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Subependymal giant cell tumor (SGCT) is a benign intraventricular tumor, usually located near the foramen of Monro. It is almost always associated with tuberous sclerosis complex (TSC). SGCTs may obstruct cerebrospinal fluid (CSF) pathways. Rarely, they may secrete a protein-rich exudate, causing communicating hydrocephalus. Surgery is indicated for symptomatic lesions or growing asymptomatic lesions. The operative approach to SGCT has shifted from simple shunt placement to a more aggressive approach, leading to early attempts at gross total resection. Recently, the mTOR inhibitor everolimus has been approved for treating SGCT. In this article, we present two cases of recurrent shunt malfunctions in adult TSC patients with protein-secreting SGCTs. We describe the complexity of treating such patients with an emphasis on the role mTOR inhibitors may have in their management. We also review the literature on surgical management of SGCT-related hydrocephalus.

To examine the visual outcome of anterior visual pathway meningioma (AVPM) patients followed for at least one year.Data were collected on demographics, clinical course and management. Visual disability was classified at the first and last examination as follows: I--no visual disability; II--mild visual defect in one eye; III--mild visual defect in both eyes; IV--loss of driver's license; V--legally blind.Eight-one AVPM patients had their tumor originate in the clinoid process in 23 (28%), sphenoid-wing area in 18 (22%), cavernous sinus in 15 (19%), tuberculum sellae in 8 (10%), and mixed in 17 (21%). On last examination, 46 patients (57%) had good visual acuity in one or both eyes (Class I or II) and 17 (21%) were mildly affected in both eyes. The rate of Class IV disability was 16%, and Class V disability was 6%.Attention needs to be addressed to the considerable proportion of patients with AVPM (22% in this study) who may lose their driver's license or become legally blind. Occupational therapists should play an important role in the multidisciplinary management of those patients to help them adapt to their new physical and social situation.Anterior visual pathway meningiomas (AVPMs) are commonly not life-threatening but they can lead to profound visual disability, especially when the tumor originates in the tuberculum sellae and cavernous sinus. Particular attention should be paid to visual acuity and visual field deficits, as these can profoundly affect the patient's quality of life including ability to drive and activities of daily living. The interdisciplinary management of patients with AVPM should include the neurosurgeon, neuro-ophthalmologist and occupational therapist. Also, early intervention by the occupational therapist can help patients adapt to their current physical and social situation and return to everyday tasks more rapidly.

One of the complications of untreated acute subdural hemorrhage (aSDH) is the late development of chronic subdural hematomas (cSDH). cSDH may cause major neurologic deficits, requiring their surgical evacuation. The aim of our work was to find risk factors for the development of significant cSDH requiring surgery following conservative treatment of trauma-related aSDH.In a retrospective manner, we analyzed the data of 95 adult patients admitted with a non-surgical, traumatic aSDH. The patients were divided into two groups. The first group contained 52 patients who did not, on follow-up, develop cSDH requiring surgery. The second group contained 43 patients who ended up with a significant cSDH, based on clinical and radiological criteria, requiring surgical evacuation. Data acquisition and comparison between the two groups was performed by analyzing the patients' charts for diverse medical conditions and other trauma-related parameters.The operation rate was significantly higher in patients with medical history of ischemic heart disease (IHD) or hypertension (66.7% vs. 38%, p = 0.019 and 56.9% vs. 20%, p0.01, respectively), with a 4-fold increase in the risk for developing surgical cSDH in patients with IHD and a 6-fold increase in the risk in patients with hypertension (odds ratio 4.2 [95% CI for odds, 1.3-13.1] and 5.9 [95% C.I for odds, 1.6-21.5], respectively). Among 21 patients, 20 (95%) patients, who were either on more than 1 anti-aggregant agents (AAA), used Clopidrogrel, or took anti-coagulant drug were in the operative group (OG). A larger initial thickness of the aSDH was statistically significant in the OG as compared to the non-OG (8.9 mm ± 4.6 vs. 5.5 mm ± 2.1, p0.001).Head-trauma patients with a medical history of IHD or hypertension, patients on more than one AAA or anti-coagulant agents and patients with worse initial CT scan parameters are at risk of developing significant cSDH requiring surgery after conservative treatment of aSDH and consequently should have closer follow-up.

