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INTRODUCTION: The management of refractory post-traumatic cerebral oedema remains a frustrating endeavor for the neurosurgeon and the intensivist. Mortality and morbidity rates remain high, despite refinements in medical and pharmacological means of controlling intracranial hypertension. METHOD AND MATERIAL: In this retrospective study we have evaluated the efficacy of decompressive craniectomy as a last resort therapy, from the data of nine patients with severe brain injury and delayed cerebral oedema (diffuse injury type III), treated between January 1997 and September 1999. The following parameters were considered: age, Glascow Coma Scale, injury severity, intracranial pressure, CT findings, pupil reaction/posturing. Follow-up period was over at least 2 years and outcome measured on the GOS. RESULTS: Patients have been operated on post-trauma median day 3, mean age 26+/-9, GCS 7+/-3.7, mean APACHE II 16+/-6.4, mean ISS 27.8+/-16.1, mean preoperative ICP 37.7+/-10.0, mean postoperative ICP 18.1+/-16.01. Seven patients have been operated by a frontotemporoparietal approach (six of them bilateral, one unilateral) and two patients have been operated on by a bilateral subtemporal approach. Mortality rates 22%, severe disability 11%, good recovery 66%. DISCUSSION: Patients with STBI, developing delayed intracranial hypertension caused by diffuse cerebral oedema, definitely benefit from craniectomy when current medical treatment has failed. The encouraging results of outcome in this and more recent studies, indicate the need for a multi-institutional randomized prospective study evaluating early indicators of raised ICP, timing, efficacy of treatment, operative technique and complications of decompressive craniectomy.

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Two cases with fusiform aneurysm in the posterior cerebral artery are presented: The first one is a large fusiform aneurysm of the P(2) segment of posterior cerebral artery (PCA) in a 58 years old patient and the second a fusiform aneurysm of the P(3) segment of PCA in a 43 years old patient. The aneurysms were successfully treated the first by proximal ligation and the second by trapping of the aneurysm. The patients had no additional neurological deficits postoperatively and they are in an good condition, in four years and one year follow up respectively. The operative approaches and the radiological investigation in relation to the micro-anatomy of the posterior cerebral artery, as well as the outcome in these cases are discussed.

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The present study was conducted to evaluate the activity and toxicity profile of radiation (RT) and concomitant chemotherapy in patients with glioblastoma multiforme (GBM). Thirty-nine patients were treated postoperatively with RT and concomitant administration of paclitaxel. Cranial irradiation was initiated 2-3 weeks postoperatively and was administered in 2.0 fractions, one fraction per day, for 5 consecutive days per week, to a total of 60 Gy. Paclitaxel was delivered at a dose of 100 mg/m2 over 3-h once weekly for 6 weeks. Thirty-three patients received all 6 cycles of paclitaxel according to the protocol. Totally, 217 cycles were delivered all of them at full dose. The median relative dose intensity of paclitaxel was 1 (range 0.88-1.1). Three (7.5%) patients achieved complete and 9 (23%) partial response, while 12 (30.5%) patients demonstrated stabilization of the disease. Side effects from combined chemoradiotherapy were mainly mild. Grade III toxicity included infection (7.5%) and alopecia (5%). Median time to progression was 6 (range 0.9-27) months and median survival 10.7 (range 0.9-39.5+) months. The present study has clearly shown that 100 mg/m2 of paclitaxel in 1-h infusion weekly can be safely given concomitantly with RT in patients with GBM with manageable toxicity. However, the efficacy of this combined modality treatment does not appear to be superior to that of RT alone.

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Twenty-two patients with supratentorial malignant gliomas were treated postoperatively with concurrent intracarotid chemotherapy and radiation therapy. There were seven women and 15 men with a median age of 56 years (range, 22-69) and median performance status (Karnofsky score) of 70 (range, 40-90). In all except two cases, histologic studies confirmed malignant glioma. All patients were irradiated with a cobalt 60 equipment. They should have received 45 Gy to the whole brain plus a 15-Gy coned-down boost to the tumor area. Chemotherapy consisted of cisplatin infusion at a dose of 60 mg/m2 on days 2, 22, and 42. Treatment was interrupted in two patients because of progressive disease and voluntary withdrawal in one patient each. In all, 63 courses of cisplatin infusion were administered, all at full dose. Two patients achieved a partial response, and nine had stable disease. Toxicities included nausea/vomiting in nine patients (41%) and transient hemiparesis, confusion, diarrhea, and thrombophlebitis in one patient each. Median time to progression was 26 weeks (range, 4-226+), and median survival was 58 weeks (range, 14-226+). In conclusion, the present study suggests that intracarotid cisplatin administered concurrently with radiation does not improve the therapeutic index in malignant gliomas.

