Funktionelle Bildgebung bei Hirntumoren (Perfusion, DTI, MR-Spektroskopie)

This contribution considers the possibilities involved with using functional methods in magnetic resonance imaging (MRI) diagnostics for brain tumors. Of the functional methods available, we discuss perfusion MRI (PWI), diffusion MRI (DWI and DTI) and MR spectroscopy (H-MRS). In cases of brain tumor, PWI aids in grading and better differentiation in diagnostics as well as for pre-therapeutic planning. In addition, the course of treatment, both after chemo- as well as radiotherapy in combination with surgical treatment, can be optimized. PWI allows better estimates of biological activity and aggressiveness in low grade brain tumors, and in the case of WHO grade II astrocytoma showing anaplasically transformed tumor areas, allows more rapid visu-alization and a better prediction of the course of the disease than conventional MRI diagnostics. Diffusion MRI, due to the directional dependence of the diffusion, can illustrate the course and direction of the nerve fibers, as well as reconstructing the nerve tracts in the cerebrum, pons and cerebellum 3-dimensionally. Diffusion imaging can be used for describing brain tumors, for evaluating contralateral involvement and the course of the nerve fibers near the tumor. Due to its operator dependence, DTI based fiber tracking for defining risk structures is controversial. DWI can also not differentiate accurately between cystic and necrotic brain tumors, or between metastases and brain abscesses. H-MRS provides information on cell membrane metabolism, neuronal integrity and the function of neuronal structures, energy metabolism and the formation of tumors and brain tissue necroses. Diagnostic problems such as the differentiation between neoplastic and non-neoplastic lesions, grading cerebral glioma and distinguishing between primary brain tumors and metastases can be resolved. An additional contribution will discuss the control of the course of glial tumors after radiotherapy.     

MR-Spektroskopie bei Demenz

With an increasingly aging population we are faced with the problem of an increasing number of dementia patients. In addition to clinical, neuropsychological and laboratory procedures, MRI plays an important role in the early diagnosis of dementia. In addition to various morphological changes functional changes can also help in the diagnosis and differential diagnosis of dementia. Overall the diagnosis of dementia can be improved by using parameters from MR spectroscopy. This article focuses on MR spectroscopic changes in the physiological aging process as well as on changes in mild cognitive impairment a precursor of Alzheimer’s dementia, in Alzheimer’s dementia, frontotemporal dementia, vascular dementia and Lewy body dementia.     

Dreidimensionale Bestrahlungsplanung bei Hirntumoren

Purpose

Radiotherapy became an important component in the treatment of brain gliomas. The aim of this study is to analyse several advantages of the three-dimensional conformal radiation therapy in comparison with a two-dimensional conventional technique and to present the clinical results of 43 patients with brain gliomas treated according to a three-dimensional planning.

Patients and Method

Between January 1994 and December 1995, 43 Patients with malignant brain gliomas (WHO III and IV) were treated in our department according to a three-dimensional treatment planning. The patients received a total irradiation dose of 60 Gy, 2 Gy/day, 5 days/week. The rate of survival was analysed in relation with the known prognostical factors: histology, Karnofsky index, age, resection status. In 10 patients a three-dimensional treatment planning was compared with a conventional two-dimensional planning: the volume of the normal brain tissue irradiated to high dose levels (95% isodose) and the normal tissue complication probability (NTCP) for the brain by Kutcher and Lyman were comparatively analysed.

Results

The survival rate for the whole group was 14 months. The histology of the tumor, age, Karnofsky index and resection status were important prognostical factors. The three-dimensional planning allows a 15 to 20% reduction in the volume of normal brain tissue irradiated to high dose levels (95% isodose). The NTCP is significantly lower using the three-dimensional technique (range 0.03% to 13%), in comparison with the two-dimensional conventional technique (range 0.1% to 26%). The value of NTCP increases with tumor volume.

