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Aims. Rac1 is a member of the Ras superfamily of small GTPase and plays a fundamental role in cytoskeleton reorganization, regulation of gene expression and cell proliferation, and cellular transformation. Though recent studies point to an involvement of rac1 in tumorigenesis, little is known about the alteration of rac1 gene in human brain tumours. Methods. Reverse transcription-polymerase chain reaction (RT-PCR), TA cloning, and DNA sequencing were performed to detect rac1 gene mutations in the surgical specimens of 45 human brain tumours. Results. Twelve of 45 cases had base changes in the rac1 gene. The frequency of rac1 alterations was seven of 18 meningiomas, three of 14 astrocytomas, one of seven pituitary adenomas, and one of four metastatic brain tumours. No mutation was detected in acoustic neurilemomas. The subtypes of seven meningiomas include three meningotheliomatous, two atypical, one transitional and one angioblastic meningioma. Three astrocytomas had rac1 gene mutation, including one grade II, one grade III, and one grade IV astrocytoma. All of single base changes were transitions, five of them being T to C transitions. Sites of rac1 mutation were found in codons 34, 41 (two cases), 42 (two cases), 43, 44, 46 and 58. These mutations are mainly localized in the putative effector-domain of rac1 gene and may enhance the activity of rac1, which increases the survival of brain tumours. Conclusion. Our results suggest that rac1 gene may play a role in some brain tumours of divergent histogenesis and that the alterations of rac1 gene may contribute to tumorigenesis and/or metastasis.

The purpose of this study was to demonstrate the existence of a newly recognized midline posterior column pathway that mediates the perception of visceral pain resulting from hepatobiliary or pancreatic cancer. A punctate midline myelotomy (PMM) of T(3) level was performed in 6 patients who experienced severe visceral pain caused by hepatobiliary or pancreatic cancer. Preoperatively, the pain was refractory to strong opioids. Clinical efficacy of PMM was evaluated by comparing patient pain rating on a visual analogue scale. Follow-up periods ranged from 2-18 weeks after operation. All 6 patients had immediate pain relief after operation. Although the pain recurred from 2-12 weeks later in 3 patients, the severity of recurrent cancer pain markedly decreased. No adverse neurological sequelae were observed. Our results of high thoracic PMM offer clinical support for the concept that neurosurgical interruption of midline visceral pain pathway can effectively control severe visceral pain without causing adverse neurological sequelae in patients with hepatobiliary or pancreatic cancer.

Summary Esthesioneuroblastoma is a rare neoplasm arising from the olfactory epithelium, and shows intracranial extension in the advanced disease. We report here a 40-year-old female, who had initially been diagnosed to have a Kadish stage C esthesioneuroblastoma. Recurrence presented about 10 months after the first operation, radiotherapy and chemotherapy, with pure bilateral subdural extension but without local signs. Although recurrence is common in advanced esthesioneuroblastoma, such a pattern of presentation is rare, with only three similar cases reported previously. We discuss the possible pathophysiology of such an event and propose possible means of prevention.

Background. Both experimental and human tumors often synthesize high levels of prostaglandins, most notably prostaglandin E2 (PGE2). This compound may play an important role in tumor growth and immunosuppression. Little is known of the production of PGE2 by brain tumors. The present study was designed to investigate the levels of PGE2 in the plasma of human brain tumors before and after tumor removal.

The authors sought to analyze trends in hospital resource utilization and mortality rates in a population of patients who had received traumatic brain injury (TBI) surgery.This nationwide population-based cohort study retrospectively analyzed 18,286 patients who had received surgical treatment for TBI between 1998 and 2010. The multiple linear regression model and Cox proportional hazards model were used for multivariate assessment of outcome predictors.The prevalence rate of surgical treatment for patients with TBI gradually but significantly (p0.001) increased by 47.6% from 5.0 per 100,000 persons in 1998 to 7.4 per 100,000 persons in 2010. Age, sex, Deyo-Charlson comorbidity index score, hospital volume, and surgeon volume were significantly associated with TBI surgery outcomes (p0.05). Over the 12-year period analyzed, the estimated mean hospital treatment cost increased 19.06%, whereas the in-hospital mortality rate decreased 10.9%. The estimated mean time of overall survival after TBI surgery (± SD) was 83.0 ± 4.2 months, and the overall in-hospital and 1-, 3-, and 5-year survival rates were 74.5%, 67.3%, 61.1%, and 57.8%, respectively.These data reveal an increased prevalence of TBI, especially in older patients, and an increased hospital treatment cost but a decreased in-hospital mortality rate. Health care providers and patients should recognize that attributes of the patient and of the hospital may affect hospital resource utilization and the mortality rate. These results are relevant not only to other countries with similar population sizes but also to countries with larger populations.

To evaluate the incidence and influencing factors related to preoperative and postoperative seizures, a retrospective analysis was performed in 190 patients with astrocytic tumours. Preoperative seizures occurred in 50 (26%) patients and 27 (54%) of the m had recurrent seizures. Late-onset seizures developed after craniotomy in 11 (8%) of 140 patients. Seizures at presentation were significantly correlated with age at diagnosis (P=0.0204) and pathological grade of tumour (P=0.0040). The patients aged less than 40 years had a high risk of seizures at presentation (odds ratio=3.076, P=0.0134). Postoperative seizures were significantly associated with the presence of preoperative seizures (P

Background. Relative survival rates can offer a general description of tumor outcome and, traditionally, are used for surveillance and comparison purposes. However, they are not informative for individual tumor survivors. Conditional survival estimates can calculate the probability of surviving next some years given survival to a specific period of time after craniotomy for individual tumor survivors. However, clinically, they have not been used for predicting the tumor outcome. Methods. We calculated conditional probabilities of survival within 6 years after craniotomy in 112 patients with primary supratentorial astrocytic tumors and evaluated factors affecting the survival time more than 2 years after craniotomy. Results. Our data showed that the conditional probability of survival can predict yearly survival rate when patients survive for a specific period of time. The conditional survival rates within 6 years after craniotomy were always higher than those evaluated by relative survival rates. Overall, the longer the patients survived, the higher the conditional probabilities of surviving sixth year postoperatively were. Conclusion. Our study demonstrates the conditional probabilities of survival have good availability and are important estimates for individual tumor survivors.

