Les gliomes sont des tumeurs cérébrales infiltrantes difficilement curables, notamment à cause de la difficulté à visualiser toutes les infiltrations au bloc opératoire. Dans cette thèse, nous réalisons une étude clinique de spectroscopie de fluorescence de la protoporphyrine IX (PpIX) dans les gliomes de 10 patients selon l’hypothèse que les spectres collectés proviennent de la contribution de 2 états de la PpIX dont les proportions varient suivant la densité en cellules tumorales. Après avoir présenté le développement du système interventionnel proposant une excitation multi-longueurs d’onde, nous présentons son utilisation sur fantômes de PpIX mimant les propriétés des gliomes. Ceci permet tout d’abord d’obtenir les spectres émis par les 2 états séparément puis de proposer un modèle d’ajustement des spectres comme une combinaison linéaire des 2 spectres de référence sur la bande spectrale 608-637 nm. Ensuite, nous présentons la mise en place de l’étude clinique, notamment l’analyse de risques, avant d’appliquer ce système in vivo. Les mesures in vivo détectent de la fluorescence dans des tissus où le microscope chirurgical n’en détecte pas, ce qui pourrait s’expliquer par un changement d’état de la PpIX entre le cœur des gliomes et leurs infiltrations. L’intérêt de l’excitation multi-longueurs d’onde est démontré par la décroissance de la corrélation des spectres acquis aux trois excitations suivant la densité en cellules tumorale. Enfin, nous soulevons des pistes d’étude de l’identification peropératoire des zones de fonctionnalité cérébrale à l’aide d’une caméra optique ainsi que l’étude du temps de vie de fluorescence et de la fluorescence deux photons de la PpIX sur fantômes / Gliomas are infiltrative tumors of the brain which are yet hardly curable, notably because of the difficulty to precisely delimitate their margins during surgery. Intraoperative 5-ALA induced protoporphyrin IX (PpIX) fluorescence microscopy has shown its relevance to assist neurosurgeons but lacks sensitivity. In this thesis, we perform a spectroscopic clinical trial on 10 patients with the assumption that collected fluorescence is a linear combination of the contribution of two states of PpIX which proportions vary with the density of tumor cells. This work starts with the development of the intraoperative, portable and real time fluorescence spectroscopic device that provides multi-wavelength excitation. Then, we show its use on PpIX phantoms with tissues mimicking properties. This first enables to obtain a reference emitted spectrum for each state apart and then permits the development of a fitting model to adjust any emitted spectrum as a linear combination of the references in the spectral band 608-637 nm. Next, we present the steps led to get approvals for the clinical trial, especially the risk analysis. In vivo data analysis is then presented, showing that we detect fluorescence where current microscopes cannot, which could exhibit a change in PpIX state from glioma center to its margins. Besides, the relevance of multi-wavelength excitation is highlighted as the correlation between the three measured spectra of a same sample decreases with the density of tumor cells. Finally, the complementary need to intraoperatively identify cerebral functional areas is tackled with optical measurements as a perspective and other properties of PpIX on phantoms are also raised

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The thesis "Effects of surgery treatment of epilepsy on psychosocial condition of the patients" deals with the disease which causes many social effects on the patients. The most frequent ones are limitations in the working life and mental problems. I am interested in the epilepsy issue and therefore I have selected this topic which continues the bachelor thesis written in 2008. The objective of my work was to determine effects of epileptosurgery on the work life and on the mental area. Two hypotheses were established which assumed that the surgical treatment improved the patient´s life both in the working and in the mental spheres. The hypotheses were tested by means of quantitative research; questionnaires were used for the collection of data and the respondents were adult patients, who underwent surgical treatment of epilepsy and have been in the care of the Center of Epilepsy Na Homolce in Prague, and patients in the care of neurology departments in České Budějovice and in Strakonice. The results have shown that the epileptosurgery failed to improve the lives of the patients in the working sphere and thus the first hypothesis was not confirmed. Many of the patients are still unemployed and they still find it difficult to find jobs. The offer of vacancies has not increased much after the surgery. Those who work often feel stress and anxiety as a result. Some patients even lost jobs after the surgery or their working positions do not correspond to the achieved qualification level, experience and potential. The improvement in the mental area has been confirmed and many of the patients no more suffer from mental problems they had before the surgery. In some of the respondents mental disorders diminished or disappeared entirely. They are more self-confident, more even-tempered and they need less professional help. In this area I see the effects of surgical treatment as very beneficial. The results of my thesis might be used in publications for the general public, as well as for professionals specializing in the field.