Conclusions

Concerning the tumor control and survival rate, the three-dimensional treatment planning shows no advantages compared to the standard conventional methods. The main advantage of the three-dimensional treatment planning is the possibility to spare normal brain tissue. This should enable a dose escalation in the tumor, with a minimal risk of side effects in the surrounding normal tissue. The possibility to integrate mathematical models in the evaluation of the therapy could give this technique new dimensions.     

Differenzialdiagnose infratentorieller Hirntumoren bei Kindern

Zusammenfassung Bei Kindern kommen in der ersten Lebensdekade mit Ausnahme des ersten Lebensjahrs besonders häufig infratentorielle Hirntumoren vor. Es handelt sich in absteigender Häufigkeit um niedriggradige Astrozytome des Kleinhirns, Medulloblastome, Hirnstammgliome und Ependymome des IV. Ventrikels. Die Differenzialdiagnose dieser Tumoren ist durch Beachtung der Lokalisation und Morphologie in MRT und CT sowie durch Berücksichtigung des Ausbreitungsmusters sehr häufig möglich. Für die Planung der Behandlung sind besonders bei malignen, zu einer Meningeose neigenden Hirntumoren Kenntnisse über das Ausmaß einer evtl. Dissemination erforderlich, sodass nicht nur kranielle, sondern auch spinale MRT-Untersuchungen zum Staging unerlässlich sind. Unmittelbar postoperativ können ausschließlich operationsbedingte Veränderungen in Form einer Kontrastmittelaufnahme im spinalen subduralen Raum auftreten, die mit einer Meningeose verwechselt werden könnten. Anhand typischer Bilder werden die Morphologie und die Differenzialdiagnose der infratentoriellen Tumoren im Kindesalter und des unspezifischen postoperativen subduralen Enhancements demonstriert.Das Referenzzentrum für Neuroradiologie der HIT-Studien der GPOH in Würzburg (Leitung: Priv.-Doz. Dr. M. Warmuth-Metz) wird gefördert durch die Deutsche Kinderkrebsstiftung.     

Grundlagen der MR-Spektroskopie

MR spectroscopy (MRS) is a non-invasive method for investigating tissue metabolism. In the clinical setting proton spectroscopy based on the hydrogen nucleus (¹H) is primarily used for determining concentrations of important brain metabolites. This paper illustrates the physicochemical principles of MRS and the requirements for high quality spectra. Moreover, different techniques for acquiring localized spectra are demonstrated.     

Intraaxiale Hirntumoren

Neuroradiology plays a key role in the diagnosis of brain tumors. Computed tomography (CT) and specially magnetic resonance imaging (MRI) allow accurate anatomic depiction of intracerebral lesions. The implementation of native and contrast studies allows the characterization of the various lesions encountered in the majority of cases. In this review the imaging aspects on CT and MRI of the most common primary intra-axial brain tumors will be discussed.     

Extraaxiale Hirntumoren

Neuroradiology plays a key role in the diagnosis of patients with brain tumors. Computed tomography (CT) and especially magnetic resonance imaging (MRI) allow accurate anatomic depiction of intracerebral lesions. The implementation of native and contrast studies allows the characterization of the various lesions. This review discusses the imaging aspects with CT and MRI of the most common primary extra-axial brain tumors.     

Vergleich des Kontrastverhaltens von Gadobenat-Dimeglumine und Gd-DTPA bei intraaxialen Hirntumoren Eine doppelblinde randomisierte intraindividuelle Cross-over-Studie