The constellations have some connections with neuromedicine. As neurosurgeons, we can learn something from the night sky. Medical terms or descriptions are generously used from mythology or celestial lore. Neurosurgeons spend so much time on their professional careers that they may ignore something wonderful which is worthy of their attention. The puzzling issues between the constellations and neuromedicine can be exciting. Imagination allows neurosurgery to make great strides and progression. With that same imagination we can take an odyssey!

Degenerative cervical spondylosis (DCS) is part of the aging process and is the most common reason for degenerative changes with the spinal column. Anterior cervical discectomy and fusion (ACDF) is a major option for operative management of DCS in our institution. This retrospective study investigated the frequency of postoperative complications and resource utilization in 145 patients who underwent ACDF procedures from January 2009 to December 2011. Patients with degenerative changes that involved cervical intervertebral levels C1–C2, spinal injury of traumatic origin, spinal tumors, or previous cervical fusion were excluded. Patients were then further classified into two groups: (1) level 1 or 2 disease (Group M) and (2) level 3 or 4 disease (Group S). Measures of mortality, complications after surgery as well as immediate reoperation for any reason were evaluated. Operation time, length of hospital stay, and hospitalization cost were defined as resource utilization. Ninety seven patients met the inclusion criteria and were further reviewed to characterize the sample better. There were no hematomas, airway complications or deaths, except in one patient who developed postoperative hemorrhage that required immediate surgical intervention, and resolved without any neurological deficit or casualty. Resource utilization indicated that the average operation time for Group S was significantly higher than for Group M (4.31±1.25 vs. 2.88±0.90 hours, p

Although instrumented posterior lumbar interbody fusion (PLIF) has been becoming a popular and effective method for treating degenerative lumbar scoliosis, the clinical outcome is rarely reported. We retrospectively evaluated the clinical and radiographic outcomes in patients with degenerative lumbar scoliosis after instrumented PLIF.A total of 58 patient's clinical characteristics had been reviewed retrospectively including clinical presentations, preoperative medical comorbidities, intraoperative status, and postoperative status. Oswestry disability index (ODI), visual analog scale (VAS), and patient satisfaction were evaluated before surgery and last follow-up period. The relationship between the difference of radiographic parameter and functional outcome was evaluated.Functional outcomes including ODI scores and VAS were significantly improved at the last visit. The ODI was 28.1 ± 8.0 before surgery and 12.2 ± 8.8 at the last visit. VAS was 7.4 ± 2.0 before surgery and 2.4 ± 2.0 at the last visit. Patient satisfaction was 72% at the last visit. ODI was significantly related to postoperative radiographic parameters including Cobb's angle (p 0.001), L4 inclination (p = 0.011), coronal balance (p = 0.007), lateral vertebral translation (p 0.001), Nash-Moe grade (p = 0.033), Nash-Moe degree (p = 0.025), and sagittal balance (p = 0.041) Using multiple regression analysis, ODI was significantly related to female gender, number of levels fixed, coronal balance, lateral vertebral translation, and Nash-Moe degree. The was no significant correlation between postoperative radiographic parameters and pain (VAS). Only lateral vertebral translation demonstrated a significant correlation in multiple regression analysis.Based on the VAS and ODI instrument, our studies demonstrated that instrumented PLIF for adult degenerative lumbar scoliosis can achieve a high rate of patient satisfaction and improvement in radiographic and clinical outcomes at a minimum of 2 years of follow-up.

Background: : Chronic subdural hematoma (CSDH) is a relatively frequent problem in neurologic or neurosurgical practice. Although CSDH is a well-known disease, data on bilateral CSDH are scarce compared with data on unilateral CSDH. The purpose of this study was to compare the clinical presentations, precipitating factors, computed tomography (CT) scan findings, postoperative complications, and outcomes between patients with bilateral and unilateral CSDH. Methods: : A retrospective study was performed on 129 surgical patients with CSDH from January 2002 to January 2005. These patients were divided into two groups: bilateral CSDH (45 cases) and unilateral CSDH (84 cases). Clinical presentations, precipitating factors, CT scan findings, postoperative complications, and outcomes of patients were analyzed. Results: : The mean age was 75 years for patients with bilateral CSDH and was 68 years for patients with unilateral CSDH (p = 0.696). Males predominated in each group (p = 0.696). The frequency of presenting symptoms of nausea and vomiting, headache, or unsteady gait was significantly greater in bilateral CSDH than in unilateral CSDH (p < 0.05). The incidence of usage of anticoagulant and antiplatelet therapy was significantly higher in bilateral CSDH group than in unilateral CSDH group (p < 0.05). The frequency of marked midline shift on CT scans was significantly greater in unilateral CSDH than in bilateral CSDH (p < 0.05). Coexisting systemic diseases, postoperative complications, and outcomes had no significant differences between both groups. Conclusions: : Bilateral CSDH tended to occur more in patients with anticoagulant or antiplatelet therapy. Compared with patients with unilateral CSDH, patients with bilateral CSDH had more symptoms of increased intracranial pressure and lower incidences of midline shift on CT scans. Most patients with either bilateral or unilateral CSDH had a good postoperative outcome.