Introdução: Radiocirurgia estereotática (RCE) e radioterapia estereotática fracionada (RCEF) são inovações modernas de procedimentos radioterápicos, de alta precisão que modelam o feixe de radiação para coincidir com o contorno da lesão, por meio de um sistema de imobilização exata do paciente ao aparelho, com definição do alvo através da fusão de imagens de RM, TC, Angiografia e PET/CT; em que pelas coordenadas de referência estereotática, determina-se que a dose de radiação de alta energia prescrita pelo médico seja depositada somente no volume-alvo, com preservação dos tecidos sadios, órgãos ou estruturas localizadas em suas adjacências. Meningeomas do seio cavernoso (MSCs) representam um problema especial porque podem evoluir comprimindo ou infiltrando estruturas neurovasculares presentes no seio cavernoso. Há evidências de que a RCE e a RCEF proporcionam controle satisfatório do crescimento dos meningeomas do seio cavernoso (MSCs) com efeitos adversos reduzidos. Objetivo: Avaliar resultados da avaliação clínica e da neuroimagem de doentes sintomáticos com MSCs tratados com RCEF ou RCE exclusivamente ou de modo adjuvante à neurocirurgia. Casuística e métodos: Estudo tipo coorte e retrospectivo sobre a avaliação de 89 doentes com MSC sintomático tratados com RCE (36%) ou RCEF (64%) entre janeiro de 1994 e março de 2009 e acompanhados até o final de 2012. Haviam sido submetidos à ressecação neurocirúrgica parcial (Simpson IV) ou à biopsia (Simpson V) previamente à radioterapia 29,2% dos doentes. A dose média de RCE foi de 14Gy, e a dose total de RCEF variou entre 50,4 e 54Gy, sendo fracionada em 1,8-2Gy/dose/dia. Resultados: O período de acompanhamento variou entre 36 e 180 meses (mediana de 73 meses). A percentagem de melhora dos sintomas neuroclínicos individuais e de melhora clínica e radiológica (p > 0,05) apresentou valores semelhantes nos doentes tratados com RCE ou RCEF, sendo respectivamente de 41,6% e 48,3%. Em 37% dos doentes, houve manutenção de, pelo menos, uma queixa neurológica apresentada antes do tratamento e, em 43,8%, a imagem do MSC manteve-se inalterada. O período livre de progressão do MSC em 5, 10 e 15 anos foi de 98,8%, 92,3% e 92,3%, respectivamente. Houve progressão da doença em quatro doentes (4,5%). A melhora dos sintomas neurológicos em doentes submetidos previamente à neurocirurgia ocorreu de maneira mais lenta em relação aos não operados, em razão de manipulação de nervos cranianos. Alguns sintomas pós-operatórios, como a ptose palpebral unilateral, persistiram permanentemente. Nenhuma complicação grave foi observada. Sete doentes apresentaram neuropatia óptica transitória durante 3 meses que melhorou com o uso de corticoides, dois neuropatia trigeminal que melhorou com uso de esteroides e um doente apresentou obstrução total da artéria carótida interna sem repercussão neurológica. Letargia e cefaléia foram os sintomas temporários imediatos mais frequentes. Conclusões: A RCEF e a RCE são métodos seguros e eficazes para tratar doentes com MSC sintomático. Proporcionam melhora ou estabilização da sintomatologia na maioria dos casos, e estabilização ou regressão do tumor demonstrado pela neuroimagem em mais de 90% deles. Ocorreu recuperação dos sintomas neurológicos preexistentes mais rapidamente em doentes não submetidos previamente à neurocirurgia. Houve recorrência do tumor em 4,5% dos doentes. Em até 15 anos de acompanhamento, não se evidenciou indução tumoral com o tratamento / Introduction: Stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (FSRS) are modern innovations in radiotherapy procedures, precision shaping the radiation beam to match the contour of the lesion, through a system of accurate patient immobilization to the device, defining target through the fusion of MRI, CT, angiography