Total endoscopic approach to the cauda in a patient with a tight filum.

In this report we describe a patient with a tight filum associated with a small concentric lipoma that was treated by cutting the filum terminale through a totally endoscopic approach. Our approach required the creation of a midline surgical corridor provided by the placement of a telescopic self-retaining retractor over the ligamentum flavum at L5-S1, under endoscopic control. The ligamentum was partially removed, the dura and the arachnoid opened and the filum terminale and the roots of the cauda exposed. After neurophysiological confirmation of the absence of neural structures the filum was coagulated and cut, the dura was closed by a continuous suture and sealed with fibrin glue. The entire surgery was performed under the illumination and magnification provided by a rigid endoscope working in an aerial environment. This case shows that the cauda can be explored and the filum terminale cut with a minimally invasive endoscopic approach that does not significantly compromise the structural integrity of the spine, requires only a short dural incision, therefore reducing the risk of postoperative cerebrospinal fluid leakage, and allows the use of multiple surgical instruments in an aerial environment.

[Angiomatous meningioma and epilepsy in a 2.6-years-old girl]. / Meningioangiomatosi ed epilessia in una bambina di 2 anni e sei mesi.

A case of meningo-angiomatosis (MA), in a 2.6 -years-old girl with refractory focal and secondary generalized seizures, starting at the age of 2 years, is presented. MRI evaluation revealed a lesion located at the left temporal lobe; the patient underwent surgical intervention. Histology revealed the lesion to have the features of MA.

Intramedullary epidermoid cyst: preoperative diagnosis and surgical management after MRI introduction. Case report and updating of the literature.

Many patients with spinal tumours of developmental origin do not receive preoperative diagnosis and the surgical management, especially as for capsule resection, is often unplanned. Like other uncommon tumours, the intramedullary epidermoid cyst is often an operative or histological finding. Since magnetic resonance imaging (MRI) introduction, evidence has accumulated that they may be preoperatively suspected. In reporting the case of a young patient with a T3-T4 intramedullary epidermoid cyst, the authors present an overview of the clinical, radiological and surgical aspects of such tumors and review the latest literature in which MRI and microsurgical excision were performed. Despite the introduction of new diagnostic and surgical instrumentation, the preoperative diagnosis and surgical management of such tumours need further discussion.

Multiple intracranial lesions in head injury: clinical considerations, prognostic factors, management, and results in 95 patients.

BACKGROUND: The goal of this study was to identify clinical and radiological predictors of prognosis in patients with multiple post-traumatic intracranial lesions. METHODS: We reviewed 95 patients (75 male and 20 female) between the ages of 18 and 70 (average 38) admitted between 1993 and 2000 with multiple post-traumatic intracranial lesions. Intracranial pressure (ICP) monitoring was carried out in 67 patients (70%); 77 received intensive care unit (ICU) treatment. Since in all cases it was possible to identify a clearly predominant lesion, 3 groups of patients emerged from the data: the first with extradural hematoma (EDH), the second with a combination of homolateral subdural (SDH) and intracerebral hematoma (ICH), and the third with pure focal intracerebral hematoma (ICH). RESULTS: Twenty-seven patients were treated conservatively, 2 of whom died (7.4%); both had bilateral ICH and compression of the basal cisterns. Sixty-eight patients underwent one or more surgeries; 8 died (11.7%). In the group with EDH-predominant lesions (27 cases) all patients were operated (16 for multiple lesions); no one died. In the group with SDH+ICH-predominant lesions, 26 of 32 patients were operated (10 had multiple procedures); 6 died (18.7%), 3 were vegetative. In the group with ICH-predominant lesion, 15 of 36 patients were operated (7 bilaterally); 4 died (11%). Decompressive craniectomy proved to be a useful means to control ICP. Bilateral lobectomy is not recommended because of poor results. Immediate postoperative computed tomography (CT) scan proved to be mandatory to detect additional surgically treatable lesions (16 cases). Statistical analysis was performed by means of chi(2) analysis and multiple linear regression model. The multiple linear regression model was used to ascertain risk factors independently associated with the outcome. The type of lesion (presence of SDH+ICH predominant lesion), the worst recorded Glasgow Coma Scale (GCS) score, the presence of prolonged increased ICP, and the absence of pupillary reflexes were all statistically significant predictors of a bad outcome (dead or vegetative state). CONCLUSIONS: Multiple lesions have the same prognosis as the corresponding single lesions; therefore, their management should be guided by the predominant pathology.