Purpose Meningiomas threatening the anterior visual pathways (AVPs) and not amenable for surgery are currently treated with multisession stereotactic radiotherapy. Stereotactic radiotherapy is available with a number of devices. The most ubiquitous include the gamma knife, CyberKnife, tomotherapy, and isocentric linear accelerator systems. The purpose of our study was to describe a case series of AVP meningiomas treated with linear accelerator fractionated stereotactic radiotherapy (FSRT) using the multiple, noncoplanar, dynamic conformal rotation paradigm and to compare the success and complication rates with those reported for other techniques. Patients and Methods We included all patients with AVP meningiomas followed up at our neuro-ophthalmology unit for a minimum of 12 months after FSRT. We compared the details of the neuro-ophthalmologic examinations and tumor size before and after FSRT and at the end of follow-up. Results Of 87 patients with AVP meningiomas, 17 had been referred for FSRT. Of the 17 patients, 16 completed >12 months of follow-up (mean 39). Of the 16 patients, 11 had undergone surgery before FSRT and 5 had undergone FSRT as first-line management. Tumor control was achieved in 14 of the 16 patients, with three meningiomas shrinking in size after RT. Two meningiomas progressed, one in an area that was outside the radiation field. The visual function had improved in 6 or stabilized in 8 of the 16 patients (88%) and worsened in 2 (12%). Conclusions Linear accelerator fractionated RT using the multiple noncoplanar dynamic rotation conformal paradigm can be offered to patients with meningiomas that threaten the anterior visual pathways as an adjunct to surgery or as first-line treatment, with results comparable to those reported for other stereotactic RT techniques.

Object Convection-enhanced delivery (CED) is a novel intracerebral drug delivery technique with considerable promise for delivering therapeutic agents throughout the CNS. Despite this promise, Phase III clinical trials employing CED have failed to meet clinical end points. Although this may be due to inactive agents or a failure to rigorously validate drug targets, the authors have previously demonstrated that catheter positioning plays a major role in drug distribution using this technique. The purpose of the present work was to retrospectively analyze the expected drug distribution based on catheter positioning data available from the CED arm of the PRECISE trial. Methods Data on catheter positioning from all patients randomized to the CED arm of the PRECISE trial were available for analyses. BrainLAB iPlan Flow software was used to estimate the expected drug distribution. Results Only 49.8% of catheters met all positioning criteria. Still, catheter positioning score (hazard ratio 0.93, p = 0.043) and the number of optimally positioned catheters (hazard ratio 0.72, p = 0.038) had a significant effect on progression-free survival. Estimated coverage of relevant target volumes was low, however, with only 20.1% of the 2-cm penumbra surrounding the resection cavity covered on average. Although tumor location and resection cavity volume had no effect on coverage volume, estimations of drug delivery to relevant target volumes did correlate well with catheter score (p < 0.003), and optimally positioned catheters had larger coverage volumes (p < 0.002). Only overall survival (p = 0.006) was higher for investigators considered experienced after adjusting for patient age and Karnofsky Performance Scale score. Conclusions The potential efficacy of drugs delivered by CED may be severely constrained by ineffective delivery in many patients. Routine use of software algorithms and alternative catheter designs and infusion parameters may improve the efficacy of drugs delivered by CED.

The aim of this study was to evaluate the efficacy of an intraoperative monitoring hearing preservation strategy that includes simultaneous recordings of an auditory brainstem response (ABR) and non-invasive electrocochleography (ECochG). The combined ABR and tympanic membrane (TM) ECochG testing was performed in 74 patients undergoing acoustic neuroma (AN) surgery. In addition, EMG recordings were conducted to monitor the facial nerve function. Hearing was preserved in 19 of the 30 patients with residual hearing prior to surgery (63%), and facial nerve function was maintained in 89% of the patients. In most cases, the presence of both auditory brainstem and TM-ECochG responses at the end of surgery was associated with preservation of postoperative functional hearing; however, eight patients had a TM-ECochG response with a complete loss of the ABR, pointing to deafferentation of the auditory nerve. Tumour size and preoperative hearing thresholds significantly affected the postoperative hearing. The TM-ECochG response yielded large reproducible responses, which, in some patients, was the only way to monitor the auditory function. This auditory monitoring approach offers a valuable auditory tool that helps to improve the hearing preservation during AN surgery.

Background: Glial brain tumors span a wide range of neoplasms with distinct clinical and histopathological features. This report presents the descriptive epidemiology of glial tumors by histological subtype and tumor behavior. Methods: The study population included all incident cases of glial tumors diagnosed in Israel during March 2001 to July 2003. Age-standardized incidence rates (ASR) were calculated using the world population as a standard. Results: A total of 548 tumors were diagnosed, of which 520 had histological confirmation. The ASR of all adult (>20 years) glial tumors was 5.82/100,000 (7.11 for males; 4.75 for females, p < 0.001). The majority of tumors (78%) were classified as high grade; astrocytic tumors were the most frequent (85%), with glioblastoma multiforme accounting for 70% of them. A significant positive association was shown between age at diagnosis and grade. The highest ASR was seen for Europe- and-American-born, followed by Israeli, Asian and African-born individuals (6.78, 5.86, 4.94 and 3.84/100,000, respectively). Conclusions: In general, these results describing data of incident cases of pathologically validated glial tumors are consistent with previous reports. To enhance our understanding of these diseases, epidemiological studies should rely on well-defined histological tumor types, incorporating comprehensive information which will allow comparability between different groups of patients.

