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Background: CNS germinoma, being marker-negative, are mainly diagnosed by histological examination. These tumors predominantly appear in the suprasellar and/or pineal region. In contrast to the suprasellar region, where biopsy is the standard procedure in case of a suspected germ-cell tumor to avoid mutilation to the endocrine structures, pineal tumors are more accessible to primary resection. We evaluated the perioperative course of patients with pineal germinoma who were diagnosed by primary biopsy or resection in the SIOP CNS GCT 96 trial. Methods: Overall, 235 patients had germinoma, with pineal localization in 113. The relationship between initial symptoms, tumor size, and postoperative complications was analyzed. Results: Of 111 evaluable patients, initial symptoms were headache (n = 98), hydrocephalus (n = 93), double vision (n = 62), Parinaud syndrome (n = 57), and papilledema (n = 44). There was no significant relationship between tumor size and primary symptoms. A total of 57 patients underwent primary resection and 54 underwent biopsy. Postoperative complications were reported in 43.2% of patients after resection and in 11.4% after biopsy (p < 0.008). Biopsy was significantly more commonly performed on larger tumors (p= 0.002). Conclusions: These results support the practice of biopsy over resection for histological confirmation of pineal germinoma.

Selective dorsal rhizotomy (SDR) reduces spasticity in children with cerebral palsy (CP). We analyzed potential preoperative predictors of complications after SDR via single-level laminectomy at the conus medullaris. One hundred and forty SDRs performed in children (2–17 years) with CP were included in this retrospective study (March 2016 to July 2019). Of these children, 69% were ambulatory (Gross Motor Functional Classification System (GMFCS) II and III). Variables associated with wound dehiscence and infections, cerebrospinal fluid (CSF) leaks, and prolonged epidural pain management were analyzed statistically. Five children (3.6%) showed prolonged wound healing, which was associated with obesity (BMI z-score ≥ 1.64; odds ratio (OR) 24.4; 95% confidence interval (CI) 3–199; p = 0.003). Two cases (1.4%) had superficial surgical site infections (SSIs), which was associated with obesity (p = 0.004) and thrombocytopenia (

OBJECTIVE Focal cortical dysplasia (FCD) is a common cause of early-onset intractable epilepsy, and resection is a highly sufficient treatment option. In this study, the authors aimed to provide a retrospective analysis of pre- and postoperative factors and their impact on postoperative long-term seizure outcome. METHODS The postoperative seizure outcomes of 50 patients with a mean age of 8 ± 4.49 years and histologically proven FCD type II were retrospectively analyzed. Furthermore, pre- and postoperative predictors of long-term seizure freedom were assessed. The seizure outcome was evaluated based on the International League Against Epilepsy (ILAE) classification. RESULTS Complete resection of FCD according to MRI criteria was achieved in 74% (n = 37) of patients. ILAE class 1 at the last follow-up was achieved in 76% (n = 38) of patients. A reduction of antiepileptic drugs (AEDs) to monotherapy or complete withdrawal was achieved in 60% (n = 30) of patients. Twelve patients (24%) had a late seizure recurrence, 50% (n = 6) of which occurred after reduction of AEDs. A lower number of AEDs prior to surgery significantly predicted a favorable seizure outcome (p = 0.013, HR 7.63). Furthermore, younger age at the time of surgery, shorter duration of epilepsy prior to surgery, and complete resection were positive predictors for long-term seizure freedom. CONCLUSIONS The duration of epilepsy, completeness of resection, number of AEDs prior to surgery, and younger age at the time of surgery served as predictors of postoperative long-term seizure outcome, and, as such, may improve clinical practice when selecting and counseling appropriate candidates for resective epilepsy surgery. The study results also underscored that epilepsy surgery should be considered early in the disease course of pediatric patients with FCD type II.