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OBJECTIVE: To quantitate the relief of intractable cancer pain by the use of intraventricular morphine administration. METHODS: Intraventricular morphine administration was performed through an Ommaya reservoir. An initial dose of 0.25 mg of morphine sulfate per 24 hours was administered to all of the patients. This dose was progressively increased in 0.25-mg increments until optimal analgesia was attained. RESULTS: Sixty men and 30 women with a median age of 58 years (range, 23-80 yr) entered the study. The median duration of pain was 6 months (range, 0.5-120 mo). A daily morphine dose of up to 1 mg was adequate to achieve an analgesic effect in 77% of the patients. Only nine patients (10%) achieved < 50% pain relief. Using a multiple regression analysis, only the morphine dosage was found to be an independent prognostic factor. The most frequent side effect (22%) was nausea/vomiting. Also, there were two patients with opioid intolerance and two with intracerebral hematomas. Three reservoirs failed. CONCLUSION: Intraventricular morphine administration is a useful method for palliation of intractable cancer pain.

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Two patients with a non-traumatic hematomyelia at T9 and C3-C7 respectively, are presented. Both patients presented with pain and a Brown-Sequard syndrome. The preoperative diagnosis was made by magnetic resonance imaging, while myelography and computerized tomography were not helpful. Surgical evacuation of the hematomas and in one patient removal of a vascular malformation were performed. The neurological symptoms and signs, after a temporary worsening, progressively improved. The prompt surgical treatment of this entity and the usefulness of magnetic resonance imaging in the preoperative diagnosis and on the planning of the surgical strategy is particularly emphasized.

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The bacteriology for 21 patients with brain abscesses is presented and correlated with their predisposing conditions. Chronic otomastoiditis was the most common predisposing factor, and the overall most frequent infected sites were the frontal and temporal regions. Gram-negative non-sporeforming anaerobes of the genus Bacteroides and Fusobacterlum followed by aerobic streptococci were the predominant pathogens. Enterobacteria were only identified in postcraniotomy abscesses, while a substantial number of fastidious species was detected in suppurations related to congenital heart disease. Altogether, anaerobes alone were recovered in seven patients, aerobes alone in six, and mixed aerobes and anaerobes in four patients. These findings confirm the predominant role of anaerobes in the etiology of intracranial suppurations.

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A series of 27 glioblastomas multiforme were studied to compare the prognostic value of age and histologic parameters known to influence survival with that of proliferating cell nuclear antigen (PCNA). The labelling index (LI) of PCNA has been found in previous studies to correlate well with flow cytometry, tritiated thymidine, bromodeoxyuridine incorporation and Ki 67. The histologic parameters estimated were endothelial proliferation, number of mitoses per high power field, cellularity and a grading of necroses. The correlation coefficients between survival and each of the histologic parameters as well as with age were found to be negative but statistically insignificant. The values of these correlations in descending order were survival/age (r = -0.22), survival/endothelial proliferation (r = -0.20), survival/mitoses (r = -0.16), survival/cellularity (r = -0.07) and survival/necroses (r = -0.04). The correlation coefficient between survival and PCNA LI was also found to be negative, higher than those between survival and other estimated parameters (r = -0.37) but in a wide variation and still statistically insignificant. Despite this variation, our finding that for PCNA LI > 35% no patient survived more than 6 months may be of clinical importance.

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Magnetoencephalography (MEG) non-invasively infers the distribution of electric currents in the brain by measuring the magnetic fields they induce. Its superb spatial and temporal resolution provides a solid basis for the 'functional imaging' of the brain provided it is integrated with other brain imaging techniques. MAGNOBRAIN is an applied research project that developed tools to integrate MEG with MRI and EEG. These include: (1) software for MEG oriented MRI feature extraction; (2) the Brain Data Base (BDB) which is a reference library of information on the brain used for more realistic and biologically meaningful functional localisations through MEG and EEG; and (3) a database of normative data (age and sex matched) for the interpretation of MEG. It is expected that these tools will evolve into a medical informatics environment that will aid the planning of neurosurgical operations as well as contribute to the exploration of mental function including the study of perception and cognition.