Dorsally exophytic brain stem tumors: total removal of a medullary pilocytic astrocytoma in child. Clinicopathological considerations and case report.

The authors describe the case of 4-year-old girl who was operated on for a pilocytic astrocytoma of the brain stem, exophytic and protruded backward into the fourth ventricle. The removal through a suboccipital midline approach was performed and macroscopically complete. Postoperative complications compelled a heavy reanimation with a prolonged follow-up therapy. The neurological recovery was favorable. Three years later, this little girl is almost autonomous in all daily activities. Postoperative scans showed total tumor resection. The patient received no complementary treatment such as radiotherapy, chemotherapy or corticotherapy. The long-term survival, without the need for adjunctive therapy, confirms the good prognosis for this unusual group of brain stem tumors. The clinicopathological and radiological features are described and surgical questions are discussed especially regarding complete or subtotal removal of brain stem tumors in demarcated-benign astrocytomas.

Management of head-injured patients in the emergency department: a practical protocol.

BACKGROUND: The management of head-injured patients admitted to emergency departments is not standardized. METHODS: The authors performed a retrospective analysis of 10,000 head-injured patients admitted to the Emergency Department of our hospital in a 21-month period and, on the basis of a statistical correlation between each clinical parameter (symptoms and signs upon arrival at the hospital or risk factors) and the presence of intracranial lesions, they propose a practical protocol in an attempt to avoid the overuse or radiologic examinations and yet identify patients with possible life-threatening complications. RESULTS: On the basis of this correlation the patients have been divided into four groups. In the first group (called group alpha) are patients with: no history of loss of consciousness, no vomiting or amnesia, a normal neurologic examination, and minimal if any subgaleal swelling. They can be released into the care of relatives who are given a special instruction sheet (X rays unnecessary). No patient in group alpha had complications of any kind. The second group (group beta) is made up of patients with at least one of the following features: transient loss of consciousness, post-traumatic amnesia, a single episode of vomiting or significant subgaleal swelling. They undergo a computed tomography (CT) scan and if this is normal, only a short period of observation is needed. If CT scan is not available, the skull is X rayed and, if this X ray is negative, the patient is sent home with the warning sheet after an observation period. If a fracture is found, CT scan should be performed promptly. No patient in group beta with normal skull X rays developed intracranial lesions. The third group (group gamma) contains patients with at least one of the following symptoms: impaired consciousness, repeated episodes of vomiting, neurologic deficits, otorrhagia, otorrhea, rhinorrea, signs of basal skull fracture, seizures, penetrating or perforating wounds, lack of cooperation for varying reasons, patients who have undergone previous intracranial operations or been affected by coagulopathy or submitted to anticoagulant therapy, and finally, epileptic or alcoholic patients. They receive a CT scan immediately and, if necessary, again prior to discharge. Six patients in group gamma with GCS = 15 upon admission were operated on for intracranial hematoma. The fourth group (group delta) is composed of comatose patients. Immediately following resuscitation maneuvers and prior to any surgical intervention, they undergo a CT scan. A linear association between the severity groups and the presence of intracranial lesions has been demonstrated. CONCLUSIONS: The present protocol stresses the importance of the patient's clinical and anamnestic evaluation upon arrival in the Emergency Department, especially in minor head injuries.

