2.5 mg/kg body weight and was tolerated without any allergic reaction. The response rate in three of six patients in recurrent gynaecological malignancies encourages us to pursue PDT in gynaecological disease.

TPS153 Background: Bevacizumab has been approved by the FDA for treatment of recurrent GBM. Standard MRI using Macdonald criteria is insufficient to adequately predict response to antiangiogenic tr...

11 patients with recurrent brain tumours underwent intraoperative radiotherapy (IORT) at a dosage of 15-25 Gy of fast electrons (17-20 MEV). IORT allows a higher dose of irradiation to be delivered to a well-defined target than is possible with external radiation, in anticipation of favourable results. However, tumour growth was not influenced in 7 out of the 11 patients and these patients died between 2 and 10 months following IORT. The remaining four patients are living still up to 15 months postoperatively. Due to the inhomogeneity of our patients no definitive conclusions can be drawn. However, well-defined tumours which can be radically excised are definitely more suitable for IORT than large, infiltrating tumours.

30 patients with primary or recurrent malignant brain tumors (9 primary, 18 recurrent malignant gliomas, 1 malignant meningioma, 2 melanomas) were treated altogether 37 times by photodynamic therapy (PDT) whether after intravenous, intraarterial or direct intratumoral sensitisation by hematoporphyrin (HPD) after conventional surgical removal of the tumor mass. The light was produced by an Argon pumped dye laser at doses varying from 40-220 J/cm2. A single dose of radiation of 4 Gy was administered to 18 patients immediately after PDT. The 9 patients with primary glioblastomas received in addition a full course of radiation therapy. The histological specimens taken during PDT demonstrated tumor necrosis, with oedema of normal brain tissue adjacent to the tumorbed. The median survival of patients with multiple recurrences and various radio- and chemotherapeutic modalities was 6 months (range 4-13 months). 9 patients with primary manifestation of a glioblastoma had a median survival of 19 months (0.5-29 months). Increased phototoxicity of the skin was the only side effect of PDT and did not reduce the quality of life of the patients.

Cytosolic oestrogen and progesterone receptors (ER and PR) were determined in 58 primary and 13 recurrent meningiomas and related to their histological and clinical features. ER levels were low or not detectable (range 0-34 fmol/mg prot., median 0 fmol), whereas considerable amounts of PR were found in 69% of primary tumours (range 0-583 fmol/mg prot., median 72 fmol) and in 5/5 long-term recurrences (range 69-505 fmol/mg prot., median 143). Eight tumours recurred within a short-term period (less than 5 years) with a low PR expression (range 0-34 fmol/mg prot., median 0 fmol) and all presented raised cellularity and mitotic rate ("atypical" meningioma) or criteria of definitely malignant meningioma. The primary tumours of the short-term recurrences were not available for receptor analysis; however, they also were either "atypical" or anaplastic meningiomas. Long-term recurrences never displayed other than classical histology. From our results we conclude that polymorphy, as well as a lack of PR are strong indicators for short-term recurrence.

Persistent trigeminal neuralgia, herpes zoster neuralgia of the first division of the trigeminal nerve and pain caused by cancer situated in the head and neck pose frustrating problems for patients and physicians. Tractotomy and/or partial vertical nucleotomy of the subnucleus caudalis nervi trigemini offers a logical approach to the treatment of such pain, since these structures contain fibres of the Vth nerve, as well as the somatosensory fibres of the VIIth, IXth and Xth nerve. Tactile and some thermal sensitivity of the face is preserved and anaesthesia dolorosa and keratitis neuroparalytica is avoided. Over the past 30 years 370 patients with therapy-refractory trigeminal pain, pain due to cancer of the head and neck and herpes zoster trigeminal pain were treated by means of tractotomy (personal series of V. Grunert), including 30 patients who underwent partial vertical nucleotomy. The mean age of the patients was 68 years (range 54-84 years). The mortality in this series was 0.9% (4 patients; one operative mortality due to air embolism, one postoperative cardiac failure following myocardial infarction and two intracerebral haematomas). 60% of the patients with persistent trigeminal neuralgia were pain-free and 28% improved, whereas 12% were unchanged or suffered from recurrent pain. Of the patients with cancer who complained of pain derived from the Vth, VIIth, IXth and Xth nerve, 40% demonstrated marked pain relief and 60% showed no improvement. Tractotomy and partial vertical nucleotomy offer a valuable method in experienced hands for relieving pain where other methods have failed.