To test the benefit of hydroxyurea in the treatment of recurrent and non-resectable slow-growing meningiomas.Twelve patients with regrowing non-malignant meningiomas, were enrolled for a protocol of 2 years with continuous chemotherapy with hydroxyurea, 20 mg/kg/day. Response to treatment was evaluated both clinically and by diagnostic imaging using computed tomography (CT) and 201-Thallium single photon emission CT. One minimal response was documented by CT, accompanied by clinical stabilization. Nine patients showed progressive disease, at least by one imaging procedure, with a median time to progression of 13 months (range 4-24). Two other patients were not available for response due to early removal from the study, following abrupt manifestation of grades 3-4 hematological toxicity.In this series hydroxyurea has not shown effectiveness in the treatment of non-resectable slow-growing meningiomas: neither for achieving response, nor for arresting disease progression.

Cancer cells of different solid and hematopoietic tumors express growth factors in respective stages of tumor progression, which by autocrine and paracrine effects enable them to grow autonomously. Here we show that the murine B16 melanoma cell line and two human primary cultures of stomach adenocarcinoma and glioblastoma multiforme (GBM) constitutively secrete interleukin (IL)-10 in an autocrine/paracrine manner. This cytokine is essential for tumor cell proliferation because its neutralization decreases clonogenicity of malignant cells, whereas addition of recombinant IL-10 increases cell proliferation. The immunomodulator ammonium trichloro(dioxoethylene-o,o′)tellurate (AS101) decreased cell proliferation by inhibiting IL-10. This activity was abrogated by exogenous addition of recombinant IL-10. IL-10 inhibition by AS101 results in dephosphorylation of Stat3, followed by reduced expression of Bcl-2. Moreover, these activities of AS101 are associated with sensitization of tumor cells to chemotherapeutic drugs, resulting in their increased apoptosis. More importantly, AS101 sensitizes the human aggressive GBM tumor to paclitaxel both in vitro and in vivo by virtue of IL-10 inhibition. AS101 sensitizes GBM cells to paclitaxel at concentrations that do not affect tumor cells. This sensitization can also be obtained by transfection of GBM cells with IL-10 antisense oligonucleotides. Sensitization of GBM tumors to paclitaxel (Taxol) in vivo was obtained by either AS101 or by implantation of antisense IL-10-transfected cells. The results indicate that the IL-10 autocrine/paracrine loop plays an important role in the resistance of certain tumors to chemotherapeutic drugs. Therefore, anti-IL-10 treatment modalities with compounds such as AS101, combined with chemotherapy, may be effective in the treatment of certain malignancies.

Summary: The outcome of patients harboring intracranial abscesses has improved in the last decade as a result of improvement in imaging technologies, the introduction of potent antibiotics that penetrate the blood–brain barrier more readily, and minimally invasive surgical techniques with the possibility of image and real-time guidance. These therapeutic advances have, however, been counterbalanced by the increase in immunocompromised patients with pathogens that are more aggressive and difficult to eradicate. This review highlights the current approach to the diagnosis and treatment of intracranial abscesses, emphasizes pitfalls in management, and discusses dilemmas in treatment strategies. Key Words: Brain abscess—Intracranial infection— Surgery—Imaging—Antibiotics—Complications—Outcome.

To establish the safety of intravenous dexanabinol in severe head injury.Prospective, randomized, double-blind, placebo- (vehicle) controlled, multicenter, escalating dose study of a single administration of drug (48 or 150 mg) or vehicle (1 or 3 mL).All Israeli neurosurgical intensive care units (a total of six units).Sixty-seven patients, aged 16-65 yrs, Glasgow Coma Scale score of 4-8, injured within 6 hrs of treatment.Intracranial pressure, cerebral perfusion pressure, blood pressure, and heart rate were measured continuously in the intensive care unit. Adverse medical events were recorded and clinical outcome was assessed by the Glasgow outcome scale throughout a 6-month follow-up period. A highly significant reduction in the percentage of time with intracranial pressure25, cerebral perfusion pressure50, and systolic blood pressure90 mm Hg was observed in the drug-treated group. The nature and incidence of adverse medical events were similar in the two groups. The percentage of patients achieving good neurologic outcome on the Glasgow outcome scale was 21% and 14% higher in the drug-treated group at 3 and 6 months, respectively. Statistical analysis of these differences by a logistic model using dose, entry Glasgow coma scale score, and computed tomograph as covariates yielded p values for the effect of treatment of .03 and .14 at 3 and 6 months, respectively.Dexanabinol was safe and well tolerated in severe head injury. The treated patients achieved significantly better intracranial pressure/cerebral perfusion pressure control without jeopardizing blood pressure. A trend toward faster and better neurologic outcome was also observed.