Object Apoptosis is implicated in vasospasm and long-term sequelae of subarachnoid hemorrhage (SAH). The authors observed that 17β-estradiol (E2) can attenuate cerebral vasospasm, lower endothelin-1 production, and preserve normal endothelial nitric oxide synthase expression by reduction of inducible NO synthase expression in experimental SAH. The authors investigated the potential antiapoptotic effects of E2 in an experimental rat model of SAH. Methods The authors examined the antiapoptotic effects of E2 in a double-hemorrhage SAH model in male Sprague-Dawley rats. The rats underwent subcutaneous implantation of a Silastic tube containing corn oil either with or without E2, and some E2-treated animals also received ICI 182,780 (a nonselective estrogen receptor [ER] antagonist) for 7 days after SAH. The degree of vasospasm was determined by averaging the cross-sectional areas of the basilar artery 7 days after SAH. The expression of apoptotic indicators, including TNF-α, caspase 3, Bcl-2, Bax, terminal deoxynucleotidyl transferase–mediated deoxyuridine triphosphate nick end labeling (TUNEL), and cell death assays were used for detection of apoptosis. Results Treatment with E2 significantly attenuated SAH-induced vasospasm. Seven days after the induction of SAH, positive TUNEL-staining was seen, and DNA fragmentation was increased in the dentate gyrus. Increased TNF-α and cleaved caspase-3 protein expression and decreased Bcl-2 protein expression in the dentate gyrus were also observed. These changes were reversed with E2-treatment but not in the presence of ICI 182,780. However, the expression of Bax did not change after SAH either with or without E2 treatment. Conclusions The authors found that E2 appears to confer an antiapoptotic effect that reduces secondary brain injury after SAH via estrogen receptor–dependent mechanisms. This finding provides support for possible future applications of E2 treatment for the reduction of secondary injury after SAH in patients.

A rare case of low-grade astrocytoma associated with abscess formation occurred in a 52-year-old man presenting with Broca's aphasia. He underwent craniotomy and tumor removal under the impression of brain tumor with necrotic cystic change. Abscess accumulation within the intra-axial tumor was found intraoperatively. Literature related to brain abscess with brain tumor is reviewed, with an emphasis on abscesses with astrocytoma. We discuss the common brain tumors that are associated with abscess, pathogens that coexist with brain tumor, and the pathogeneses of coexisting brain abscess and tumor. It is very important to know how to differentiate between and diagnose a brain abscess and tumor, or brain abscess with tumor, preoperatively from clinical presentation and through the use of computed tomography, conventional magnetic resonance imaging, diffusion-weighted imaging or magnetic resonance spectroscopy.

Clinical and radiologic study evaluating the outcome after anterior corpectomy with iliac bone fusion compared with discectomy with interbody titanium cage fusion for multilevel cervical degenerated disc disease.To investigate the safety and effectiveness of interbody titanium cage with plate fixation in multilevel postdiscectomy fusion.The operation for segmental multilevel cervical degenerated disc disease remains controversial. Data on safety and efficacy of titanium cages in multilevel postdiscectomy fusion are rarely available. We investigated the safety and effectiveness of interbody fusion cages with plate fixation and compared the clinical and radiographical results between anterior corpectomy and iliac bone fusion with plate fixation and multilevel discectomy and cage fusion with plate fixation.Sixty-two patients were treated with either a multilevel discectomy and cage fusion with plate fixation (27 patients, group A) or an anterior corpectomy and iliac graft fusion with plate fixation (35 patients, group B). We evaluated the patients for cervical lordosis, fusion status, and stability 24 months postoperatively on the basis of spine radiographs. The patients' neurologic outcomes were assessed by the Japanese Orthopedic Association (JOA) scores. Neck pain was graded using a 10-point visual analog scale.Both groups A and B demonstrated a significant increase in the JOA scores (preoperatively 11.1+/-2.1 and 10.4+/-3.5, postoperatively 14.3+/-2.4 and 13.9+/-2.1, respectively) and a significant decrease in the visual analog pain scores (preoperatively 8.5+/-1.1 and 8.7+/-1.5, postoperatively 2.9+/-1.8 and 3.0+/-2.0, respectively). However, there was no significant difference between groups A and B. Both groups A and B showed a significant increase in the cervical lordosis after operation and reached satisfactory fusion rates (96.3% and 91.4%, respectively). Three patients (two 2-level corpectomies and one 3-level corpectomy) had construct failures that required a second operation. Eight of 35 patients who underwent iliac bone fusion had donor site pain. The hospital stay in group A was significantly shorter than that in group B (P=0.022).Either a multilevel discectomy and cage fusion with plating or a corpectomy and iliac bone fusion with plating provides good clinical results and similar fusion rates for cervical degenerative disc disease. However, absence of donor site complications and construct failures and shorter hospital stay make the multilevel discectomy and cage fusion with plate fixation better than corpectomy and strut graft fusion with plate fixation.