Der 20jahrige Patient J.M. wurde mit den klinischen Zeichen eines erhohten intrakraniellen Druckes der Universitatsklinik fur Neurochirurgie Innsbruck zugewiesen. Ein Schadel-Nativrontgen, das einen Wolkenschadel, Sprengung der Schadelnahte und eine Erosion der Sella gezeigt hatte (Abb. 1 u. 2), hatte zu einer computertomographischen Abklarung und zur Entdeckung eines Neurinoms im rechten Kleinhirnbruckenwinkel gefuhrt (Abb. 3 u. 4). Dieses verlegte den Aquaeductus Sylvii und fuhrte so zu einem Verschlushydrocephalus. Da der Patient 7 Jahre vorher ein Schadelhirntrauma mit Fraktur der Schadelbasis erlitten hatte, war eine rechtsseitige Facialisparese und Taubheit am rechten Ohr nicht beachtet worden. Der Patient hatte namlich erklart, er konne seit dem Unfall nichts mehr horen und hatte sogar auf Schadenersatz geklagt.

The effect of nimodipine, a 1,4 dihydro-piridine calcium entry blocker (200 micrograms/kg), was investigated in rats after definitive ischemia or 2 min of global ischemia (neck tourniquet method). The brains were freeze-clamped at the desired time intervals and subjected to high pressure liquid chromatography analyses for nucleotides and enzymatic lactate estimation. Although in the definitive ischemia (removal of the brain) no difference was observed in the treated versus the untreated animals, there was a statistically significant difference in both groups after global ischemia followed by reperfusion. Thirty minutes after reflow the brains of the treated animals contained 1,690 +/- 62 nmol ATP/g as compared to 765 +/- 259 nmol ATP/g in the untreated animals (p less than 0.05). The normal controls amounted to 1,932 +/- 77 nmol ATP/g. Also the adenylate energy charge returned to normal in the treated animals (treated animals and controls 0.69 and 0.72, respectively). From these preliminary data we conclude that nimodipine is able to restore mitochondrial function after ischemia and to maintain a high level of energy-rich phosphates. Thus, calcium entry blockers may be effective in preserving and protecting cerebral tissue from irreversible injury after ischemia.

Serious side effects of photodynamic therapy (PDT) are rare (A.L. Abramson, M.J. Shikowitz, M.J. Shikowitz, V.M. Mullooly, Clinical effects of photodynamic therapy on recurrent laryngeal papillomas, Arch. Otolaryngology Head Neck Surg., 118 (1992) 25–29; A.L. Abramson, M.J. Shikowitz, Clinical exacerbation of systemic lupus erythematosus after photodynamic therapy of laryngotracheal papillomatosis, Laser Surg. Med., 13 (1993) 677–679). The most frequent side effects of PDT are hypersensitive skin reactions, local edema, nausea, a metallic taste and liver-toxicity (J. Feyh, E. Kastenbauer, Treatment of laryngeal papillomatosis with photodynamic laser therapy, Laryngorhinootologie, 71 (1992) 190–192; J. Feyh, R. Gutmann, A. Leunig, Die Photodynamische Therapie im Bereich der Hals-, Nasen-, Ohrenheilkunde Laryngorhinootologie, 72(6) (1993) 273–278; M.S. Kavuru, A.C. Mekta, Treatment of recurrent respiratory papillomatosis, N. Engl. J. Med., 326 (1992) 204–205; B.L. Wenigg, D.M. Kurtzmann, Photodynamic therapy in the treatment of squamous cell carcinomas of the head and neck, Arch. Otolaryngol Head Neck Surg., 116 (1990) 1267–1270). In this case a patient (aged 57 years) suffering from a recurrent larynx papillomatosis was treated with PDT. He was sensitized with Photosan 3 (DHE) 2.5 mg kg −1 body weight, 24 h to photoradiation. As a light source, an argon dye lase, operating at a wavelength of 630 nm was used, coupled with a cylindrical light applicator. After treatment the patient was admitted to an intensive care unit for 24 h. 3 h after photoradiation, general urticarial wheals arose, as well as techycardia and a decrease in blood pressure followed by all the signs of serious anaphylaxis. 1.5 h after treatment with adrenaline and cortisone and stabilization of the cardiac and circulatory situation no more skin lesions were visible.