Ionizing irradiation to the skull is a known risk factor for meningioma development. To gain insight into the molecular mechanisms that underlie radiation-associated meningioma (RAM), we characterized the somatic genetic alterations in 16 RAMs by using comparative genomic hybridization and compared the pattern of alterations with 17 nonradiation-associated meningiomas (non-RAM). Most tumors (29/33;87.9%) displayed at least one DNA copy number alteration, and 11 out of 33 (33%) exhibited four or more changes. The mean number of DNA copy number changes was similar in RAMs (2.4+/-1.9) and in non-RAMs (2.5+/-1.9). The most common DNA losses were noted in chromosome 22 (56.2% in RAM, and 47% in non-RAM) and chromosome 1 (37.5% in RAM and 35.3% in non-RAM), with no significant differences between the two groups. Noteworthy, gain in DNA copy number of chromosomes 8 and 12 was detected in two RAM tumors only. In conclusion, no significant differences were noted between RAMs and non-RAMs regarding the number of genetic changes and the extent and frequency of chromosomes 1 and 22 losses. These preliminary data suggest that the tumorogenic pathways of meningioma formation are similar, regardless of previous skull irradiation.

✓ The authors report on a young woman with Ehlers—Danlos syndrome (EDS) Type IV in whom a spontaneous direct carotid—cavernous fistula (CCF) was treated by transvenous occlusion with regular and fiber-coated Guglielmi detachable coils. To the authors' knowledge, this is the first time this approach has been used in a patient with EDS. The different treatment options are discussed, and the literature on endovascular treatment of direct CCFs in EDS is reviewed.

Multilevel laminectomy to open the spinal canal carries the risk of spinal deformities and instability. With the aim of preserving and reconstructing the posterior structures the authors developed a novel, minimally invasive, multilevel spinous process splitting and distracting laminotomy approach with or without complementary corticocancellous iliac crest or PEEK cage “archbone” grafting. The technique allows exploration of the spinal canal and the removal of intramedullary pathologies. Moderate enlargement of the spinal canal with preservation of the majority of posterior structures is also possible, so that muscle attachments remain intact and postoperative complications are substantially reduced.

Nowadays meningiomas are frequently detected incidentally. Their natural history has not yet been established because it is difficult to predict the growth pattern. Therefore, the management, after the radiological diagnosis, is still controversial.To evaluate the clinical outcome and growth rate of conservatively treated meningiomas at our tertiary center, identify prognostic factors of tumor growth, and suggest guidelines based on the available data and our experience.We reviewed the clinical records of 56 patients with 63 untreated meningiomas. Most were diagniosed incidentally. Clinical features and imaging findings at diagnosis and during follow-up were compared between growing and non-growing tumors. Potential patient- and tumor-related predictive factors for growth were analyzed.The study group included 46 women (52 meningiomas) and 10 men (11 meningiomas) aged 39-83 years. Mean tumor size was 18 +/- 11 mm (range 3-70 mm) at diagnosis and 22 +/- 11 mm (range 8-70 mm) at last follow-up; mean follow-up time was 65 +/- 34 months (range 15-152 months). During follow-up 24 tumors (38%) grew ata rate of 4 mm per year; none became symptomatic. Only two prognostic factors were statistically significantly associated with low growth rate: older age and tumor calcifications.Given our finding of a low growth incidence of meningiomas in the elderly, we support conservative management in patients aged 70 years or older. Calcifications into the meningioma are also indicative of slow growth, suggesting a conservative strategy. Surgery is recommended in younger patients in whom tumor growth occurs more often and a longer follow-up is necessary.

The issue of free will is at the heart of understanding ourselves, what it means to be a conscious, thinking, and responsibly acting human being. A position on this issue has profound implications on how we see ourselves as moral agents and on our place in the universe. The developments in neuroscience over the last half century have provided us with much data concerning the function of the brain and its relationship to the mind. In this article we shall review contributions of both neurosurgeons and other neuroscientists to our understanding of free will. The volitional motor model will be emphasized for heuristic purposes. Ultimately, by understanding the limits of our freedom, we can enhance our concept of the meaning of our lives.

We studied retrospectively 143 adult patients treated in our department from 1979 to 1991 for chronic subdural haematoma (SDH) in order to identify the incidence of seizures and the necessity for prophylactic anticonvulsant treatment. Furthermore, after review of the literature, we selected an additional 879 cases for comparison. Results indicated a low incidence of epilepsy. Before surgery 5.6% of patients in our series and 4.3% in the literature had epilepsy, whereas after surgery, the frequencies were 3% and 1.8%, respectively. According to our data, antiepileptic drugs need not be administered prophylactically in patients with chronic SDH. But the situation is different for alcoholic patients, because they have a major risk of epilepsy.

