Sponsored by the European Association of Neurosurgical Societies Advances and Technical Standards in Ne urosurgery VoI. 23 Edited by F. Cohadon, Bordeaux (Editor-in-Chief), V. V. Dolenc, Ljubljana, J. Lobo Antunes, Lisbon, H. Nomes, Oslo, J. D. Pickard, Cambridge, H.-J. Reulen, Munich, A. J. Strong, London, N. de Tribolet, Lausanne, C. A. F. Tulleken, Utrecht Springer-Verlag Wien GmbH With 89 partly coloured Figures This work is subject to copyright. AII rights are reserved, whether the whole or part of the material is concemed, specifically those of translation, reprinting, re-use of illustrations, broadcasting, reproduction by photocopying machines or similar means, and storage in data banks. © 1997 Springer-Verlag Wien Origina11y published by Springer-VerlagIWien in 1997 Softcover reprint ofthe hardcover lst edition 1997 Library of Congress Catalogue Card Number 74-10499 Graphic design: Ecke Bonk Product Liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceuticalliterature. Printed on acid-free and chlorine-free bleached paper ISSN 0095-4829 ISBN 978-3-7091-7348-0 ISBN 978-3-7091-6549-2 (eBook) DOI 10.1007/978-3-7091-6549-2 Valedictory Note Atthetimeofhis retirementfrom activepracticein 1995,ProfessorLindsay Symon stepped down as Editor-in-Chiefof"Advances and Technical Stan dards in Neurosurgery". I would like to express, in the name of all the membersoftheEditorialBoard,ourappreciationandgratitudetohimforhis distinguished service to our Publication over the last ten years. Under his direction "Advances and Technical Standards" has maintained and re inforceditspositionasamajorsourceofreferencesinNeurosurgerythrough out Europe and beyond, amply fulfilling the aims ofits founders in 1974. During his period of office it was the priviledge of the Board to meet every first Saturday of December at the National Hospital, Queen Square; the intellectual vigor and integrity, and the spirit of leadership of Lindsay Symon has made each one of these meetings a feast of shared knowledge and friendship. The work of the Editorial Board continues in Bordeaux in the same tradition, dedicated to academic excellence, professional reliabili ty and, not the least, European friendship. Franr;ois Cohadon Editor-in-Chief Preface As an addition to the European postgraduate training system for young neurosurgeons we began to publish in 1974 this series of Advances and Technical Standards in Neurosurgery which was later sponsored by the European Association ofNeurosurgical Societies. This series was first discussed in 1972 at a combined meeting of the Italian and German Neurosurgical Societies in Taormina, the founding fathers ofthe series being Jean Brihaye, Bernard Pertuiset, Fritz Loew and Hugo KrayenbtihI. Thus were established the principles of European co operation which have been born from the European spirit, flourished in the European Association, and have throughout been associated with this series. The fact that the English language is well on the way to becoming the international medium at European scientific conferences is a great asset in terms of mutual understanding. Therefore we have decided to publish all contributions in English, regardless ofthe native language ofthe authors. All contributions are submitted to the entire editorial board beforepubli cation ofany volume. Our series is not intended to compete with the publications of original scientific papers in other neurosurgical journals. Our intention is, rather, to present fields of neurosurgery and related areas in which important recent advances have been made. Thecontributionsare written by specialists inthe given fields and constitute the first part ofeach volume. In the second part of each volume, we publish detailed descriptions of standard operativeprocedures, furnished by experienced clinicians; in these articles the authors describe the techniques they employ and explain the advantages, difficulties and risks involved in the various procedures. This partisintendedprimarilytoassistyoung neurosurgeonsintheirpostgraduate training. However, we are convinced that it will also be useful to experi enced, fully trained neurosurgeons. The descriptions ofstandard operative procedures are a novel feature of ourseries. We intend that this section shouldmake available thefindings of European neurosurgeons, published perhaps in less familiar languages, to neurosurgeons beyond the boundaries of the authors' countries and of Europe. We will however from time to time bring to the notice of our European colleagues, operative procedures from colleagues in the United VIII Preface States and Japan, who have developed techniques which may now be regarded as standard. Our aim throughout is to promote contacts among neurosurgeonsinEuropeand throughoutthe worldneurosurgicalcommuni ty in general. We hope therefore that surgeons not only in Europe, but throughout the world will profit by this series of Advances and Technical Standards in Neurosurgery. The Editors Contents ListofContributors xv A. Advances A Critical Review ofthe CurrentStatus and PossibleDevelopments in Brain Transplantation. By S. REHNCRONA, Department of Neurosurgery, University Hospital ofLund, Lund (Sweden) Introduction 4 Grafting in Parkinson's Disease ................................... 