— Partly purified chromaffin granules were incubated in vitro with Ca2+ (with trace amounts of 45Ca2+) in concentrations ranging from 4 μm to 1 mm. After incubation the granules were washed with media containing EDTA and then subjected to density gradient centrifugation (1.3 to 2.0 m-sucrose solutions) in order to characterize the particles which had taken up 45Ca2+. By using marker enzymes and various inhibitors of Ca2+ uptake into such cell particles as mitochondria it was established that under the conditions of the experiments chromaffin granules took up Ca2+ from the incubation medium. To characterize this uptake a simplified density gradient procedure was tested and found to be suitable. The uptake of Ca2+ into chromaffin granules was strongly dependent on temperature. It was not activated by ATP. The uptake was linear up to 10 min. At high calcium concentrations (above 200 μm) the rate of uptake levelled off. The uptake at 37°C was 1 nmol Ca2+/mg protein/min at a Ca2+ concentration of 500 μm. Mg2+ had no influence on Ca2+ uptake, whereas Sr2+ (1 mm) inhibited it. The methods established in this study should prove useful for a further characterization of this Ca2+ uptake into chromaffin granules which is likely to represent a useful model for the Ca2+ uptake occurring in the intact gland.

Intravenous Nimodipine was administered to 109 patients (65 female and 44 male) with either pre- or post-operative progressive neurological deterioration from cerebral vasospasm following subarachnoid hemorrhage from a ruptured aneurysm. In 91 of the patients the efficacy of Nimodipine in relieving ischemic symptoms was assessed and in all of the 109 patients the tolerance was evaluated. The aneurysms were related to following arteries: anterior communicating artery (41%), middle cerebral artery (24%), internal carotid artery (10%), vertebro-basilar arteries (4%) and others (5.5%); 11% of the patients had multiple aneurysms. On 16 of the 91 patients no surgery was performed. On 16% of the remaining 75 patients surgery was performed within 72 hours after the hemorrhage, 57% were operated between day 4 and day 15 and 29% after day 16. The ischemic neurological deficits occurred preoperatively in 67% of the patients and post-operatively in 23%. At the beginning of treatment 84% of the patients were graded III-V according to the Hunt and Hess grading system. Most of the patients received doses of 24-48 mg Nimodipine daily as constant i.v. infusion for 7-10 days. The grade of neurological deficit at the end of the treatment was evaluated according to the Glasgow Outcome Scale. 59 (65%) of the patients showed complete recovery or marked improvement of the ischemic symptoms while 22% remained unchanged and 11% died due to severe vasospasm. Administration of Nimodipine seemed to be more efficient in cases where treatment was started within 24 hours. In the patient group which was treated pre-operatively, recurrent hemorrhage was recorded in 8% of the patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Partly purified chromaffin granules from bovine adrenal medulla were incubated in vitro with [ 3 H]adenosine triphosphate (ATP). After several washes the particles were subjected to density gradient centrifugation. It was demonstrated that chromaffin granules had taken up radioactive material. Thin-layer chromatography revealed that more than 60% of the radioactivity was confined to [ 3 H]ATP. Incubation experiments with a mixture of [ 3 H]ATP and [ 32 P]ATP indicated that ATP was taken up by chromaffin granules as an intact molecule. The uptake of [ 3 H]ATP was temperature dependent and linear up to 10 min. The rate of uptake depended upon the ATP concentration and levelled off at ATP concentrations above 2 mM. At this ATP concentration the rate was 0.268 nmol ATP/mg protein/min. The uptake of ATP was compared with that of catecholamines. Both processes were activated by Mg 2+ , but inhibited by N -ethylmaleimide and an uncoupler of oxidative phosphorylation. Atractyloside inhibited only the ATP-uptake, whereas reserpine only interfered with that of the catecholamines. It is suggested that this uptake mechanism for ATP is carrier-mediated and that it enables newly formed chromaffin granules to accumulate and to maintain a high nucleotide concentration, which is required for the formation of a storage complex with catecholamines.

The effects of hematoporphyrin derivative, light, and cobalt 60 (60Co) irradiation were studied in a rat glioma model using an in vivo and an in vitro clonogenic assay. There was no effect on tumor growth by visible light or by a single dose of 60Co irradiation at 4 Gy or 8 Gy, whereas 16 Gy inhibited tumor growth to 40% versus the control. Hematoporphyrin derivative alone slightly stimulated growth (P less than 0.1). Light in the presence of 10 mg hematoporphyrin derivative/kg inhibited tumor growth to 32%. 60Co irradiation in the presence of hematoporphyrin derivative produced a significant tumor growth inhibition (P less than 0.02). This growth inhibition was directly related to the concentration of hematoporphyrin derivative. The addition of 60Co to light in the presence of hematoporphyrin derivative produced a greater growth inhibition than light or 60Co irradiation alone. This effect was most pronounced when light was applied 30 minutes before 60Co irradiation. Our experiments in a subcutaneous rat glioma model suggest a radiosensitizing effect of hematoporphyrin derivative. Furthermore, the photodynamic inactivation is enhanced by the addition of 60Co irradiation. These findings may be of importance in planning new treatment modalities in malignant brain tumors.