Objectives The pathophysiology of traumatic brain injury (TBI) largely involves the brains vascular structural integrity. We analyzed the value of an intraoperative cortical indocyanine green (ICG) angiography in patients with severe TBI and acute subdural hematoma who underwent decompressive craniectomy. Methods ICG-derived fluorescence curves of cortex and cerebral vessels were recorded by the use of software integrated into a surgical microscope in 10 patients. The maximum intensity, rise time (RT), time to peak, and residual fluorescence intensity (FI) were estimated from cortical arteries, the parenchyma, and veins. Results ICG-derived fluorescence parameters were correlated with the short-term outcome 3 months after discharge. Five patients had a favorable and 5 an unfavorable outcome. Patients with a favorable outcome showed a significant longer RT in the arteries and a trend towards a significant longer RT in the veins. Overall mean residual FI was 47.5 ± 6.8% for the arteries, 45.0 ± 7% for the parenchyma and 57.6 ± 6% for the veins. The residual FI of the parenchyma and the veins was significantly greater in patients with an unfavorable clinical outcome. Conclusions Patients with an unfavorable clinical outcome showed an altered shape of the ICG-derived fluorescence curve, a shorter increase of the ICG-derived fluorescence intensity in the cortical arteries, and significantly greater residual fluorescence intensity. These observations are likely a correlate of an increased intracranial pressure, a capillary leak, and venous congestion. Intraoperative quantification of the ICG-derived fluorescence might help to appreciate the clinical outcome in patients with severe TBI.

INTRODUCTION CNS germinoma, being marker-negative, are diagnosed by surgical biopsy. Here we evaluate the perioperative status and postoperative complications of patients with pineal germinoma who underwent a primary biopsy or resection, treated according to SIOP CNS GCT 96. METHODS 235 patients with histologically confirmed germinoma were registered, of which 113 were pineal: 55 were biopsied and 58 underwent primary resection. Initial symptoms, tumour size, complications and neurological status were assessed. 111 patients were evaluable. RESULTS Pure germinoma was present in 101 patients; 10 had additional teratoma components. The main clinical symptoms at diagnosis were headache (n=98), hydrocephalus (n=93), double vision (n=62), Parinaud syndrome (n=57) and papilloedema (n=44). Tumour size was documented in 81 patients (50%, 26 subtotal resection CONCLUSION Although surgical techniques have improved within recent decades, these results support the practice of biopsy over resection for histological confirmation of germinoma arising at the pineal site. Supported in part by German Cancer Aid.

Subgroups of ependymoma, especially RELA fusion-positive and posterior fossa type A tumors, are associated with poor prognosis. Curative therapeutic strategies have not yet been identified. We set up a high-throughput drug screening (HTS) pipeline to evaluate clinically established compounds (n=196) in primary ependymoma cultures (n=12). As culturing ependymoma is challenging, assay miniaturization to 1536-well microplates emerged as a key feature to process HTS despite smallest cell numbers. DNA methylation profiling showed that entity and subgroup affiliation from primary diagnosis was maintained in primary cultures, as assessed through molecular neuropathology 2.0 based classification (MNP 2.0, Capper, D. et al., Nature, 2018). A comparison of HTS data of ependymoma and other pediatric brain tumor models (n=48) revealed a remarkable chemoresistance in vitro. However, we identified Neratinib, an irreversible ERBB2 inhibitor, as the most prominent candidate which was preferentially active in a subset of the investigated ependymoma cultures (n=5). Combinatory treatment with Copanlisib, a PI3K inhibitor, was able to overcome resistance to single agent treatment using Neratinib in established cell lines of ependymoma (n=3) and 2/4 primary cultures for which combinatory treatment could be tested. Finally, we validated efficacy of Neratinib combined with Copanlisib in mice bearing ependymoma xenografts which revealed significantly reduced tumor size compared to vehicle-treated animals. In summary, our study demonstrates that HTS may reveal targeted therapies for pediatric brain tumors. Specifically, we found a synergistic interaction of Neratinib and Copanlisib for treatment of ependymoma, thereby providing a novel therapeutic approach in an otherwise largely chemoresistant entity.