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There were 276 patients with severe head injuries admitted to the Neurosurgical Clinic of the A.H.E.P.A University Hospital during the last two years. Comatose state, dilated pupils without reaction to light and respiration disturbances (Glasgow Score 7) were the main characteristic state in 60% of the patients. Computed Tomography (CT) cases. The appearance of delayed hematomas, three intracerebral and one extradural, was noted 48 hours after injury. Because of these cases we stress the value of a CT-scan, it s timing and discuss briefly the literature regarding the pathophysiology of delayed hematomas.

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Two female professional painters, who underwent a neurosurgical operation, are described. Their artistic production before and after the neurosurgical intervention is compared and the observed modifications are discussed.

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This experimental study presents the ultrastructure of regenerating sciatic nerve of the rabbit, after transection and immediate end to end anastomosis, using perineural fascicular nerve autograft, in a sterile environment. Twenty-four hours, 1, 2, and 6 weeks after the anastomosis, the treated sciatic nerves were exposed and three segments were excised and studied. The first at the region of the graft and the others from the proximal and distal stump of the nerve, in the vicinity of the graft suture. The sections taken from the proximal part showed that the nerve structure was identical with the control. Degeneration and regeneration of nerve fibres were observed on the sections taken from the region of the grafts and from the distal parts. Macrophagic activity appeared mainly one week after the operation. Fibroblastic invasion started 24 hours after operation. A moderate amount of collagen fibres was gradually formed. The fibres were disposed in parallel with the neuraxon. Schwann cells were slightly affected initially but consequently they fully recovered and showed signs of extra-activity of the cytoplasm organelles, e.g., enlargement of the granular endoplasmic reticulum cisternae. The present study showed that the bridging of experimental gaps of rabbit's sciatic nerve, by means of autograft and by use of perineural suturing, was successful. The regenerating nerve fibres were growing through the graft towards the distal part of the nerve. In this process Schwann cells and fibroblastic activity play a key role, which is most favourably influenced by using the technique described in this paper.

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Since in a previous study (preliminary report) (18) the iv. administration of 15 mg X kg-1 of phenytoin (PNT) over 30 min in men produced toxic levels (25 micrograms/ml), a smaller iv. dose of 7 mg X kg-1 was given during anaesthesia to 80 patients under going craniotomy, for the prevention of post-operative seizures. Plasma PNT concentrations were studied in 22 patients before its iv. infusion 20 min, 40 min, and 1, 2, 3, 5, 8 and 12 hours later. Mean serum phenytoin levels were 9.3, 31.9, 27.8, 25.5, 19.4, 17.2, 15.4 and 19.2 micrograms/ml respectively. In this study it appeared that although the initial dose was 50% smaller than before, toxic levels were still encountered one hour after PNT administration (therapeutic range 10-25 micrograms/ml). Bearing in mind that in both our studies PNT appeared to have approximately the same efficacy in seizure prevention (from 95-97%), we suggest, that 7-10 mg X kg-1 would be adequate if administered as an intraoperative iv. infusion over an hour and that whenever possible serial serum levels should be monitored.

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Various morphological changes of the skull and brain were observed after surgical treatment for internal hydrocephalus. An interesting variation is described by the authors, at the site of the cisterna magna, the size of which can vary. Generally it is the last one to dilate when an internal hydrocephalus occurs, but it is the first to regress after inserting a drainage of the cerebrospinal fluid. This behavior of the cisterna magna is discussed, illustrated and reviewed in the literature, after presentation of three clinical histories. From a physiopathological point of view the cisterna magna is considered to be an intermediate formation between the ventricular and the subarachnoid systems.

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The authors described the lesions associated with post-traumatic internal hydrocephalus in 4 cases who died after a prolonged post-traumatic coma. The internal hydrocephalus, quite severe in all cases, and the demyelination in the periventricular white matter in 3 cases, are thought to be produced by a chronic increase in the intraventricular pressure, probably secondary to malfunction of circulation and resorption of the cerebro-spinal fluid.

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