Objective: To evaluate the nasal complications after transnasal transsphenoidal operations for pituitary tumors, comparing two surgical techniques: traditional sublabial transseptal and endoscopic transseptal techniques. Study Design: We retrospectively evaluated by self-reported questionnaire and endoscopic examination the nasal condition of 40 consecutive patients with pituitary tumors: 20 patients had endoscopic surgery and 20 had surgery with the traditional sublabial technique. Results: Compared with the traditional technique, the endoscopic approach was associated with a shorter operative time (about 40 min), shorter hospitalization time (about half), absence of recurrent epistaxis snoring and denture problems, and lower incidence of septal perforation, synechia, and crust formation. Furthermore, loss of nasal tip projection was found only in the group that had surgery with the sublabial technique. Conclusions: Endoscopically guided transseptal transsphenoidal surgery is simple to perform and time-saving, and it results in fewer nasal and denture complications than the sublabial technique. At the same time, it allows the surgeon all the benefits of the binocular microscopic surgical field that are associated with the traditional approach.

Acute cerebral ischemia increases the generation of free radicals, causing cell damage, and theoretically may decrease the activity of the scavenging enzyme superoxide dismutase. To investigate the role of superoxide dismutase in cerebral ischemia, we used a model of middle cerebral artery occlusion in rats. In this model an infarct is produced in the pyriform and frontoparietal cortices, extending into the lateral basal ganglia. We measured superoxide dismutase activity by using the xanthine oxidase cytochrome c reduction assay in these areas of rat brains. Tissue samples were analyzed 20 minutes, 2, 6, or 24 hours, or 7 days after middle cerebral artery occlusion and 2 or 24 hours or 7 days after sham operation (n = 8-10 at each time). There was no significant change in superoxide dismutase activity relative to control values in any brain area at any time up to 24 hours after surgery. However, 7 days after middle cerebral artery occlusion a significant decline in superoxide dismutase activity, to 55%-68% (p less than 0.05) of that in unoperated controls, was observed in all brain areas. Our results do not support an important role for changes in the activity of endogenous superoxide dismutase during the acute phase of cerebral ischemia. However, the decrease in superoxide dismutase activity 7 days after ischemia could indicate ongoing additional damage to peri-infarct tissue.

In 16th Century Prague, Rabbi Loew created a Golem, a humanoid made of clay, to protect his community. When the Golem became too dangerous to his surroundings, he was dismantled. This Jewish theme illustrates some of the guiding principles in its approach to the moral dilemmas inherent in future technologies, such as artificial intelligence and robotics. Man is viewed as having received the power to improve upon creation and develop technologies to achieve them, with the proviso that appropriate safeguards are taken. Ethically, not-harming is viewed as taking precedence over promoting good. Jewish ethical thinking approaches these novel technological possibilities with a cautious optimism that mankind will derive their benefits without coming to harm.

Cushing's syndrome due to an ACTH-secreting pituitary tumor is associated with serious morbidity and mortality. As there is no definitive medical treatment, surgical removal of the tumor via the transsphenoidal route remains the first choice. Postoperative hypocortisolemia is recognized as the best indicator of cure.To report the postoperative outcome and long-term follow-up of patients with surgically treated Cushing disease at the Rabin Medical Center.We reviewed the medical records of 27 patients with Cushing disease operated on between the period 1990 and 2003. The same experienced surgeon performed all surgeries.Cushing disease accounted for 15% of all pituitary surgeries in our center. The mean age was 46 years, and the female to male ratio was 25:2. Macroadenomas were found in 19% of cases, and a negative MRI in another 19%. The cure rate was 70% overall and 80% when only microadenomas were considered. There were no major perioperative complications. Four out of 8 surgical failures were re-operated, and three achieved cure. After a mean follow-up period of 5.9 years, there was only one recurrence.Our results are in accordance with those reported by others and confirm that in the hands of an experienced neurosurgeon, pituitary surgery constitutes an effective treatment for Cushing disease.

Irradiation to the head is associated with a significantly increased incidence of meningiomas. Radiation-induced meningiomas morphologically resemble their sporadically arising counterparts; however, they frequently exhibit a more malignant phenotype. Several genes have been shown to carry mutations in meningiomas, with the NF2 gene being most frequently affected. To examine whether the NF2 gene also plays a role in the development of radiation-induced meningiomas, we compiled a series of meningiomas from 25 patients with a history of previous cranial radiation. This series was compared with 21 atypical WHO grade II meningiomas and 15 anaplastic WHO grade III meningiomas, all from patients without a history of prior irradiation. NF2 mutations occurred significantly more often in sporadic atypical and anaplastic than in radiation-induced meningiomas (p < 0.02). In addition, all meningiomas were examined for mutations in the PTEN, TP53, HRAS, KRAS and NRAS genes. Two mutations in the TP53 gene in a sporadic and a radiation-induced tumor were detected. PTEN mutations were observed in 1 anaplastic and 1 radiation-induced meningioma. No structural alterations were seen in the RAS genes. Our data suggest that, while there is a certain overlap in the mutational spectrum, NF2 mutations may not play such a prominent role in the pathogenesis of radiation-induced compared to sporadic meningiomas.