A case of two sporadic cellular neurofibromas with atypia and one widespread hyalinization neurofibroma of the lumbar spine in a 51-year-old man without evidence of neurofibromatosis-1 is reported. Cellular neurofibroma with atypia is an unusual variant. The definite criteria for low-grade and high-grade malignant peripheral nerve sheath tumors as well as cellular neurofibroma are not well defined in the literature. The clinical significance of atypical cellular neurofibroma has rarely been systematically studied. To our knowledge, the concomitance of cellular architecture and cytologic atypia is rarely documented, and this is a rare report of atypical cellular neurofibroma. The recognition of this entity is of great importance to both pathologists and clinicians because atypical cellular neurofibroma is clever at masquerading both histologically and cytologically as a sarcoma; therefore, a precise diagnosis of this variant is essential because of the differences in treatment and clinical behavior between benignancy and malignancy. We also examined the immunohistochemical characteristics of CD34 positive cells and focal high expression of p53 up to 73% encountered in our case. To our knowledge, seldom have series or case reports elucidated this phenomenon.

Although prominent FRAT/GBP exhibits a limited degree of homology to Axin, the binding sites on GSK3 for FRAT/GBP and Axin may overlap to prevent the effect of FRAT/GBP in stabilizing beta-catenin in the Wnt pathway. Using a yeast two-hybrid screen, we identified a novel protein, GSK3beta interaction protein (GSKIP), which binds to GSK3beta. We have defined a 25-amino acid region in the C-terminus of GSKIP that is highly similar to the GSK3beta interaction domain (GID) of Axin. Using an in vitro kinase assay, our results indicate that GSKIP is a good GSK3beta substrate, and both the full-length protein and a C-terminal fragment of GSKIP can block phosphorylation of primed and nonprimed substrates in different fashions. Similar to Axin GID(381-405) and FRATtide, synthesized GSKIPtide is also shown to compete with and/or block the phosphorylation of Axin and beta-catenin by GSK3beta. Furthermore, our data indicate that overexpression of GSKIP induces beta-catenin accumulation in the cytoplasm and nucleus as visualized by immunofluorescence. A functional assay also demonstrates that GSKIP-transfected cells have a significant effect on the transactivity of Tcf-4. Collectively, we define GSKIP as a naturally occurring protein that is homologous with the GSK3beta interaction domain of Axin and is able to negatively regulate GSK3beta of the Wnt signaling pathway.

There are numerous histologic variants of meningioma. Among the more uncommon are intracranial masses composed of meningiomatous and plasma cell-lymphocytic elements. We report a 22-year-old woman with lymphoplasmacyte-rich meningioma who initially presented with dizziness and progressive headache. Neuroradiologic images revealed typical meningiomas of the sphenoid ridge with extensive perifocal edema. Complete macroscopic removal of the tumor was performed. Histologic examination revealed a meningioma with massive infiltrates of plasma cells and lymphocytes. Brain computed tomography on the 6 th postoperative day revealed total removal of the tumor with marked reduction of brain edema. Complete resolution of symptoms occurred with no evidence of tumor recurrence during 2 years of follow-up.

A very rare case of a giant nondural-based cauda equina meningioma with multiple cysts was presented. Spinal meningioma most commonly occurs in the thoracic or cervical region and typically adheres to the dura. Only six cases of nondural-based meningioma have been reported in English literature. All occurred in the cauda equina region. These patients were predominantly female and younger than those with typical intraspinal meningioma.A 46-year-old woman had a 4-year history of lower back pain and right leg pain. Progressive weakness of both lower extremities occurred. Magnetic resonance imaging revealed a giant cauda equina tumor with multiple cysts from T(12) to L(4). Following laminectomies from T(11) to L(5) and intradural exposure, the tumor was found to be draped loosely by the roots of the cauda equina and attached to a root without any firm connection with dura mater. Complete removal of the tumor was achieved after microdissection of arachnoid and sacrifice of an involved rootlet of the cauda equina. The appearance of tumor was that of a typical neurilemmoma. However, histological and immunohistochemical analyses were consistent with meningioma. Nondural-based intraspinal meningiomas are very rare, particularly a giant tumor with multiple cysts as our presenting case. All of the cases previously reported, including our case, have been located in the cauda equina region. Most of the patients were female and were young, suggesting that the nondural-based cauda equina meningiomas are age- and sex-related. An accurate preoperative and operative diagnosis are difficult. Care must be taken in the management of cauda equina tumors resembling neurilemmoma which may in fact represent meningioma, particularly in the younger female.

Squamocin is one of the annonaceous acetogenins and has been reported to have anticancer activity. Squamocin was found to inhibit the growth of K562 cells in a time- and dose-dependent manner. Cell cycle analysis showed G2/M phase arrest in K562 cells following 24 h exposure to squamocin. During the G2/M arrest, cyclin-dependent kinase inhibitors (CDKIs), p21 and p27 were increased in a dose-dependent manner. Analysis of the cell cycle regulatory proteins demonstrated that squamocin did not change the steady-state levels of Cdk2, Cdk4, cyclin A, cyclin B1, cyclin D3 and cyclin E, but decreased the protein levels of Cdk1 and Cdc25C. These results suggest that squamocin inhibits the proliferation of K562 cells via G2/M arrest in association with the induction of p21, p27 and the reduction of Cdk1 and Cdc25C kinase activities.

