There has been considerable controversy over the concept of treating glioblastoma multiforme with cytoreductive surgery. Therefore, a retrospective study of cases treated between 1986 and 1991 was conducted to analyze and compare the results of stereotactic biopsy followed by radiation therapy performed in 58 patients with those of surgical resection plus radiation therapy in 57 patients. In both groups, conventionally fractionated radiation (1.7 to 2.0 Gy/day) was delivered, with a total dose of 50 to 60 Gy. Biopsy was performed only in patients with tumors judged to be inoperable. These patients carried a higher surgical risk and were in worse neurological condition than the patients in the resection group. The median survival time for the resection group was 39.5 weeks, as compared with 32 weeks for the biopsy group. This difference was not significant. The most important prognostic factor was the patient's age. The treatment variable biopsy versus resection did not reach prognostic relevance. In patients with midline shift who underwent biopsy, the Karnofsky Performance Scale score decreased in more patients during radiation therapy. The clinical status 6 weeks after surgery, however, showed no significant differences between the two groups. The comparable survival times for the two groups place doubt on the concept of treating glioblastoma multiforme with cytoreductive surgery. Presently, radiation therapy is the most effective treatment for patients with glioblastoma. There is no question that decompressive surgery followed by radiation therapy should be performed whenever necessary for sever space-occupying lesions and when it will not cause new neurological deficits.

Burr-hole craniotomy (BHC) and closed-system drainage undoubtedly is currently the most accepted treatment offered in chronic subdural haematoma (CSDH). Although twist-drill trephination (TDT) techniques have been available for years, now a special subdural catheter kit has been launched for treatment of CSDH. In a prospective study, 33 patients with 36 CSDH were treated with a 5-mm TDT regimen and insertion of a CORDIS subdural catheter (CORDIS Corp., Miami, USA). The results are compared with a consecutive series of 33 patients treated previously with an 11-mm BHC and closed-system drainage for 40 CSDH: Recurrence and persistence rate of CSDH treated with TDT necessitating a second intervention was 18.1%, no further surgical intervention was necessary. In BHC treated patients, 33.3% of haematomas had to be reoperated on, another 6.0% had to be re-operated on a third time. Infection rate in BHC treated patients was 18.1% as compared with a 0% infection rate in patients treated with the TDT technique. Mortality rate for the BHC method was 9.0% as compared with 6.0% in the TDT treatment regimen. Significantly better clinical results are achieved using the TDT technique with insertion of a special subdural catheter, making this procedure superior to the BHC regimen.

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Objectives-Haemangioblastoma of the CNS occurs as a sporadic entity and as a manifestation of the autosomal dominant von Hippel-Lindau disease with the major additional components retinal angioma, renal cancer, and pheochromocytoma. Genetic testing for germline mutations predisposing to von Hippel-Lindau disease has been available since identification of the VHL tumour suppressor gene. The impact of this testing was evaluated in patients with haemangioblastomas seen in this centre. Methods-A register and database of patients with symptomatic haemangioblastomas for the last 15 years was evaluated. The VHL gene was analysed by the SSCP method for all exons and Southern blotting for mutations and deletions of the gene. Results-141 patients with haemangioblastoma of the CNS were registered. In 81 patients (57%) there was a disease predisposing germline mutation including eight novel mutations. Population related calculation of patients from the administrative district of Freiburg disclosed VHL germline mutations in 22% of the patients with haemangioblastoma. Analysis of mutation carriers for clinical information suggestive of the syndrome showed (1) a positive family history of a brain tumour in 50%, (2) a history for the patient of extracranial manifestations in 36% (retinal angioma 30%, pheochromocytoma 6%), and (3) 19% presenting with multiple brain tumours when first admitted. By genetic testing of haemangioblastoma patients without any indications of von Hippel-Lindau disease mutation carriers were identified in 14%. Sensitivity of VHL germline testing was 86%. Conclusions-DNA analysis for VHL germline mutations is clearly superior to clinical information in the diagnosis of von Hippel-Lindau disease. Although the percentage of von Hippel-Lindau disease associated haemangioblastoma decreases after the fourth decade of life and is infrequent in patients without other symptomatic lesions and a negative family history, it is recommended that every patient with CNS haemangioblastoma should be screened for von Hippel-Lindau disease germline mutations. This provides the key information and enables screening for extraneurological tumours of the patients and investigations of the patient´s family to ameliorate management of von Hippel-Lindau disease. (J Neurol Neurosurg Psychiatry 1999;67:758-762)

A very rare case of otogenic pneumocephalus in a healthy 24-year-old man with a widely pneumatized right mastoid, precipitated by forceful Valsalva's maneuver, is reported. When a pneumocephalus is suspected, computed tomography scans are mandatory. The pertinent literature is discussed and the potential mechanisms causing spontaneous pneumocephalus are described. To the best of our knowledge, only two other similar cases have been reported up to now.