Object. Thromboembolic phenomena (TEPs) continue to be a significant source of morbidity and mortality in patients undergoing neurosurgery. Although the efficacy of low-dose heparin in preventing TEPs in neurosurgical patients is well established, neurosurgeons are reluctant to use it perioperatively because of concern for increased bleeding complications. To clarify this issue, the authors used a prospective, randomized, double-blind design to evaluate the safety of minidose heparin treatment in patients undergoing surgery for supratentorial brain tumors. Methods. One hundred three patients, all 40 years of age or older, were treated with either 5000 U of heparin (55 patients) or placebo (48 patients) starting 2 hours before surgery and continuing until full mobilization or for 7 days. Both groups were well matched for sex, weight, duration of surgery, and tumor diagnosis. Subjective and objective parameters were used to estimate and calculate the perioperative bleeding tendency in all patients. Red blood cell mass loss was calculated by assessing the preoperative and postoperative hematocrit and the patient's weight. Intraoperative blood loss was determined by measuring the quantity of blood in the suction containers and subtracting the amount of irrigation fluids. Postoperative bleeding was measured by determining the amount of fluid in the subgaleal drain, and blood cell replacement was monitored during and after the procedure. Intracranial bleeding was graded according to findings on the postoperative computerized tomography scan obtained 48 to 72 hours after surgery. In addition, the senior surgeon in each case was asked to assess each patient's bleeding tendency during the operation. The results showed that perioperative administration of heparin did not significantly alter bleeding tendency by any measured parameter. The surgeon was blinded to which group individual patients had been allocated. Conclusions. Perioperative minidose heparin is safe for use in patients undergoing craniotomy for supratentorial tumors. This relatively simple and inexpensive measure is recommended as a routine regimen for the prevention of TEPs in patients undergoing neurosurgery.

Objective and importance A unique case of spontaneous pneumocephalus is described. It appeared a few years after the uneventful introduction of a cerebrospinal fluid shunt and was probably attributable to a defect of the posterior mastoid plate. Clinical presentation A 65-year-old man presented with a subacute onset of vertigo, vomiting, and atactic gait instability. The patient had undergone a ventriculoperitoneal shunt implantation 2 years previously for communicating hydrocephalus. A computed tomographic scan revealed a posterior fossa pneumatocele without hydrocephalus. Intervention A simple mastoidectomy was performed. Detection of the area of the bone defect was followed by mastoid obliteration with abdominal fat. Conclusion Clinicians should be aware that pneumocephalus can occur spontaneously, with or without obvious shunt problems. Treatment should be directed toward the area through which air penetrated the posterior fossa.

A cerebellar glioblastoma multiforme was diagnosed in a 22-year-old woman. This originated in the zone adjacent to a field irradiated 14 years earlier after the removal of a noncontiguous astrocytoma of the spinal cord. The accepted criteria for radiation-induced tumors of the central nervous system are discussed.

Purpose: In this study we present our findings concerning the dynamics of language modalities in the isolation of the speech area syndrome (ISAS). The aim of the study was to establish: (1) the linguistic characteristic features of this group of patients; (2) the course of dynamics of language of each patient; (3) whether this course of dynamics is common for the whole group; (4) whether the course of dynamics we found matches with the report in the literature. Method: Over a period of 5 years, nine patients with ISAS were diagnosed and treated in our department. They received varying lengths of treatment, and four were followed for 2-6 years after discharge. Results: Despite the common belief that the prognosis for language rehabilitationfor these patients is poor, we found that some ISAS patients improved, even dramatically, after prolonged language treatment. Conclusion: It is hoped that these findings will alter clinicians' attitudes towards these patients, and provide some hope for rehabilitation out...

The harvesting of organs for transplantation is dependent on a stringent definition of brain death. Different societies have had to struggle with their cultural heritage, adapting it to conform to the advances in medical science and the need of the sick. In this article, the development of the concept of brain death as it applies to organ transplantation in Judaism is outlined. The ability of traditional Jewish values to address themselves to the challenges of modern medicine can serve as a basis for cultural cross-fertilization and comparison in modern societies.