The purposes of the study was to assess intraaxial brain tumors by a blinded comparison of gadobenat-dimeglumine and Gd-DTPA. 27 patients with known cerebral gliomas or metastases were included into an intra-individual randomized double-blinded cross-over study. The protocol included T1 SE, T2 FSE and after contrast a series of five T1 SE sequences followed by T1 SE with MT, T1 SE, and 3D GRE sequences. Imaging data acquired at two centers were assessed on-site by the investigators and off-site by two experienced readers using quantitative and qualitative criteria. For a quantitative analysis tumor contrast and contrast-to-noise ratios were determined out of ROI in tumor, unaffected white matter, a region outside the head, and an external reference tube. For the qualitative assessment on- and off-site readers were asked to compare both MR scans for lesion contrast, lesion delineation and information upon the internal morphology and structure. In the quantitative analysis lesions examined with gadobenat-dimeglumine present a maximal 26% increase of the lesion contrast. In both, the on-site, as well as the off-site assessment the intensity of enhancement and the lesion contrast were found to be significantly better with gadobenat-dimeglumine enhanced MRI. There was a trend towards gadobenat-dimeglumine for the delineation of the lesion from the surrounding tissue and the internal lesion morphology. Based on our observations gadobenat-dimeglumine proved to be a safe and valuable contrast media for the assessment of CNS neoplasms. Compared with Gd-DTPA it provides a more intense contrast enhancement and a better tumor contrast which might be of importance for the further management of these patients.     

Hirntumoren im Kindesalter

Central nervous system (CNS) tumors are the most common solid neoplasms in childhood and the second most common malignancies after leukemia in the pediatric age group. Supratentorial tumors are more common in children younger than 2 years old and in adolescents, whereas in patients between 2 and 12 years of age brain tumors originating in the posterior fossa dominate. This implies a relationship between the type of tumor, its location and the age of the patient, which has to be considered in differential diagnoses. Medulloblastoma represents the most common malignant brain tumor in childhood. In the posterior fossa medulloblastomas are approximately as frequent as astrocytomas. Supratentorial astrocytomas are by far the main tumor type. In this report some typical CNS neoplasms in children are discussed and their neuroradiological features are demonstrated.     

Genetische Grundlagen der Entstehung von Hirntumoren

Zusammenfassung Die biologischen Eigenschaften von Tumorzellen werden durch zumeist erworbene Ver?nderungen proliferationsrelevanter Gene – Protoonkogene und Tumorsuppressorgene – bestimmt, deren Nachweis neuartige diagnostische und prognostische Parameter liefern kann. Meningeome und Gliome z?hlen zu den genetisch am besten charakterisierten soliden Tumoren: Es sind artspezifisch eine Reihe spezifischer prim?rer und sekund?rer genetischer Aberrationen bekannt, die mit klinischen Parametern wie z.B. der Rezidivneigung von Meningeomen oder der malignen Progression von Astrozytomen assoziiert sind. Die insbesondere für Gliome typische fokale Progression mit der Folge einer intratumoralen Heterogenit?t ist auf komplexe sekund?re Mutations- und Selektionsmechanismen zwischen Tumorzellen zurückzuführen, die auch iatrogen durch Strahlen- oder Chemotherapien mitbestimmt werden.      

Hirntumoren des neuroepithelialen Gewebes im Kindesalter

Tumors of neuroepithelial tissue represent the largest group of pediatric brain tumors by far and has therefore been divided into several discrete tumor subtypes each corresponding to a specific component of the neuropil. The neuropil contains several subtypes of glial cells, including astrocytes, oligodendrocytes, ependymal cells and modified ependymal cells that form the choroid plexus. This review discusses the imaging aspects of the most common pediatric tumors of neuroepithelial tissue.     

Vergleich des Kontrastverhaltens von Gadobenat-Dimeglumine und Gd-DTPA bei intraaxialen Hirntumoren Eine doppelblinde randomisierte intraindividuelle Cross-over-Studie Eine doppelblinde randomisierte intraindividuelle Cross-over-Studie

In einer doppelt verblindeten randomisierten intraindividuellen Cross-Over Vergleichsuntersuchung wurden 27 Patienten mit intraaxialen Hirntumoren mittels der MR-Kontrastmittel Gadobenat-Dimeglumine (Multihance^?) und Gd-DTPA (Magnevist^?) untersucht.     