Enterogenous cyst of the cervical canal: report of a case in a 68-year-old woman and review of the literature.

A case of a cervical enterogenous cyst in a 68-year-old woman with associated vertebral malformation is presented. The diagnostic value of Magnetic Resonance Imaging, positive reaction to Periodic-Acid-Schiff and immunohistochemical staining for carcinoembryonic antigen are emphasized. The literature is reviewed: controversies about embryogenic theories and classification of these lesions are discussed.

Recurrence of brain abscess associated with asymptomatic arteriovenous malformation of the lung.

On the basis of the data provided by literature the majority of patients with an arteriovenous malformation of the lung who develop a brain abscess suffer from hereditary hemorrhagic telangiectasia, or Rendu-Osler-Weber disease. Only nine cases of brain abscesses in which the arteriovenous malformation of the lung was isolated have been described and in all of these, clinical signs and/or alterations in the laboratory data were detected which can be attributed to the arteriovenous malformation itself. The case taken in this article would seem to be the first case of a recurrent brain abscess in a patient not suffering from Rendu-Osler-Weber with a completely asymptomatic arteriovenous malformation of the lung, both from the clinical point of view and from laboratory data. The authors stress the appropriacy of an angiographic pulmonary study in cases of recurrent brain abscesses, even where the chest X-ray has been negative.

Intracranial meningiomas in patients over 70 years old. Follow-up in operated and unoperated cases.

Forty-six cases of intracranial meningioma in patients above 70 years of age form the basis of this study; 34 underwent surgery while 12 did not. The decision to operate was based on the general condition of the patient, evaluated according to the Karnofsky index, neurological conditions, the site and dimensions of the tumor, and the presence of peritumoral edema. The post-surgical mortality rate was 11.5% at 30 days, and 20% at 3 months. Long-term follow-up in both patient groups ranged from 1 to 5 years, and quality of life was evaluated by the Karnofsky index. Five operated patients died during follow-up (only 1 from intracranial pathology); the 22 survivors showed further improvement in their grading level compared to scores immediately following surgery. Among the unoperated patients, 6 died within two years of diagnosis, all from causes related to intracranial pathology; among the survivors, the Karnofsky index was unchanged in 2, and diminished in the other 4 cases.

Depletion of calcitonin gene-related peptide in perivascular nerves during acute phase of posthemorrhagic vasospasm in the rabbit.

The behaviour of various neuropeptides during early and late vasospasm following experimental subarachnoid hemorrhage has been investigated by several authors. Recently, a reduction of the content of vasodilatory neuropeptides (vasodilatory intestinal peptide, substance P and calcitonin gene-related peptide) has been demonstrated in the perivascular nerves of cerebral arteries after few days from induction of experimental subarachnoid hemorrhage. In the present immunohistochemical study, the authors investigated secretion and expression of CGRP a few minutes after injection of autologous blood into the cisterna magna of the rabbit. The authors propose that the marked decrease of calcitonin gene-related peptide immunoreactivity in the perivascular nerves, observed after experimental subarachnoid hemorrhage, is due to compensatory secretion of the peptide.

A case of amnesia after excision of the septum pellucidum.

Tumours of the septum pellucidum (SP) are rare and seldom associated with memory impairment either before or after operation. A patient is described who developed amnesia after transcallosal excision of a tumour of the SP. Radiology did not show any major lesion of the brain areas traditionally associated with amnesia. Because septal nuclei could have been damaged during surgery their possible role in memory functions is discussed.

Treatment of intracranial meningiomas in patients over 70 years old.