M.-J. Chiu, Taipei, Taiwan M.C. Christensen, Bagsvaerd, Denmark A.B. Conforto, Sao Paulo, Brazil L.A. Corey, Richmond, Va., USA G. Corso, Aosta, Italy E. Cubo, Madrid, Spain A. Culebras, Syracuse, N.Y., USA R. D’Alessandro, Bologna, Italy J.-F. Dartigues, Bordeaux, France F. Davis, Chicago, Ill., USA M. Debouverie, Nancy, France L.M. de Lau, Rotterdam, The Netherlands V. Demarin, Zagreb, Croatia J. de Pedro Cuesta, Madrid, Spain R.K. Dhamija, New Delhi, India O. Dogu, Mersin, Turkey Y. Doi, Wako, Japan W.J. D’Souza, Melbourne, Vic., Australia A. Elbaz, Paris, France M. Elias, Orono, Me., USA A.W. Engberg, Hellerup, Denmark J.M. Ferro, Lisbon, Portugal J.L. Fisher, Columbus, Ohio, USA M. Flaherty, Dublin, Ireland G. Franklin, Seattle, Wash., USA P.D. Frenzen, Washington, D.C., USA G. Friday, Wynnewood, Pa., USA R. Friedland, Cleveland, Ohio, USA L. Frost, Silkeborg, Denmark V. Gallo, London, UK E. Granieri, Ferrara, Italy J. Grigsby, Aurora, Ill., USA W. Grisold, Vienna, Austria M.N. Haan, Ann Arbor, Mich., USA G. Hankey, Perth, W.A., Australia J. Harsh, Hattiesburg, Miss., USA W.A. Hauser, New York, N.Y., USA J.E. Heck, Lyon, France H. Heinzl, Vienna, Austria V.W. Henderson, Stanford, Calif., USA P. Heuschmann, Munster, Germany R. Hilsabeck, Encino, Calif., USA R. Hintzen, Rotterdam, The Netherlands M. Hutterer, Innsbruck, Austria A.A. Adeolu, Ibadan, Nigeria H. Akiyuki, Chiba, Japan S.M. Albert, Pittsburgh, Pa., USA K.D. Allen, Durham, N.C., USA N.B. Allen, New Haven, Conn., USA L.E. Almaguer-Mederos, Holguin, Cuba A. Alperovitch, Paris, France R. Al-Shahi, Edinburgh, UK M. Alter, Wynnewood, Pa., USA L.-C. Alvaro, Bilbao, Spain A. Anand, Chandigarh, India N. Andelic, Oslo, Norway D. Anderson, Bethesda, Md., USA M.A. Arami, Tehran, Iran C. Armon, Springfield, Mass., USA J. Artigas-Pallares, Sabadell, Spain H.O. Atladottir, Aarhus, Denmark L. Ayalon, Ramat Gan, Israel M. Balderesch, Florence, Italy A. Barber, Auckland, New Zealand S. Barker-Collo, Auckland, New Zealand E. Beghi, Milano, Italy J. Benito-Leon, Madrid, Spain D. Bennett, Chicago, Ill., USA D. Bennett, Oxford, UK D. Benninger, Bethesda, Md., USA F. Bermejo-Pareja, Madrid, Spain N. Bharucha, Mumbai, India M. Billiard, Montpellier, France M.M. Blewett, Madison, Wisc., USA J. Bower, Rochester, Minn., USA G. Boysen, Copenhagen, Denmark C. Brayne, Cambridge, UK J. Breitner, Seattle, Wash., USA M. Breteler, Rotterdam, The Netherlands L. Broer, Rotterdam, The Netherlands R. Brouns, Antwerp, Belgium K. Bruins Slot, Oslo, Norway A. Brusco, Torino, Italy S.F. Cappa, Milano, Italy A. Carolei, L’Aquila, Italy K. Carter, Christchurch, New Zealand T.D. Carter, Melbourne, Vic., Australia H. Chen, Bethesda, Md., USA

Six patients with delayed epidural hematoma demonstrated by serial computed tomography scan are presented. Three of the patients had no neurologic deficit but suffered from severe headache. We suggest routinely performing repeat CT, before discharge, in patients having sustained head trauma with or without skull fracture, who suffer non-resolving headache, even when there is no neurologic deterioration. Serious symptomatology that may have occurred due to the development of delayed intracranial hematomas is thereby anticipated.

The harvesting of organs for transplantation is dependent on a stringent definition of brain death. Different societies have had to struggle with their cultural heritage, adapting their traditional attitudes to conform to the advances in medical science and the needs of the sick. In this article, the development of the concept of brain death as it applies to organ transplantation in Judaism is outlined. The ability of traditional Jewish values to address themselves to the challenges of modern medicine can serve as a basis for cultural cross-fertilization and comparison in modern societies.

During surgical exposure of the trigeminal root for the treatment of trigeminal neuralgia, biopsy specimens of the nerve root were taken in 12 consecutive patients. The biopsies were taken from areas as close as possible to the site of vascular compression, when present. The tissue was prepared for electron-microscopic evaluation. Except for 1 case, massive disruption of tissue ultrastructure was observed. The major findings included zones of de- and dysmyelination, juxtaposition of denuded axons, apparent axon loss and degeneration, and collagen deposition. Adjacent areas of normal root structure were present in most specimens. The ultrastructural changes observed in the biopsy samples demonstrate important pathology within the trigeminal root. Dysmyelination and the proximity of denuded axons in close apposition to each other support neurophysiological theories of pain production including ectopic electrogenesis, ephaptic contacts, and crossed after-discharge. The findings in this study demonstrate a pathophysiological basis for the syndrome of trigeminal neuralgia.