Background/Aims Ventriculoperitoneal shunts (VPS) are a mainstay of treatment for hydrocephalus. Morbidity related to infection and dysfunction is well known, whereas data on psychosocial outcome and quality of life are scarce. Our aim was to assess headache burden and shunt-related impact on daily life in children growing up with a VPS. Methods Patients between 3 and 21 years of age were identified and their families were contacted. A set of standardized questionnaires was used to assess headache and quality of life. Results Fifteen patients with a mean age of 12 years agreed to participate in this study. Satisfaction with the VPS and improvement of the patient's condition was reported by 87%. A total of 67% denied negative impact on everyday life, reported a headache less than once a month, and never or rarely miss school. However, 53% take precautions before special activities. Conclusions The results demonstrate that modern VPS systems are tolerated very well and do not per se reduce quality of life. However, patients adapt to the presence of a VPS by avoiding risks and taking precautions. Chronic headache is not a major problem and not necessarily attributed to the VPS. Nevertheless, most patients asked for technical improvements, which might guide future research and the technical development of VPS.

88 Objectives To determine if 18F-FDG (FDG) could replace 67Ga (Ga) for differentiating acute interstitial nephritis (AIN) from acute tubular necrosis (ATN). Methods 50 rats were divided into 3 groups: Controls (10), AIN (20) & ATN (20). Half of the animals in each group were studied with FDG & half with Ga. AIN animals were imaged 14 days after a single injection of 150 mg/kg puromycin aminonucleoside. ATN animals were imaged 8 days after intraperitoneal injection of 6 mg/kg cisplatin. FDG imaging was performed on a micro-PET system 45 min after tail vein injection of 7.4 MBq FDG. Kidney SUV’s were determined. After imaging, organs were removed & kidney/spine tissue counting ratios generated. Renal tissue samples were evaluated by a pathologist for evidence of cellular infiltration. Ga imaging was performed 48 hr after tail vein injection of 3.7 MBq Ga. Static images were acquired at maximum magnification (zoom = 2.19, 5.9 mm/pixel) with a pinhole collimator for 10 min. Regions of interest were drawn around kidneys & adjacent lumbar spine; kidney:spine image count ratios were generated. An experienced Nuclear physician interpreted all images visually. Results For FDG, AIN & ATN SUV’s were significantly higher than Control SUVs, but similar to each other (Table). Tissue analysis results were similar. The reader could distinguish FDG AIN & ATN from Controls, but not from each other. For Ga, kidney:spine ratios were significantly higher for AIN than ATN & Controls, which were similar to each other. Tissue analysis results were similar. The reader could differentiate AIN from ATN & Controls, but not ATN from Controls. Cellular infiltration was predominantly mononuclear, & was significantly higher in AIN than in ATN & Controls (2.3±0.5 versus 0.6±0.5 cells, p=0.002). Conclusions The results indicate that FDG-PET cannot replace Ga for differentiating acute interstitial nephritis from acute tubular necrosis.

5-aminolevulinic acid (5-ALA) can be used as an adjunct for the surgery of adult malignant glioma and improves the rate of gross total resection and patient survival. So far, only three casuistic reports of fluorescence-guided surgery used in children have been published. We report our pilot series of 16 pediatric brain tumors treated with 5-ALA.Sixteen patients (mean age 9 years, range 1-16 years) received a standardized 5-ALA dose according to the published protocol after informed parental consent. The fluorescence status (positive versus negative) in correlation with histology as well as blood samples and adverse clinical symptoms were recorded.Histology revealed pilocytic astrocytoma (n = 7), classical medulloblastoma (n = 4), anaplastic astrocytoma (n = 1), glioblastoma (n = 3) and anaplastic ependymoma (n = 1). Positive fluorescence was observed in cases of anaplastic astrocytoma, glioblastoma, and medulloblastoma, respectively. Significant increases were registered for alanine aminotransferase (14.92 ± 1.106 U/l vs. 37.70 ± 3.795 U/l, P = 0.0020) and gamma glutamyl transpeptidase (12.69 ± 1.638 U/l vs. 39.29 ± 6.342 U/l, P = 0.0156), correlated with young age. No further adverse reactions were evident.Positive fluorescence was observed in two high-grade gliomas and one medulloblastoma after oral administration of 5-ALA. Thus, 5-ALA appears capable of inducing fluorescence in pediatric high-grade tumors. Adverse reactions observed in children were similar to those reported for adults, although very young children might be at increased risk. Further studies are required to elucidate pharmacokinetic and pharmacodynamic properties of 5-ALA in children and to assess its prognostic role in the resection of pediatric brain tumors.