On the basis of 191 patients with epidural haematomas in an observation period of 15 years, an analysis of the patient group with non-classical symptoms was carried out. The opinions and theories regarding the generation of long-lasting lucid intervals found in the literature are mentioned and discussed on the basis of 3 typical examples. Owing to improved examination methods and early recognition, the mortality rate of the patients with epidural haematomas could be reduced from 54 per cent in the years 1961 to 1965 to about 10 per cent in the years 1975 to 1980.

In 27 patients, who suffered from SAH from a ruptured cerebral aneurysm direct operation and treatment with Nimodipine (Bay e 9736) was performed. Nimodipine was given intravenously over ten days (30 micrograms/kg bodyweight/hour) and thereafter orally over four days in diminishing dosages. There were no noteworth side effects. In comparison with a group of nine similar patients who were not given Nimodipine the study shows that Nimodipine is not able to reduce angiographic spasm or brain oedema in CT-scan. In spite of that the general recovery with Nimodipine was better than in the control group. The worse the initial neurological symptoms are, the more effective Nimodipine seems to be. The study shows that treatment should begin between the first and sixth day after SAH, at least two days before operation and at the latest two days after the onset of secondary spasm.

A total of 4,408 patients were treated for head injuries from 1980 to 1986 at the University Hospital of Innsbruck in Austria. Nine of them (0.2%) showed a traumatic, space-occupying hematoma in the posterior fossa. Clinical signs are often elusive, but tentorial or foraminal herniation with apnea may suddenly arise. Heightened awareness of these lesions and closely monitoring these patients are both necessary, especially when there is a fracture over the transverse sinus or the foramen magnum. Computed tomography helps to establish the diagnosis and leads to appropriate neurosurgical treatment. The overall mortality of patients with these lesions was 22% in our patients.

Cerebral vasospasm is caused by many factors. Primarily it is caused by Noradrenalin (NA) localised in the vessel walls and by platelet aggregation, with raising of the concentration of 5-HT in the intima. Its prolongation is based on blood breakdown products and or biochemical disturbances of brain metabolism. The most potent vasoconstrictors are acting through the vessel's own receptors (Serotonin, NE, Histamin), so the most effective therapy is based on the contractile system of the vessel. By blocking the alpha-receptors by Phenoxybenzamine, blockade of the Phosphodiesterase by Papaverin, Euphyllin to raise the concentration of cAMP and stimulation of Adenyl-Cyclase-System by beta-stimulation, it is possible to get good results in the treatment of cerebral arterial vasospasm.

The operative removal of the tumour mass as early and completely as possible is the most important step in the treatment of malignant brain tumours, whereby the quality of life must be maintained as a prerequisite. The operation is followed by radiotherapy at a dosage of 60 Gy which again is followed by chemotherapy with CCNU and Oncovin. New strategies in chemotherapy, radiotherapy, hyperthermia and photochemotherapy will be evaluated over the coming years. The therapy of malignant brain tumours represents a universal challenge, and despite the only small increase in life span by 6-9 months, this must be considered a partial progress in the combat against brain tumours.

Our last 30 patients, who were operated upon 3rd-ventricle-tumors, are discussed on symptomatology, diagnosis and therapy. Depending on the localization we classify oral, basal and caudal tumors. The peak of these tumors is found in the first ten years of life. They are distributed as followed: spongioblastomas, ependymomas, pinealoma and other rare tumors. Mainsymptom is the sudden diffuse headache depending on this skull's position. The three groups show different symptomatic features, the oral one sepecially that headache described above. The symptoms of the caudal group are due to signs of raised intracranial pressure and content the typical syndrome of the lamina-quadrigemina. Basal tumors lead to diencephalic disturbances. The CT scan should be done as the first diagnostic step, eventually connected with ventriculography or ventriculotomography. In any case therapy should be started by implantation of an atrio-ventriculare shunt. If the disease is progressing an invasive procedure has to be done. Irradiation therapy is bound to a clear histologic diagnosis or to a clear inoperability. Our 5-years survival was 40% in average.

This article deals with the diagnosis, therapy and prognosis of intracerebellar haematomas. The characteristic symptoms and the value of computer tomography for an early diagnosis and the surgical therapy are discussed. Prognosis and complications are analysed in comparison with other works. Guiding rules for a rapid diagnosis and the choice of the respective therapy are given and an early surgical therapy is recommended.