Aberrant calpain activation is a key mediator of neuron death. We examined the cell-permeable calpain inhibitor MDL28170 in the pathophysiological processes after spinal cord injury (SCI) including p35-p25- cyclin-dependent kinase-5 (Cdk5) activation, tau hyperphosphorylation, neuron cell death, calpain I activation, astrogliosis, and microglia activation. Our study showed that intrathecal administration of MDL28170 improved neurologic dysfunction, prevented neuron loss, decreased the number of apoptotic cells, and abated astrogliosis and microglia activation 7 days after spinal cord hemisection in rats. Reverse transcription polymerase chain reaction demonstrated calpain inhibition significantly attenuated the ratio of proapoptotic Bax/anti-apoptotic Bcl-2 mRNA in the lesion and penumbra after SCI. Calpain, the calcium-activated proteolytic enzyme, was found to digest p35 to its truncated product, p25. Moreover, abnormal Cdk5 activation by p25 and subsequent tau hyperphosphorylation triggers pathologic events leading to neurodegeneration and neurofibrillary tangles. We found p35-p25-Cdk5 activation and tau hyperphosphorylation in SCI, and then we showed that intrathecal MDL28170 treatment could diminish p35 truncation, and abrogate aberrant tau phosphorylation. Double labeling of calpain I and phosphorylated tau (AT8) in the same cells of spinal cord lesion further implicated pathogenesis of SCI. In conclusion, MDL28170 abated calpain I activation, inhibited apoptosis and neuron loss, quenched microglia and astrocyte activation, and significantly improved neurologic deficit one week after spinal cord hemisection. The neuroprotective mechanisms of calpain inhibitor in SCI could be attenuating upregulation of Bax/Bcl-2 ratio, preventing p35 truncation in the lesion and penumbra, and abrogating tau hyperphosphorylation.

Tcf family transcription factors are the downstream effectors of the Wnt signal transduction pathway that regulates developmental and oncogenetic processes among species. The alternative splicing of consecutive exons in the 3' part of the Tcf-4 gene and an error-prone A9 repeat in exon 17 have recently been examined in several tumors. To further understand the roles played by differential expression and splicing isoforms of human Tcf-4 in brain tumorigenesis, the expression of the 3' part of the Tcf-4 gene (exons 10-17) was analyzed by RT-PCR, nested RT-PCR and DNA sequencing. The results showed that at least 13 of the Tcf-4 alternative splicing isoforms were found and most of them were overexpressed in various brain tumors. L3 isoform was particularly dominant in metastasis. Several novel splicing isoforms were identified. One that contains different combinations of exon 16 (10-11-12-16-17, S5) was found in normal brain and pituitary adenoma but not in astrocytoma, meningioma or metastasis, whereas the other that contains part of intron 16, designated exon-16', was found in metastasis. Overall 23% of sequencing analysis in brain tumors exhibited frameshift mutations in an A9 repeat region of exon 17. These mutants exhibited 2-base or 1-base deletion (A7, A8) and 1-base insertion (A10). Nonetheless, in vitro functional assay showed that these mutants did not affect the transactivity of Tcf-4 comparing to wild-type Tcf-4. Collectively, our data suggest that a large number of alternative splicing isoforms may together with variable mutations of A9 repeat region maintain balanced pools of Tcf-4 isoforms during brain tumorigenesis.

Rac1 and Rac2 are interchangeable in NADPH oxidase activation. Rac1 plays an important role in regulating nuclear signalling and in the activation of transcriptional factors that regulate gene expression and cell growth. Our previous study observed mutation in effector region of Rac1 gene in brain tumors. Little is known about the expression and mutation of Rac2 in human brain tumors.We examined the expression of Rac2 by using reverse transcriptase-polymerase chain reaction (RT-PCR) and northern blot analysis and the mutation of Rac2 gene by using DNA sequence analysis.The decreased expression of Rac2 was found in 15 cases (57.7%) including 8 of 10 astrocytomas, 2 of 8 meningiomas, and 5 of 8 pituitary adenomas. Two of 13 cases with decreased expression of Rac2 had gene mutation. Only two of 26 cases had Rac2 overexpression in which no Rac2 gene mutation was found. Four of 8 cases with normal Rac2 expression had Rac2 gene mutation. The site of Rac2 gene mutation had no hot spots and was not concentrated in the effector region.Our results showed a low frequency of mutation and no hot spots of mutation in Rac2 gene in brain tumors, suggesting a decreased possibility of Rac2 in the brain tumorigenesis. The role of high frequency of decreased Rac2 expression in brain tumors, particularly in malignant astrocytomas, needs further investigations to be elucidated.

Rac3 may play an important role in tumor growth but little is known about its expression and mutation in human tumor tissues. We examined the expression of Rac3 using RT-PCR and mutation of the Rac3 gene by DNA sequencing. Overexpression of the Rac3 gene occurred in 19% (5/26) of brain tumors; 3 of 9 (33%) meningiomas, 1 of 11 (9%) astrocytomas and 1 of 6 (17%) pituitary adenomas. Two of the 3 meningiomas with Rac3 overexpression were recurrent meningiomas. The only astrocytoma with Rac3 overexpression was a glioblastoma multiforme. Mutation of the Rac3 gene occurred in 63% (12/19) of brain tumours; 4 of 7 (57.1%) meningiomas, 4 of 5 (80%) pituitary adenomas and 4 of 7 (57.1%) astrocytomas. Except in one astrocytoma, the other four tumors with Rac3 overexpression (3 meningiomas and one pituitary adenoma) did not have Rac3 mutations. Our data is the first report of the frequency of Rac3 overexpression and mutation in human brain tumors. Overexpression may be associated with aggressive tumor behavior. The relationship between Rac3 expression and mutation requires further investigation.

Nine patients, 16 years of age or younger with primary spinal cord tumors, diagnosed between 1991 and 2003 at The Kaohsiung University Hospital, were reviewed retrospectively. There were 2 female and 7 male patients. Two tumors were located primarily in the cervical cord (1 meningioma, 1 neurofibroma), five were predominantly thoracic (1 lymphoma, 1 meningioma, 1 astrocytoma, 1 fibrosarcoma and 1 osteoblastoma), one lumbar (ependymoma), and one sacral (Ewing's sarcoma). The most common clinical presentation was limb weakness (100%) followed by back pain (44.4%). All the patients underwent laminectomy for removal of their tumors. Five children with benign tumors improved postoperatively. At discharge, these 5 children could walk without assistance and have remained stable with long-term of follow-up. Radical surgery should be considered in benign primary spinal cord tumors. As would be expected, patients diagnosed and treated early and in whom a total resection was achieved had a better prognosis.