and PET / CT, which is determined by reference to stereotactic coordinates. The radiation dose of high energy prescribed by the doctor to be delivery only in the target interest, with preservation of healthy tissues, organs or structures located in their vicinity. Cavernous sinus meningiomas (CSMs) pose a special problem because they can evolve compressing or infiltrating the neurovascular structures present of the cavernous sinus. There are evidences that SRS and FRS are efficient in the treatment of CSMs. Objectives: The evaluation of the long-term clinical results and neuroimaging findings in patients with symptomatic CSM treated with FSRT or SRS as single therapy or after a previous neurosurgical treatment. Patients and methods: Retrospective cohort study involving 89 patients with symptomatic CSMs treated with SRS (36%) or FSRS (64%) from January 1994 to March 2009, and followed until the end of 2012. Previous neurosurgical partial resection (Simpson IV) or biopsies (Simpson V) had been performed in 29.2% of the patients. The median dose of SRS was 14Gy and the total dose of FSRT ranged from 50.4 to 54Gy, fractionated in 1.8 to 2Gy/dose/day. Results: The follow-up period ranged from 36 to 180 months (median= 73months). There was improvement in the individual symptoms and in the clinical and radiological findings regardless the radiotherapeutic method in 41.6% and 48.3% of the patients treated with SRS or FSRT, respectively (p > 0,05). In 37% of the patients, at least one neurological complaint present before the treatment did not change and in 43.8% patients, the image of the tumor remained stable. The progression-free survival in 5, 10 and 15 years was 98.8%, 92.3% and 92.3%, respectively. The improvement of neurological symptoms in patients previously treated with neurosurgery was slower or did not occur as in nonpreviously operated patients. Lethargy and headache were the most frequent transient immediate post-radiotherapy symptoms. Seven patients presented transient optic neuropathy during 3 months and improved with corticosteroids, 2 presented trigeminal neuropathy that remitted rapidly with steroids, and one, had total occlusion of the internal carotid artery without neurological consequences. Conclusions: Both FSRT and SRS were equally safe and effective in the management of symptomatic CSMs. There was improvement or stabilization of the neurological symptoms in the majority ofthe patients and stabilization or regression of the neuroimaging of the lesion in more them 90% of them. The recovery of preexisting cranial neuropathies occurred faster and was more frequent in patients not previously treated with surgical procedure. There was recurrence in 4.5% of the patients. No radiation-induced tumor was observed term during the longest 15 years follow-up

INTRODUÇÃO: A craniotomia pterional é, frequentemente, utilizada para clipagem de aneurismas cerebrais e ressecção de tumores de base de crânio. O traumatismo cirúrgico ao músculo temporal pode levar à cefaléia pós-craniotomia e disfunção mandibular (DTM). Por outro lado, as doenças bucais como cárie dentária, periodontite e câncer bucal são um problema de saúde pública e podem confundir o diagnóstico diferencial das dores orofaciais. O objetivo deste estudo foi avaliar quantitativamente a sensibilidade trigeminal, a condição de saúde oral, a função mastigatória e a qualidade de vida de doentes submetidos à craniotomia pterional para tratamento de aneurisma. MÉTODOS: doentes adultos de ambos os sexos com aneurismas cerebrais, internados no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, foram avaliados nos momentos pré e pós-operatório de 30 dias. RESULTADOS: 39 doentes examinados, dos quais 15 foram incluídos na pesquisa. A idade média foi de 47,7 anos e 73,3% eram