Der Wert der Computer-Tomographie und Angiographie für die Diagnose supratentorieller Hirntumoren

Summary In a cooperative study the examination results of CT and angiography of 756 patients with verified supratentorial tumors were compared. CT displayed the higher diagnostic accuracy. Temporobasal tumors cause diagnostic problems for both examination methods. The value of arteriography is still unquestioned, because using this examination method the differential diagnosis of mass lesions can be considered largely secured.     

Elektrokardiographische Veränderungen bei der Milchaspiration bei Kaninchen

Zusammenfassung Es wurde 13 Kaninchen eine unterschiedlich konzentrierte Lösung getrockneter Kuhmilch (Präparat Sunar) in die Trachea eingespritzt, und zwar einmalig oder wiederholt in Dosen von 3–6 ml. Bei 10 Kaninchen wurde eine EKG-Untersuchung durchgeführt. Nach der Milchaspiration kam es in der Regel zu Bradykardie, zu Kammer-Extrasystolen, Störungen der atrioventrikulären Überleitung und allmählich auch zu Veränderungen der Repolarisationsphase und Denivelation des ST-Abschnitts. Bei 4 Kaninchen kam es zum Exitus infolge Herzstillstands bereits nach 1–2 Milchgaben. Die im EKG-Bild beobachteten Veränderungen sind reflexbedingt (eine Vagusreaktion) oder hypoxiebedingt. Außer der Hypoxie und kombinierter metabolischer bzw. Respirationsacidose kann durch die wiederholte Aspiration auch einer verhältnismäßig geringen Milchdosis ein rascher Herzstillstand herbeigeführt werden.

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Electrocardiographic changes on aspiration of milk in rabbits

Summary A solution of powdered cow milk (Sunar) of various concentrations was injected into the trachea of 13 rabbits. Single or repeated doses of 3–6 ml were used. Ten rabbits were subjected to ECG examination. Bradycardia, ventricular extrasystole, disturbances of atrioventricular conduction, progressive changes in the repolarisation phase and denivelisation of the ST portion occurred regularly after aspiration of milk. Exitus due to cardiac arrest was observed in 4 rabbits already after 1 to 2 doses of milk. Changes seen in ECG were partly of reflex origin (vagus reaction) and partly due to hypoxia. In addition to hypoxia and combined metabolic and respiration acidosis, repeated aspiration of a relatively small dose of milk may result in rapid cardiac arrest.

     

Bestechlichkeit bei Patientenzuweisung

Abstrakt 1. x 331 Abs. 1 StGB a.F. setzte voraus, dass der Vorteil als Gegenleistung für eine zumindest in Umrissen bestimmte Diensthandlung und nicht nur allgemein für die Dienstausübung angenommen wurde.2. Zu den Voraussetzungen der Bestechlichkeit nach x 332 Abs. 3 Nr. 2 i.V. mit Abs. 1 StGB. (Leitsätze des Bearbeiters)     

Blutgruppenuntersuchungen bei Strafgefangenen

Ohne ZusammenfassungDie Arbeit bildet den 2. Teil einer rassenbiologischen Untersuchungsreihe an der schleswig-holsteinischen Bevölkerung. Der 1. Teil erscheint in der Zeitschrift für Immunitätsforschung.     

Hirnblutungen bei Kohlenoxydvergiftung

Ohne ZusammenfassungVorgetragen auf der 22. Tagung der Deutschen Gesellschaft für gerichtliche und soziale Medizin in Hannover, September 1934.     

Kostenerstattung bei In-vitro-Fertilisation

Abstrakt Ein Anspruch auf Erstattung der Kosten einer künstlichen Befruchtung (In-vitro-Fertilisation) besteht zumindest dann nicht mehr, wenn die Versicherungsnehmer auf diesem Weg bereits zwei Kinder (Zwillinge) gezeugt haben und der Versicherer insoweit die Kosten übernommen hatte.