The neurosurgeon often finds himself in the position to having to decide whether or not to operate on an elderly patient suffering from intracranial meningioma. The decision is rarely easy and the results often disappointing. We studied 46 cases of intracranial meningioma in patients over 70 years of age, 34 patients were operated on while 12 patients were not, although both groups were subjected to long term follow-up. The operative mortality rate was 12%, a rate which increased to 20% at 3 months follow-up. Various unfavourable prognostic factors were taken into consideration, the most significant of which were: poor overall clinical condition, peritumoral oedema, the presence of diabetes mellitus and the duration of surgery. A scored grading system was created to standardize surgical indications in elderly patients with cerebral meningioma. An analysis of the grading system, when applied to patients submitted to surgery, showed that the decreased patients within 3 months of surgery had a score which varied from 7 to 12, with a mean score of 10. The surviving patients had a score averaging from 10 to 16 with a mean of 13. The patients with the lowest scores (7-9) had a 100% mortality rate while those in the upper ranges (13-16) demonstrated a mortality rate of 0%. Among the conservatively treated patients the worst outcome was seen in patients with a grading equal to or less than 12.

Clinical evaluation and long-term follow-up in 16 patients with pseudotumour cerebri.

Medical treatment must be promptly established in patients with pseudotumour cerebri. In fact, even though a spontaneous remission of the symptoms is recognized in the literature, we have not any predictive criteria of future visual impairment.

Cavernous angiomas of the central nervous system.

The histopathological, epidemiological, clinical and neuroradiological findings of the cavernous angiomas of the central nervous system have been reviewed, based on an analysis of the literature. C.A. was considered a very rare lesion in the pre-CT era (5% of the vascular malformations). In the past mainly the cavernous angiomas operated on were responsible for a hemorrhagic syndrome or a space-occupying lesion syndrome and less frequently did they present with seizures. Since the introduction of the CT and moreover of MRI the reported cases of cavernous angiomas in the C.N.S. have increased considerably (25.1% of the vascular malformations). Familial cases, multiple localizations, association with tumors and other vascular malformations and extracerebral dural localizations have been documented. Angiographic examination can be negative, but in some cases a capillary blush in the late venous phase has been demonstrated. CT scan and MRI are the best procedures for the diagnosis of cavernous angiomas. MRI is able to demonstrate small and no recent traces of bleeding, but CT is more sensitive in distinguishing calcifications. Surgical results depending on the site of the angioma have been reported. Radical removal and good recovery have been documented in supratentorial cases, while partial removal and poor results have been reported in deeply sited cases (including spinal cord).

Subarachnoid haemorrhage due to acoustic neurinoma. Case report and review of the literature.

One case of spontaneous subarachnoid haemorrhage due to acoustic neurinoma is presented. The literature regarding this subject is reviewed and the pathogenesis of haemorrhage from neurinoma is discussed.

Solitary plasmacytoma of the calvarium: two cases treated by operation alone.

Two cases of solitary plasmacytoma of the calvarium operated on with radical removal are reported. The two patients were not submitted to postoperative radiotherapy, unlike other cases reported in the literature. The authors stress that solitary plasmacytoma of the calvarium may have a good prognosis if radically removed, and in these cases radiotherapy is not necessary.

Acute spontaneous subdural hematomas.

Fifteen cases of spontaneous subdural hematoma are presented. A review of the literature reveals the rarity of this pathology. Symptomatological onset cannot be distinguished from the other cerebrovascular lesions. High mortality is connected with patient's consciousness level. CT scan performed in all patients presenting symptoms of cerebral stroke permitted to demonstrate this clinical entity is not so rare as the literature asserted.

Acute bilateral epidural hematomas. Report of two cases and review of the literature.

Two cases of acute postraumatic bilateral epidural hematomas with different clinical pictures are presented. In the review of the literature, acute, subacute and delayed bilateral epidural hematomas must be found. Clinical findings, results of CT scan and pathophysiology are discussed.

Non tumoral aqueduct stenosis. Multiple microscopic subependymal glial protuberances demonstrated at hystological examination.

A case of hydrocephalus associated to aqueduct stenosis is described. The microscopic examination showed aqueduct gliosis which was not possible to distinguish congenital or acquired.