Previous studies have established risk factors for ventriculoperitoneal shunt failure in children. However, the role of valve type as a determinant of complications and outcome remains unclear. The aim of this study was to compare the fixed-pressure paediGAV and the programmable Codman Hakim valves in the clinical setting. We conducted a retrospective review of patients younger than 16 years who underwent primary implantation of a ventriculoperitoneal shunt with either valve type at our institution between January 2005 and December 2010. Shunt survival analyses were performed to identify variables associated with risk of shunt failure. Of the 44 patients in the paediGAV cohort, 50 % reached the endpoint of shunt failure with a mean time to shunt failure of 7 months. The Codman Hakim cohort comprised 29 patients, of which 55 % experienced shunt failure with a mean time to shunt failure of 8 months. Stratified analyses identified young age at implantation and posthemorrhagic hydrocephalus as risk factors for shunt failure. Shunt survival analysis revealed no significant difference with regard to valve type. This study confirmed important risk factors for shunt failure in children. Despite certain limitations and biases, similar findings for both valves examined in the clinical setting were obtained. Thus, valve type does not seem to influence risk of shunt failure. Prospective, randomized, and controlled trials are required to validate these results.

Ependymoma is the third most common brain tumor in children. Subsets of ependymomas, in particular RELA fusion-positive supratentorial ependymomas and posterior fossa type A ependymomas, are associated with frequent recurrence and dismal outcome. Neurosurgical resection and radiotherapy are the main therapeutic options, while response to conventional chemotherapy is limited. We aimed to establish a high-throughput drug screening (HTS) pipeline for comprehensive individualized testing of patient-derived primary cultures to identify novel therapeutic targets for ependymomas. Ependymoma primary cultures (n=6) were established following tumor resection and underwent HTS in 1536-well plates to allow large-scale drug screening despite limited cell numbers. We generated dose-response data with 9 dilution steps (dose range 32.5nM to 25µM) for a clinical inhibitor library (n=196) comprising established chemotherapeutic agents and novel anti-cancer compounds currently in phase III and IV studies. The Infinium MethylationEPIC Array was used to characterize primary tumors and matched primary cultures genomically and epigenetically. DNA methylation and copy number profiles revealed that short-term primary cultures faithfully recapitulate the genomic and epigenetic landscape of the corresponding primary tumors. Comparison of drug response data from ependymomas, other pediatric brain tumors (n=25) and controls (i.e. non-neoplastic neural progenitor cells) confirmed extraordinary chemoresistance of ependymomas but also revealed promising selectively active drugs, such as neratinib, an irreversible ERBB2 inhibitor. Thus, our data demonstrate the feasibility of HTS in primary cultures derived from pediatric brain tumors and provide preclinical evidence suggesting inhibition of ERBB2 as a promising therapeutic option in a subset of otherwise highly chemoresistant ependymomas.