4 Experimental Background 5 Graft-Host Brain Interactions 6 Rationalefor the FirstClinical Experiments ........... 7 Ethical Considerations ...................................... 7 Preparation ofTissue Grafts 8 Fetal Tissue 8 Autologous Adrenal Medulla 9 Surgical Techniques 9 Stereotactic Techniques 9 OpenMicroneurosurgery 12 Human Clinical Trials 12 Autologous Transplantation ofAdrenal Medulla 12 Transplantation ofHuman Fetal Mesencephalic Tissue 17 Graft Survival 23 Clinical Results 25 Transplantation ofOtherDopamineCells .. ....................... 26 Brain CellffissueTransplantation in OtherDiseases 27 Discussion and Perspectives ...................................... 28 Functional Interactions Between Grafts and HostBrain: Fetal Mesencephalic Versus AdrenalTissueGrafts 28 Methodological Aspects on Fetal Brain Tissue Grafting 30 WillTransplantation be a Future Neurosurgical Routine in the TreatmentofParkinson's Disease? 33 Future Transplantation Therapy in Other Neurologic Disorders ........ 34 General Conclusions ............................................ 35 References 36 Editorial Comment 46 x Contents TheNormalandPathologicalPhysiologyofBrainWater. ByK. G. Go, Depart mentofNeurosurgery, University ofGroningen, Groningen (The Netherlands) Summary..................................................... 48 Introduction 49 Brain Water, its Origin and Significance ............................ 50 Normal BrainWaterContent: EffectofMaturation 52 MeasurementofBrainWaterContent 53 Gravimetry 53 DeterminationofTissue Specific Weight 53 ComputedTomography 54 Proton Magnetic Resonance 56 Intracranial FluidCompartments 59 Intercompartmental Exchanges 59 Fluid Volume: The Coupling ofWater to the Prevailing Electrolytes NaCl: Regulation ofSystemic Fluid Volume. ........................... 60 Blood-Brain Exchanges: The Blood-Brain Barrierand the B1ood-CSF Barrier. .................................................... 64 Pathology: Breakdown ofthe Blood-Brain Barrierand Vasogenic Brain Oedema 70 The Blood-CSFBarrier 71 The Cerebral ExtracellularSpace .................................. 71 Methods to Study Extracellular Space ............................ 72 The Structure and Functional SignificanceofCerebral Extracellular Space 75 The ExtracellularMatrix 78 The Cerebrospinal Fluid ......................................... 79 Factors Determining Normal CSFFormation 80 Choroidal CSFFormation 83 The Mechanism ofCSFSecretion by the Choroid Plexus 83 Extrachoroidal CSFFormation 84 CSF Absorption 85 Morphological Aspects ofCSFAbsorption 86 AlternativeCSFAbsorption Pathways 89 The Flow ofCSF 89 The Cerebral IntracellularSpace 90 The MeasurementofIntracellular Space .......................... 93 The MaintenanceofCell Volume 94 The Abnormal Accumulation ofBrain Water 96 Brain Oedema ................................................. 97 Pathogenesis ofBrain Oedema 97 Vasogenic Brain Oedema 98 Cytotoxic Brain Oedema 101 Osmotic Brain Oedema 102 Hydrostatic Brain Oedema. .................................... 104 Brain Oedema in the Clinical Context .............................. 104 Peritumoural Brain Oedema 104 Contents XI Ischaemic Brain Oedema. ..................................... 108 Traumatic Brain Oedema ...................................... 109 Hydrocephalus 112 Cystic Lesions 113 Ex vacuoType Cysts 114 Cysts with Fluid Secreting Walls and CSF-Like Content. ............ 115 Cysts Associated withGliomas and OtherTumours ................. 118 Acknowledgement 120 References 120 B. Technical Standards Transfacial Approaches to theSkullBase. By D. UnLEY, DepartmentofNeuro surgery, Atkinson Morley's Hospital, Wimbledon, London (U.K.) Transfacial Approaches to theClivus 146 Introduction 146 Anatomy oftheClivus. ....................................... 147 Functional Anatomy 148 Surgical Pathology 150 Developmental 150 Metabolic Causes 150 Trauma 151 Inflammatory Conditions 151 Tumours 152 VascularLesions 152 Clinical Presentations ........................................... 153 Investigations 154 1. Plain x-Rays. ... ....................................... 154 2. Angiography 154 3. ComputerisedTomography (CT) 154 4. Magnetic Resonance Imaging ISS 5. Evoked Potentials 155 General OperativeConsiderations .......... ISS 1. Preoperative Preparation 156 2. General Anaesthesia 156 3. Control ofIntracranial Pressure 157 4. Prophylactic Antibiotics 157 5. Corticosteroids: Replacement 158 6. Positioning ............................................ 158 7. BloodPressureControl 158 8. Post-Operative Nutrition 159 9. Dural Closure .......................................... 160 10. Extubation 161 Surgical Approaches 161 Transfacial Approach. ........................................ 161