mulheres; o valor médio de dor foi 3,7; a abertura bucal média foi 49,5 mm, no momento pré-operatório, e 29,9 mm, no pósoperatório; 86,7% tiveram DTM moderada a grave após a cirurgia; as áreas anatômicas próximas ao traumatismo cirúrgico (no lado operado) apresentaram hipoestesia na maioria dos doentes; a sensibilidade trigeminal foi afetada e a dor esteve presente em todos os pacientes; os doentes apresentavam, em média, 17,3 dentes cariados, extraídos ou restaurados, 42,9% apresentavam periodontite e 42,9% gengivite. Não houve alteração significativa na qualidade de vida no momento pós-operatório de 30 dias, comparado ao pré-operatório. CONCLUSÕES: Todos os indivíduos dentados apresentaram algum grau de doença periodontal e a cárie dentária ocorreu na maioria. A craniotomia pterional afetou o aparelho mastigatório, causando disfunção clínica grave da mandíbula na maioria dos doentes. As sensibilidades álgica (cutânea e nas mucosas orais), térmica e tátil trigeminais foram afetadas, apenas, no lado ipsilateral à cirurgia e, preponderantemente, em regiões anatômicas próximas à área de incisão e diérese / INTRODUCTION: Pterional craniotomy is frequently used for clipping of cerebral aneurisms and resection of cranial base tumors. The surgical trauma to the temporal muscle may cause post-craniotomy headache and temporomandibular dysfunction (TMD). Conversely, oral diseases as dental caries, periodontitis and oral cancer are a public health problem and may confound the differential diagnosis of orofacial pains. This study quantitatively evaluated the trigeminal sensitivity, oral health status, masticatory function and quality of life of patients submitted to pterional craniotomy for treatment of aneurism. METHODS: adult patients of both genders with cerebral aneurysms were evaluated at Clinics Hospital of the University of São Paulo Medical School, preoperatively and at 30 days postoperatively. RESULTS: 39 patients were evaluated, among which 15 were included in the study. The mean age was 47.7 years and 73.3% were females; the mean pain value was 3.7; the mean mouth opening was 49.5 mm (preoperatively) and 29.9 mm (postoperatively); 86.7% had moderate to severe TMD after surgery; the anatomical areas close to the surgical trauma (on the operated side) presented hypoesthesia in most patients; trigeminal sensitivity was affected and pain was present in all patients; in the average, the patients presented 17.3 decayed, missing or filled teeth, 42.9% exhibited periodontitis and 42.9% gingivitis. There was no significant alteration in the quality of life at 30 days postoperatively compared to the preoperative period. CONCLUSIONS: all dentate individuals presented some degree of periodontal disease and dental caries affected most patients. Pterional craniotomy affected the masticatory system, causing severe clinical dysfunction in the mandible in most patients. The trigeminal painful sensitivity (cutaneous and oral mucosa) was affected, as well as the thermal and tactile sensitivities, only on the same side of surgery, and especially in anatomical regions close to the areas of incision and dissection

This project deals with the issue of simulation of dose irradiation. This principle is used in a radiotherapeutic device known as a Leksell Gamma Knife for the treatment of intracranial tumours. With regard to the theoretical observations obtained by studying this device, the project suggests the use of analytical geometry for the creation of a mathematical model for calculation of the intensity in the rayed area. A demonstration program Leksell_xvecer08 has been created for this model in a MatLab software background, which enables the user to change various input arguments and simulate a picture of the dosage spread in the target scanned areas.