Spinal solitary epidural cavernous angiomas are rare benign vascular malformations, which occur even less frequently in children than in adults. It is uncommon to find such lesions without adjacent vertebral involvement. Occasionally, these lesions can lead to neurological symptoms through growth or due to intralesional hemorrhage. In this report the authors describe 2 children presenting with acute symptoms and neurological deficits caused by hemorrhage within solitary spinal epidural cavernous angiomas. A 13-year-old girl and a 9-year-old girl, previously healthy, were admitted to the authors' department due to acute radicular pain and neurological deficits. In both cases MR imaging revealed a solitary epidural mass with signs of bleeding and compression of the spinal cord. Complete resection of the lesion via a dorsal approach was performed in both patients. The histological examination of the lesions revealed the characteristic structures of a cavernous angioma with hemosiderin deposits and acute hemorrhage. Both patients recovered fully after surgical removal of the lesions. Review of the literature confirmed that spinal epidural cavernous angiomas are extremely rare in the pediatric patient population, described currently in only 2 instances, but without acute hemorrhage. These cases suggest that epidural cavernous angiomas also have to be considered in the pediatric patient population in the differential diagnosis of intraspinal lesions with acute or progressive neurological symptoms. Microsurgical resection of these cavernous malformations is an effective and curative treatment option.

Pineal cysts are benign and often asymptomatic intracranial entities. Occasionally they can lead to neurological symptoms through growth or due to intracystic hemorrhage. The purpose of the current report is to describe their clinical characteristics and treatment options. In the current study, the authors illustrate the course of disease in 3 patients who developed neurological symptoms due to hemorrhage into a pineal cyst. Two of their patients had additional cerebral disease, and regular MR imaging examinations were conducted. This circumstance allowed documentation of growth and intracystic hemorrhage. After the occurrence of new neurological symptoms with severe headache, MR images showed a fluid-fluid interface due to intracystic hemorrhage. The third patient presented with acute triventricular hydrocephalus and papilledema due to aqueductal stenosis caused by intracystic hemorrhage. In all 3 cases, excision of the pineal cysts via an infratentorial/supracerebellar approach was performed. Histological examination revealed the characteristic structure of pineal cyst in all cases, with hemorrhagic residues in the form of hemosiderin deposits. All patients recovered fully after surgical removal of the cysts. Furthermore, resolution of occlusive hydrocephalus could be demonstrated in those cases with ventricular enlargement. Pineal cysts without neurological symptoms are often discovered as incidental findings on cranial MR images. In contrast, neurological symptoms such as severe headache, diplopia, or Parinaud syndrome, may occur as a result of pineal apoplexy due to intracystic hemorrhage. The authors' cases confirm that MR imaging can identify intracystic hemorrhage by a characteristic fluid-fluid interface. Their experience suggests that microsurgical resection of cysts may be an effective and curative treatment option.

Objective: Cerebrospinal fluid (CSF) shunt failure in pediatrics is related to additional severe morbidity, an increase of procedures, radiation exposure and duration of hospital stay. Misplacement of ventricular catheters up to 40% using the freehand technique is considered as one major risk factor[for full text, please go to the a.m. URL], 65. Jahrestagung der Deutschen Gesellschaft für Neurochirurgie (DGNC)

Haemangiomas are very frequent benign spinal tumours. However, pure epidural location is extremely rare. At present, only 52 cases have been reported in the literature during the last 10 years. We proposed to analyse clinical and radiological features of this rare entity treated in a tertiary care centre over the last 10 years.A study of a retrospective surgical series (2002-2012) was conducted. The clinic's electronic database was searched for "spinal" and/or "vertebral haemangiomas", which were treated by surgery and/or vertebroplasty. Clinical, radiological and histopathological data were analysed.In total, the series comprised 30 spinal haemangiomas. There were 6 epidural (20 %), 17 vertebral (57 %) and 7 intradural lesions (23 %). There were four men and two women, mean age 28.3 years, with epidural lesions. One patient presented with localised back pain only, two with radiculopathy and focal neurological deficit, two with radiculopathy only and one with isolated focal neurological deficit, respectively. The onset of symptoms was progressive in four cases over weeks to months and sudden in two cases. Preoperative MRI imaging revealed features of meningioma, neurinoma or metastasis.Epidural haemangiomas are extremely rare spinal lesions. They may mimic more common spinal tumours clinically and radiologically. The usual treatment is gross total resection confirming the diagnosis histologically.