We report a case of massive intracerebral air embolism after cardiopulmonary resuscitation in a patient with a fatal head injury. There was no pneumothorax or extravascular pneumocephalus, however, air was found in the internal carotid artery. Massive cerebral air embolism may occur after entrance of air into the circulatory system via ruptured pulmonary vessels during cardiopulmonary resuscitation.

Object. The reported incidence, timing, and predictive factors of perioperative seizures and epilepsy after subarachnoid hemorrhage (SAH) have differed considerably because of a lack of uniform definitions and variable follow-up periods. In this study the authors evaluate the incidence, temporal course, and predictive factors of perioperative seizures and epilepsy during long-term follow up of patients with SAH who underwent surgical treatment. Methods. Two hundred seventeen patients who survived more than 2 years after surgery for ruptured intracranial aneurysms were enrolled and retrospectively studied. Episodes were categorized into onset seizures (≤ 12 hours of initial hemorrhage), preoperative seizures, postoperative seizures, and late epilepsy, according to their timing. The mean follow-up time was 78.7 months (range 24–157 months). Forty-six patients (21.2%) had at least one seizure post-SAH. Seventeen patients (7.8%) had onset seizures, five (2.3%) had preoperative seizures, four (1.8%) had postoperative seizures, 21 (9.7%) had at least one seizure episode after the 1st week postoperatively, and late epilepsy developed in 15 (6.9%). One (3.8%) of 26 patients with perioperative seizures (onset, preoperative, or postoperative seizure) had late epilepsy at follow up. The mean latency between the operation and the onset of late epilepsy was 8.3 months (range 0.3–19 months). Younger age (< 40 years old), loss of consciousness of more than 1 hour at ictus, and Fisher Grade 3 or greater on computerized tomography scans proved to be significantly related to onset seizures. Onset seizure was also a significant predictor of persistent neurological deficits (Glasgow Outcome Scale Scores 2–4) at follow up. Factors associated with the development of late epilepsy were loss of consciousness of more than 1 hour at ictus and persistent postoperative neurological deficit. Conclusions. Although up to one fifth of patients experienced seizure(s) after SAH, more than half had seizure(s) during the perioperative period. The frequency of late epilepsy in patients with perioperative seizures (7.8%) was not significantly higher than those without such seizures (6.8%). Perioperative seizures did not recur frequently and were not a significant predictor for late epilepsy.

Background Palmar hyperhidrosis is a common functional disorder in the Asians. Currently, transthoracic endoscopic sympathectomy (TES) is considered to be the treatment of choice for this entity because of its high initial success rate and minimal morbidity. However, primary failure and recurrence of hyperhidrosis occurred in some patients, even with a very low incidence. We present our experience in the treatment of primary failure and recurrence of hyperhidrosis after TES by means of percutaneous computer tomography (CT) guided ethanol thoracic sympathectomy. Methods From July 1999 to July 2001, 11 patients (2 males and 9 females with a mean age of 25.9 years, range: 19–44 years) of this subgroup underwent percutaneous CT-guided chemical thoracic sympathectomy. Failure of the first sympathectomy was caused by severe pleural adhesion (from the previous operative findings) in 7 patients. The remaining 4 patients were recurrent palmar hyperhidrosis. All patients underwent unilateral procedures (3 on the right and 8 on the left). Results All patients were followed for at least 2 years after the treatment. Needle puncture was possible without difficulty in all patients. All patients had satisfactory results with minimal complication. No recurrence was noted at follow-up. Conclusion In summary, percutaneous CT-guided ethanol thoracic sympathectomy could be an easy, safe, and alternative strategy to treat patients with palmar hyperhidrosis after failure or recurrence after TES.

Background By the use of conditional probabilities of survival, we studied the yearly survival rates for individual tumor survivors. Methods Conditional survival rate was estimated in 114 consecutive patients with anaplastic astrocytoma or glioblastoma multiforme. Conditional probabilities of surviving some years given survival to a specific period of time after craniotomy and 95% confidence intervals were calculated in the individual tumor survivors. Results The estimated median survival was 30 months for 45 patients with anaplastic astrocytoma and 12 months for 69 patients with glioblastma multiforme. The conditional probabilities of surviving next one year given survival to 1 year, 2 years, 3 years, 4 years, or 5 years after craniotomy for anaplastic astrocytoma were 86.2%, 75.0%, 85.9%, 77.8%, or 85.7%, respectively; for glioblastoma multiforme 64.8%, 58.7%, 85.7%, 80.0%, or 75.0%, respectively. The conditional probability of surviving to 5 years given survival to 2 years after craniotomy for anaplastic astrocytoma, i.e., surviving an additional 3 years, was 50.1%, which was better than observed 5-year survival rate (28.6%); for glioblastoma multiforme it was 40.2%, which also was better than observed 5-year survival rate (12.4%). Conclusions The conditional probability of survival was a good method to clinically predict yearly survival rate for indi-vidual tumor survivors. In addition, the method can estimate the probabilities of surviving next some years given survival to a specific period of time after craniotomy. It also showed a more encouraging result than observed survival rate in patients with supratentorial malignant astrocytomas.