Die Arbeit behandelt die Ergebnisse von Experimenten über die Wirkung des Dipeptides Carnosin (β Alanyl L Histidin) und der Aminosäuren L Histidin und β-Alanin auf Kulturen der humanen Zellreihen U87, T98G und LN405, welche von Zellen des malignen Hirntumors Glioblastoma multiforme abgeleitet sind. Die Vitalität der Zellen nach Inkubation mit Carnosin oder L Histidin wurde anhand der Adenosintriphosphatproduktion und der Dehydrohenaseaktivität für Inkubationszeiträume von 24, 48 und 72 Stunden bestimmt. Dabei zeigte sich eine signifikant niedrigere Vitalität der mit Carnosin oder L Histidin inkubierten Zellen gegenüber der unbehandelten Kontrolle. Dieser Effekt war bei L Histidin stärker ausgeprägt. Bei Messungen der Lakatdehydrogenaseaktivität im Medium der Zellen, welche als Indikator für Zellnekrosen diente, zeigten nur die mit L Histidin inkubierte Zellen Zeichen von Nekrose. Die gleichen Messungen wurden auch an humanen embryonalen Nierenzellen durchgeführt (HEK 293), wobei sich ein ähnliches Ergebnis feststellen ließ. In den drei Zellreihen wurde zudem mittels qRT-PCR die mRNA-Expression für die beiden Enzyme Carnosinase 1 und Carnosinase 2 bestimmt, welche L Histidin von Carnosin abspalten. Im Vergleich mit Proben aus normalem Hirngewebe war die Expression beider Enzyme in den Glioblastomzellen deutlich geringer, wenngleich nachweisbar. Nachdem vorhergehende Studien [8] einen Anstieg der Expression von mRNA der Pyruvatdehydrogenasekinase 4 (PDK4) in mit Carnosin inkubierten Glioblastomzellen gezeigt hatten, wurde dieser Effekt hier auch mittels qRT-PCR in mit L Histidin inkubierten Zellen nachgewiesen. Eine Wirkung von Carnosin oder L Histidin auf ein Reportergen des PDK4-Promoters wurde ebenfalls untersucht, wobei sich kein signifikanter Effekt nachweisen ließ.:Table of contents Bibliographische Beschreibung I List of Abbreviations II List of Figures IV List of Tables V 1 Introduction 1 1.1 Overview 1 1.2 Glioblastoma 1 1.3 Carnosine 4 1.4 Histidine 8 1.5 Human pyruvate dehydrogenase kinase 4 gene and enzyme 9 2 Objectives of the study 12 3 Materials and Methods 13 3.1 Materials 13 3.1.1 Cell lines 13 3.1.2 Primers 13 3.1.3 Plasmids 14 3.1.4 cDNA of normal brain tissue 14 3.1.5 Solutions and buffers 14 3.1.6 Enzymes and kits 15 3.1.7 Media 16 3.1.8 Ready-made chemicals 17 3.1.9 Instruments 18 3.1.10 Software 19 3.1.11 Consumables 20 3.2 General microbiological and cytological methods 21 3.2.1 Production of competent E. coli 21 3.2.2 Transformation of RbCl-competent E. coli 21 3.2.3 Preparation of plasmid DNA from cultures of transformed E. coli 22 3.2.4 Cell culture conditions for human cell lines 22 3.3 Assay methods and protocols 24 3.3.1 Transfections and reporter gene assays 24 3.3.2 mRNA-isolation and qRT-PCR 25 3.3.3 Cell viability assays 26 3.4 Construction of the reporter gene (-3968/+319)_PDK4_GauIII 27 3.5 Statistical analysis 28 4 Results 29 4.1 Cell viability of glioblastoma cells under the influence of carnosine, L histidine and β-alanine 29 4.1.1 ATP production under the influence of carnosine, L histidine and β alanine 29 4.1.2 Dehydrogenase activity under the influence of carnosine, L histidine and β alanine 34 4.1.3 Lactate dehydrogenase activity and necrotic cell death under the influence of carnosine, L histidine and β alanine 38 4.1.4 Concentration dependence of viability decrease under the influence of carnosine and L histidine 42 4.1.5 Effect of carnosine and β-alanine on viability of HEK 293 cells 44 4.2 Carnosinase mRNA expression 46 4.3 PDK4-mRNA expression under the influence of L-histidine 48 4.3.1 Enhancement of PDK4-mRNA-expression under the influence of L histidine 48 4.3.2 Development of L-histidine-mediated PDK4-mRNA increase over time 51 4.4 Reporter gene assays 54 5 Discussion 60 5.1 Conclusions 60 5.2 Outlook and suggestions for further research 63 6 Summary 65 7 Literature 68 8 Appendix - Optimization of transfection conditions for U87 cells 74

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We present the case of a 7-month-old baby with Cushing’s disease due to an adrenocorticotropic hormone (ACTH)-secreting pituitary adenoma combined with cells producing thyreotropin-secreting hormone (TSH). In MRI scans, a contrast-enhancing lesion was seen inside the pituitary fossa, and it extended into the suprasellar region. On the assumption of a pituitary adenoma, surgery was performed. Corresponding with biochemical findings, histopathological evaluation revealed an ACTH- and TSH-producing tumor. Genetic analysis did not demonstrate an alteration at codon 201 (Arg) and 227 (Glu). To our knowledge, this is the first case described in a child of this age. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.