Providing high accuracy is crucial in neurosurgery especially for resection of deep seated small cerebral pathologies such as cavernous angiomas. The goal of the present series was to reevaluate the feasibility, accuracy, efficacy and safety of frame-based, stereotactically guided resection for patients suffering from small deep-seated cavernous angiomas. Additionally a review of the literature on navigational tools in cavernoma surgery is provided comparing different navigation strategies.Ten patients with deep-seated, small intracranial, cavernous angiomas being subject to frame-based, stereotactically aided resection are included in this survey. Based on the stereotactic-fused image, set entry and target point aimed at the rim of the cavernoma were calculated. A minicraniotomy (3 cm in diameter) was performed followed by positioning of the stereotactic needle. Following the needle in situ the cavernous angioma was localized and resected. Assets and drawbacks of the stereotactic-aided approach were evaluated, patients were analyzed for surgery-related neurological deficits and completeness of resection.Complete resection was achieved in all ten patients verified by post-surgery MRI imaging. The surgical procedure itself was only slightly aggravated by the stereotactic equipment. No adverse events such as bleedings or infections were observed in our series.Stereotactically guided, minimally invasive resection of deep seated and small cavernous angiomas is accurate and effective. The frame-based stereotactic guidance requires some additional time and effort which seems justified only for deep seated and small cavernous angiomas. Frameless neuronavigation is a common tool in cavernoma surgery and its spatial resolution is sufficient for the majority of cases.

Lower cranial nerve schwannomas are benign tumors of the neurolemmocytes of the cranial nerves. Among children, cranial nerve schwannomas are extremely rare and are predominantly associated with neurofibromatosis (NF) type 2. The purpose of the current case report is to describe a unique giant extra- and intracranial foramen jugular schwannoma in a young boy with lower cranial nerve deficits and glossopharyngeal neuralgia syncope syndrome and to review the pertinent literature. In the current case report, we illustrate the course of disease in a 14-year-old boy with a 4-month history of recurrent syncope and a big bulge on the left side of his neck. Audiometry showed deafness of the left ear. Magnetic resonance imaging (MRI) demonstrated a giant unilateral dumbbell-shaped intra- and extracranial foramen jugular schwannoma with a volume of 156 cm3 causing severe brain stem compression and obstructive hydrocephalus. The tumor was removed completely in a two-step surgery. The tumor was confirmed during surgery to originate from the glossopharyngeal nerve. The histological examination revealed the characteristic features of a schwannoma. The MRI 3 months after the second surgery confirmed complete tumor removal. The genetic examination for NF was negative. Review of literature showed that dumbbell-shaped lower cranial nerve schwannomas in the childhood population are rare.

Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany, Background The goal of the present study was to analyze the epidemiology and specific risk factors of traumatic brain injury (TBI) in the Asterix illustrated comic books. Among the illustrated literature, TBI is a predominating injury pattern. Methods A retrospective analysis of TBI in all 34 Asterix comic books was performed by examining the initial neurological status and signs of TBI. Clinical data were correlated to information regarding the trauma mechanism, the sociocultural background of victims and offenders, and the circumstances of the traumata, to identify specific risk factors. Results Seven hundred and four TBIs were identified. The majority of persons involved were adult and male. The major cause of trauma was assault (98.8%). Traumata were classified to be severe in over 50% (GCS 3–8). Different neurological deficits and signs of basal skull fractures were identified. Although over half of head-injury victims had a severe initial impairment of consciousness, no case of death or permanent neurological deficit was found. The largest group of head-injured characters was constituted by Romans (63.9%), while Gauls caused nearly 90% of the TBIs. A helmet had been worn by 70.5% of victims but had been lost in the vast majority of cases (87.7%). In 83% of cases, TBIs were caused under the influence of a doping agent called “the magic potion”. Conclusions Although over half of patients had an initially severe impairment of consciousness after TBI, no permanent deficit could be found. Roman nationality, hypoglossal paresis, lost helmet, and ingestion of the magic potion were significantly correlated with severe initial impairment of consciousness (p≤0.05)., Department for Neurosurgery, Acta Neurochir (2011) 153:1351–1355 Bitrate :163 KB