A case of glomangioma located at an unusual site, the extradural space of the cervical spine, is presented. To our knowledge, this is the first case that has been identified at this location. Radiographic features of computed tomography (CT) and magnetic resonance (MR) image were collected as a dumbbell-shaped tumor at epidural space of the cervical spine. These features correspond with the histological findings.

Both experimental and human tumors often synthesize high levels of prostaglandins, most notably prostaglandin E2 (PGE2). This compound may play an important role in tumor growth and immunosuppression. Little is known of the production of PGE2 by brain tumors. The present study was designed to investigate the levels of PGE2 in the plasma of human brain tumors before and after tumor removal.The plasma PGE2 levels of brain tumors before and after tumor removal were measured by high-performance liquid chromatography (HPLC).There is a significantly high concentration of PGE2 in malignant brain tumor before tumor removal. Significantly decrease of PGE2 concentration after total removal of the tumor was found both in the malignant and benign brain tumor groups (P = 0.0001 and P = 0.0039 respectively). However, compared to the control group, only malignant brain tumor showed a significant decrease of PGE2 concentration after tumor removal (P = 0.0009).Our study demonstrates the malignant brain tumor synthesized higher relative proportions of PGE2 and surgical removal of the brain tumor can reduce the production of PGE2.

Dynamin-like protein, a large GTP-binding protein, has recently been cloned, and studies have suggested that it is involved in the formation of coated vesicles. In this report, the differential expression of four human dynamin-like protein splice variants (HdynIV-wildtype [WT], -11, -26, and -37) from various brain tumors was identified by reverse transcription/polymerase chain reaction (RT-PCR). One novel variant (HdynIV-11), not described previously, was identified. The four alternatively spliced variants exhibited tissue specificity in normal tissues. The HdynIV-WT was strongly expressed in the brain, whereas HdynIV-37 was expressed in all tissues examined. Moreover, HdynIV-26 was dominant in the liver and apparently overexpressed in all astrocytomas and most meningiomas and adenomas. This report suggests that HdynIV-26 may cause aberrant protein trafficking and alter vesicle formation in brain tumors. Our results also suggest that dynamin-like protein is associated with various brain tumors and, more importantly, that aberrant expression of the HdynIV-26 variant may play a role in brain tumorigenesis.

Background The Oswestry Disability Index (ODI) is widely used for patients with back pain. However, few studies have examined its psychometric properties using modern measurement theory. The purpose of this study was to investigate the psychometric properties of the ODI in patients with back pain using Rasch analysis. Methods A total of 408 patients with back pain participated in this cross-sectional study. Patients were recruited from the orthopedic, neurosurgery, rehabilitation departments and pain clinic of two hospitals. Rasch analysis was used to examine the Chinese version of ODI 2.1 for unidimensionality, item difficulty, category function, differential item functioning, and test information. Results The fit statistics showed 10 items of the ODI fitted the model’s expectation as a unidimensional scale. The ODI measured the different levels of functional limitation without skewing toward the lower or higher levels of disability. No significant ceiling and floor effects and gaps among the items were found. The reliability was high and the test information curve demonstrated precise dysfunction estimation. Conclusions Our results showed that the ODI is a unidimensional questionnaire with high reliability. The ODI can precisely estimate the level of dysfunction, and the item difficulty of the ODI matches the person ability. For clinical application, using logits scores could precisely represent the disability level, and using the item difficulty could help clinicians design progressive programs for patients with back pain.

Summary Ganglioneuromas are benign tumors that arise from the ganglion cells of the sympathetic nervous system. They are most commonly localized in the posterior mediastinum, followed by the retroperitoneum, cervical region, and adrenal gland. We encountered a rare paraspinal neurogenic tumor with extension into the spinal extradural space that presented with a dumbbell shape and bony indentation. The clinical features, radiographic analysis, and surgical approach are briefly discussed.

Summary Fibrous dysplasia occurs rarely in the spine, especially in the thoracic spine. According to the literature, less than 20 cases have been reported. We report in this paper a 48-year-old female patient with fibrous dysplasia of the first thoracic spine and left side of the first rib with left thoracic first root compression. She complained of severe pain of the left arm, numbness on the ulnar side of the left forearm, and weakness of the middle to little fingers. Computed tomography and magnetic resonance imaging showed the characteristic appearance of fibrous dysplasia, which includes ground-glass opacity, an expansile nature, and lytic lesions with sclerotic rims. She underwent surgical intervention with radical tumor resection combined with stabilization and fusion with a mesh graft. The pain was relieved. The thoracic first root compression signs improved after the operation. Nineteen months after the operation, there was no recurrence of the tumor. We suggest that radical tumor resection combined with stabilization and fusion with an anterior or posterior approach using a mesh graft for thoracic fibrous dysplasia can achieve definite decompression and prevent tumor recurrence.

Background Anterior cervical discectomy and fusion is one of the most common surgical interventions performed by spine surgeons. As efforts are made to control healthcare spending because of the limited or capped resources offered by the National Health Insurance, surgeons are faced with the challenge of offering high-level patient care while minimizing associated healthcare expenditures. Routine ordering of postoperative hematologic tests and observational intensive care unit (ICU) stay might be areas of potential cost containment. This study was designed to determine the necessity of routine postoperative hematologic tests and ICU stay for patients undergoing elective anterior cervical discectomy and fusion and to investigate whether the elimination of unnecessary postoperative laboratory blood studies and ICU stay inhibits patient care. Methods The necessity for postoperative blood tests was determined if there were needs for a postoperative blood transfusion and hospital readmission within 1 month after surgery. The necessity for postoperative ICU observation was decided if immediate surgical intervention was required when any kind of complications occurred during the ICU stay. Results There were 168 patients collected in the study. Among them, all had routine preoperative and postoperative blood tests and were transferred to ICU for observation. No need for blood transfusion was observed, and no patient required immediate surgical intervention when the complications occurred during the ICU stay. Conclusion Cost savings per admission amounted to approximately 10% of the hospitalization cost by the elimination of unnecessary postoperative routine laboratory blood studies and observational ICU stay without waiving patient care in the current volatile, cost-conscious healthcare environment in Taiwan.