The authors report 67 cases of meningioma of the anterior cranial fossa floor treated surgically between 1978 and 1992. The olfactory groove and tuberculum sellae were the most frequent locations. Mean duration of the clinical history was 30 months. Seventy-three per cent of the tumours were large (>4 cm). All patients were examined with computed tomography and 18 with magnetic resonance imaging as well. Complete removal was performed in 56 cases (84%); in the remaining 11 (16%), partial removal was performed because of encasement of the carotid artery, cavernous sinus, or optic nerves by the tumour. Mortality was 9%. Results at follow-up of the 61 survivors were good in 56 (84%), fair in four (6%), and poor in one (1%). The clinical results were correlated to tumour location and dimension. After review of the literature, the management of these difficult tumours and the preferred surgical technique are discussed. The authors stress the importance of early diagnosis for improving the surgical results.

In a 10-year-old boy an orbitocranial penetrating wound produced by an umbrella tip caused an orbital roof bone fragment to penetrate up to the anterior part of the third ventricle behind the left foramen of Monro. Hemorrhages and encephalomalacia developed along the trajectory of the fragment and subsequently a porencephalic cyst was formed at this site. Six months after the trauma, increased pressure developed in the left ventricular system due to obstructive hydrocephalus and consequently the porencephalic cyst herniated into the orbit through the orbital roof fracture, producing intermittent diplopia, left exophthalmos, and palpebral swelling. A ventriculo-peritoneal shunt led to shrinkage of the orbital cyst content and resolution of the symptoms.

A retrospective study was designed to evaluate clinical thromboembolic phenomena (TEP) in patients operated upon for brain tumours. Among 492 patients treated surgically in the supratentorial area, the overall incidence of clinical TEP was 7%. There were 5% with deep vein thrombosis (DVT) and 4% with clinical pulmonary embolism (PE). Seven patients (1%) died from massive PE. Among 141 patients treated surgically in the infratentorial area there were no episodes of TEP. Significant risk factors for TEP development were operations in the supratentorial area, malignant gliomas (compared to meningiomas) and para- or hemiparesis. Age, sex and the specific location in the supratentorial area were not found to be statistically significant risk factors. Among 12 patients who presented initially with DVT two developed PE despite full heparinization. 7/19 patients with PE died within minutes to hours of the clinical episode despite full conservative measures. In 2/26 patients who were treated with full heparinization complications occurred. There was one case of diffuse subcutaneous bleeding and one case of tumour bed haematoma. The identification of risk factors for the development of TEP will allow the implementation of prophylactic measures in appropriate patients undergoing elective brain tumour surgery.

Purpose of study: Complete spinal cord injury is a devastating and, until now, almost untreatable condition. Experiments showing central nervous system regeneration and partial functional recovery in rats [1] served as proof of principle. Safety and efficacy have been demonstrated in extensive preclinical experiments that continue to produce promising results. Methods used : A phase 1 clinical trial is underway, involving eight patients with acute complete spinal cord injury (ASIA A). The treatment consists of activating autologous macrophages derived from the patient's peripheral blood and administering them into the parenchyma of the spinal cord within 14 days of injury. The follow-up consists of neurological, electrophysiological, rehabilitation and quality-of-life assessments. The patient outcomes are compared with historical controls. of findings: Eight patients have been followed for up to 30 months, depending on the date of treatment. In none of them short- or long-term side effects that could be linked to the experimental treatment were detected. Of these eight patients, the three patients who have been followed for more than 6 months exhibit partial recovery of sensory and motor function and have upgraded their ASIA classification from ASIA A to ASIA C. These clinical findings are also supported by elctrophysiological examinations. Relationship between findings and existing knowledge: This phase 1 also proves that the results in rats (as described by Rapalino et al. [1]) can be mimicked in human. Overall significance of findings: Based on the interim results of this small sample, it is proposed that autologous activated macrophage therapy can be an effective treatment for complete spinal cord injury. Disclosures: Device or drug: activated macrophage. Status: investigational. Conflict of interest: Nachshon Knoller, grant research support for study initiation: and consultant.

The principles of myelomeningocele repair have been clearly described in the literature and generally delineate a technique that calls for the dissection and closure of five separate layers: arachnoid, dura, fascia a subcutaneous layer, and skin. We should like to describe our technique of repairing the myelomeningocele defect following dural separation and closure by shifting complete fasciocutaneous tissue blocks from either side of the defect to the midline following dural closure. A full thickness primary closure can be obtained even in large defects.