BACKGROUND: Experience regarding the use of dynamic O-(2-[18F]-fluoroethyl)-L-tyrosine (18F-FET) PET in children and adolescents with brain tumors is limited. METHODS: Sixty-nine 18F-FET PET scans of 49 patients (median age, 13 years; range, 1-18 years) were analyzed retrospectively. Patients had been referred for: (A) assessment of newly diagnosed cerebral lesions (26 scans in 26 patients), (B) diagnosing tumor progression/recurrence (24 scans in 18 patients), (C) monitoring of chemotherapy effects (8 scans in 4 patients), and (D) the detection of residual tumor tissue after resection (11 scans in 10 patients). Maximum and mean tumor/brain ratios (TBRmax/mean) of 18F-FET uptake were determined (20-40 min p.i.) and time-activity curves were generated and assigned to one of the following patterns: (1) constantly increasing uptake, (2) uptake peaking at a midway point (>20-40 min) followed by a plateau, and (3) uptake peaking early (≤20 min) followed by a constant descent. The diagnostic values of TBRs and kinetic parameters to detect neoplastic tissue or diagnose tumor progression/recurrence were assessed using ROC analyses. Diagnoses were confirmed histologically and/or by clinical course. RESULTS: In patients with newly diagnosed cerebral lesions, highest accuracy (77%) to detect neoplastic tissue (7 of 26 patients) was obtained when TBRmax was >1.7 (AUC, 0.80 ± 0.09; sensitivity, 79%; specificity, 71%, PPV, 88%; P = 0.02). For diagnosing tumor progression/recurrence, highest accuracy (82%) was obtained when curve patterns 2 or 3 were present (AUC, 0.80 ± 0.11; sensitivity, 75%; specificity, 90%, PPV, 90%; P = 0.02). During chemotherapy, a decrease of TBRs was associated with a stable clinical course at least for 6 months. In patients after complete tumor resection (2 of 10 patients), 18F-FET PET detected metabolically active tumor (TBRmax ≥ 1.7). CONCLUSIONS: Our findings suggest that 18F-FET PET can add valuable information for clinical decision-making in pediatric brain tumor patients.

Dear Editor,Thank you very much for giving us the opportunity to replyto the comment on our article by Nikolas Lloyd.We really appreciate such comments—especially thosewhich make an effort to improve the standard of science.Thus, the study design and the follow-up were criticized byNikolas Lloyd, and it was suggested to make controlexaminations at 1 and 3 months as well as 2 years. Further, adouble-blinded test was recommended to test effects of themagicpotion(magicpotionvsplacebo).Indeed,thelimitationsofthestudyabouttraumaticbraininjuries(TBIs)intheAsterixcomic books arise from its retrospective study design and theinsufficient follow-up, as emphasized in the “Discussion” ofthe article [1]. Undoubtfully, prospective double-blindedstudies are commonly believed to have greater scientificimpact than retrospective studies with an inconsistent follow-up. Therefore, even medical “Christmas articles” weredesigned as meta-analyses [ 2]. However, characters analysedin the present paper took drugs (the magic potion) in the year50 B.C. and suffered from TBIs in the same year. For us, itwas very difficult to design a study analysing those patientswith follow-up examinations (at 1 and 3 months as well as2 years) in the year 2011 A.D.However,ourarticleaboutTBIsintheAsterixcomicbookswas meant as a Christmas article, even though it was actuallypublished by Acta Neurochirurgica at Easter. Christmasarticles have a tradition in medicine and are frequentlypublished, e.g. by the British Medical Journal [2]. Therefore,our study about TBIs in Asterix comic books was meantneither seriously nor purely as a joke. Besides, our studymight help to focus public attention on TBIs as an importantfield of our daily activities and a leading cause of morbidityand mortality. Further studies on TBI might not only lead to abetter understanding of TBI in Asterix comics but —moreimportantly—might lead to new insights and perhapssubsequently to new therapeutic opportunities for patientssuffering from TBIs.