The medical records of 117 patients with spinal tumors who underwent surgery with pathologic confirmation from January 1999 to April 2004 at Kaohsiung Medical University Hospital were reviewed. Data from this review were compared with those obtained from the same institution 10 years earlier (covering the period 1988‐1995) and from other reported series. There were 69 male and 48 female patients aged from 13 to 87 years old (mean age, 51.9). The most common pathologic findings were metastasis in 45.3% (53/117), nerve sheath tumors in 28.2% (33/117), menin‐giomas in 12% (14/117) and neuroepithelial tumors in 6% (7/117). The peak ages at diagnosis were 41‐50 years and 61–70 years. A slight male predominance was noted for all tumors, except meningiomas. Motor weakness, even paralysis, was the major clinical presentation (64–86%), followed by sensory deficits (50%) and pain (42%). The location of tumors was most often in the thoracic (50.4%; 59/117), lumbosacral (27.4%; 32/117) and cervical spine (22.2%; 26/117) segments. Among the metastatic tumors, the lung (22.6%) and breast (15.1%) were the most common primary sites of origin, followed by unknown origin, the liver (hepatocellular carcinoma), the gastrointestinal tract and the nasopharynx (nasopharyngeal cancer).

Prostaglandin E2 (PGE2) plays an important role in immunosuppression and tumor growth. PGE2 inhibitors such as aspirin and indomethacin suppress experimental tumor growth. Little is known of the relationship between PGE2 synthesis in brain tumors and the dose of aspirin or indomethacin. The present study was undertaken to evaluate the effect of different doses of aspirin and indomethacin on PGE2 synthesis in C6 glioma cells. C6 glioma cells were incubated with different concentrations (2, 4, and 8 microM) of aspirin and indomethacin for 1, 2, 4, 6, 8, 12, and 24 hours. Intracellular PGE2 concentration was measured by enzyme immunoassay. Each concentration of aspirin and indomethacin effectively inhibited PGE2 synthesis. Concentrations of 2, 4, and 8 microM of aspirin significantly inhibited PGE2 production at 6, 4, and 1 hour, respectively, and the inhibition persisted for more than 24 hours (p0.05). Concentrations of 2 and 4 microM of indomethacin were effective at 4 and 2 hours (p0.05), respectively. However, inhibition was not observed beyond 12 hours (p0.05). Indomethacin 8 microM was effective at 1 hour and the inhibition persisted beyond 24 hours (p0.05). Our study demonstrates that aspirin and indomethacin inhibit PGE2 synthesis in C6 glioma cells and that low-dose aspirin is as effective as high-dose aspirin. This study may encourage future clinical use of low-dose aspirin in the prevention or treatment of brain tumors.

Summary Pulmonary giant cell cancer is a malignant, aggressive, and rare neoplasm. It has the tendency to bleed in the brain. We present a patient with progressive impairment of short-term memory and apathy. Multiple hemorrhagic metastatic tumors in both cerebral hemispheres were found on image examination. Chest computed tomography (CT) showed suspected bronchogenic carcinoma. The left frontal brain tumor was removed, and pulmonary giant cell cancer was proved by pathology. Unfortunately, intracerebral hemorrhages in different locations were found to increase in the following brain computed tomography. A second and a third brain tumor excision were performed. Pathology showed the same metastatic giant cell carcinoma. The clinical course rapidly deteriorated, and the patient's survival duration was about 11 months. This rare case provides us a unique clinical behavior of bleeding tendency, rapid growth, and aggressive characters of this metastatic pulmonary giant cell cancer.

Purpose The prognosis of children with low-grade cerebellar astrocytoma who have partial resection of tumor is largely unpredictable. The purpose of this study was to review the long-term outcome of such patients. Methods The medical charts, imaging findings, operative notes, histopathological reports, and survival times of 12 patients with cerebellar astrocytoma were reviewed. Results Five patients had total resection and seven had partial resection. Nine patients had grade I histology and three patients had grade II. Follow-up duration ranged from 3 to 25 years. Among the seven patients with residual tumor, five had tumor progression, one had arrested tumor growth, and one had spontaneous tumor regression. Five patients with partial resection received radiotherapy and three had malignant transformation of tumor during follow-up. Six patients, including five who had partial resection, underwent a second operation. One patient with partial resection died of pneumonia 23 years after surgery. Conclusions Patients with complete tumor resection had a better prognosis than patients with partial resection. For patients with partial resection, we recommend a “wait and see” policy with surveillance using MRI. The phenomenon of arrested tumor growth and spontaneous tumor regression in patients with cerebellar astrocytoma who have subtotal resection warrants further study.

Tumor-to-tumor metastasis is a well-recognized phenomenon. However, cerebellopontine angle tumor, especially vestibular schwannoma, is a rare location of metastasis, with only six cases being reported previously in English-language literature reviews. We report a case of a 57-year-old woman with underlying breast cancer (T2N3M1, stage IV) who presented with unilateral facial tics, paresthesia and hearing loss, who turned out to have vestibular schwannoma with adenocarcinoma metastasis.