Solitary metastases to the cranial vault. Report of ten cases.

BACKGROUND: Metastatic spread of tumors to the skull is quite unusual and often represents a relevant diagnostic and therapeutic problem. Skull involvement can be observed in various neoplasms of epithelial origin (rarely in other tumors) and most often responsible are lung, breast, thyroid, kidney and prostate cancers. Less frequent than multiple involvement, single cranial vault lesions are often amenable to surgical resection instead of radiotherapy alone; scope of this paper is to highlight the key points of the management of such entities, including a brief review of the pathological and radiological features of these entities. METHODS: A retrospective study has enabled us to select from our files ten cases of surgically treated solitary cranial vault metastases, with a variable follow-up ranging from 6 months to 4 years. In all the cases the operation consisted in a monobloc resection and a cranioplasty for the repair of the defect. RESULTS: We have observed no perioperative morbidity or mortality; in all the cases surgery allowed histologic confirmation and immediate relief of neurological symptoms and cosmetic impairment (when present). CONCLUSIONS: Monobloc resection of solitary cranial vault metastatic lesions is an easy made and safe procedure, to be performed in every patient except the ones in poor general conditions, which are better addressed to radiotherapy alone.

Cavernous hemangioma of the parietal bone. Case report and review of the literature.

Intraosseous cavernous hemangiomas are a rare finding in the calvarium. It is a benign tumor arising from the intrinsic vasculature of the bone. We report one case observed in a 20 year-old male. The diagnostic peculiarities and therapeutic implications of this lesion are discussed and the available literature on this subject is reviewed. These tumors do not recur once a radical surgical removal is performed.

Advances in diagnosis, treatment and prognosis of intracerebral tuberculomas in the last 50 years. Report of 21 cases.

Intracranial tuberculosis accounts for less than 0.2% of intracranial space-occupying lesions diagnosed and treated in western countries, while it still represents a major neurosurgical finding in underdeveloped countries. The introduction of chemotherapeutic agents for the treatment of tubercular infection, as well as the general improvement in the socio-economic status of the population as a whole, have both played an important role in the dramatic reduction of intracranial tuberculomas in industrialized countries. The increasing migration flow from third world countries, along with other factors, will probably result in increased exposure to such pathologies also in western Neurosurgical centers. A series of intracranial tuberculoma lesions were selected and analyzed, with the aim of pointing out the evolution of diagnosis, treatment and prognosis of such clinical entities throughout the years.

The surgical treatment of pituitary adenomas in the eighth decade.

BACKGROUND: The surgical treatment of pituitary adenomas in elderly patients (i.e., over 70 years of age) is a special problem because of the increased rate of perioperative complications and the reduced tolerance of postoperative fluid and electrolyte imbalance. Therefore, the unquestionable progress in the pharmacological and radiotherapy may not allow these patients the option of radical surgical treatment. We report our experience with the transsphenoidal procedure for pituitary adenomas in aged patients in an attempt to contribute to a better definition of the actual role of surgery. METHODS: Transsphenoidal surgery was performed in 11 patients over 70 years of age affected by various histological types of pituitary micro- and macroadenomas, ranging from Hardy Grade I through IIIc. Special care was dedicated to the postoperative treatment, in particular to water and electrolyte balances, and to the immediate treatment of any pathological variation of these parameters. RESULTS: We had no mortality and no postoperative adjunctive morbidity. All the patients recovered well from the operation with an average hospital stay of 20 days. The tumor removal was complete in six cases and partial in the remaining five. With an average follow-up of 2 years, we did observe only one case of symptomatic recurrence of the disease. CONCLUSIONS: Transsphenoidal surgery in the elderly is feasible and quite safe in the hands of an experienced team, if special care is devoted to the preoperative selection of patients and to the postoperative treatment of fluid and electrolyte imbalance.

An early approach to controlled hypotension: Felice Visalli and the "pneumoanemizator.".

In this historical vignette, the authors describe the conception and realization of the "pneumoanemizator," an ingenious pneumatic apparatus originally designed in the 1940s for the purpose of controlled hypotension. The authors also give a biographical sketch of its inventor, the pioneering Italian neurosurgeon Felice Visalli. The general working features of this nearly forgotten device and its performance in experimental and clinical trials are evoked in the light of a brief history of controlled hypotension.

[Neurosurgery in Rome: 1880-1970]. / La neurochirurgia a Roma: 1880-1970.

Among many factors contributing to the birth of Neurosurgery, the "awareness of feasibility" of neurosurgical procedures is especially significant. June 1st, 1885 is the arbitrary birthdate of Neurosurgery in Rome: Francesco Durante, Professor of Surgery at the Royal University, successfully resects an olfactory groove meningioma, arising admiration worldwide. Roberto Alessandri succeeds Durante in 1919. In roman hospitals outstanding surgeons perform from time to time neurosurgical procedures, sometimes with satisfactory results: Paolo Postempski, Cesare Antonucci, Guido Egidi and Raffaele Bastianelli, first director of the "Regina Elena" Cancer Institute (IRE) (April 1933) and friend of Harvey Cushing. Angelo Chiasserini sr. is however the first roman surgeon constantly committed to Neurosurgery and founder of the first neurosurgical unit in Italy, in 1937; also, from 1941 to 1944 he directs a neurosurgical service at the "Celio" military hospital of Rome, to which patients from the various battle theatres are referred. While Mario Margottini and Piero Frugoni follow Bastianelli's steps at the IRE, the roman neurosurgeons Felice Visalli and Libero Ugelli serve in the Army, during the greek-albanian conflict and in Russia, respectively. In May 1955 Beniamino Guidetti, an Olivecrona pupil, is called at "La Sapienza" University of Rome and elevates the neurosurgical clinic at the highest standards. The other main neurosurgical pole is founded in 1958 at the San Camillo Hospital: within both institutions modern neurosurgical teams are formed along with neuroradiological and neuroanesthesiological staffs.

[Surgery of lumbar disk hernia: historical perspective]. / Chirurgia dell'ernia discale lombare: evoluzione storica.

Although the clinical picture of discogenic sciatica is well known already in the ancient world, it is not until 1933 that WJ Mixter and JS Barr provide the correct pathogenetic interpretation and suggest surgery as the treatment of choice. The work of the American Authors was however based on the knowledge acquired during the previous centuries starting with Domenico Cotugno, who first suggested the neurogenic nature of sciatica (1764) and later with the neurologists of the french school Valleix, Lasègue, Dejerine, Sicard who elucidated the semeiology and debated in detail the etiopathogenesis of the condition. The german pathologists Schmorl and Andrae (1927-29) are to be credited for their contribution to the pathology of intervertebral disc, recognizing the frequency and degenerative (not neoplastic) nature of nucleus pulposus herniation. Surgery of disc herniation starts with Oppenheim and Krause (1909). Mixter and Barr used laminectomy and a transdural route although a more limited approach to the spinal canal had already been proposed by the italian Bonomo (1902), unknown to many. Love, of the Mayo Clinic (1937-39) introduced the extradural/interlaminar approach while Caspar and Yasargil (1977) applied the concepts of microsurgery to the procedure. The latest advances are represented by percutaneous and endoscopic techniques.

[Current trends and prospects of fetal neurosurgery]. / Attualità e prospettive della neurochirurgia fetale.

Fetal surgery failed up to now to correct early in gestation nervous system pathologies before an irreversible damage occurs. The major hindrance is the induction of preterm labour considered for fetal surgery what rejection is for organ transplantation. Pharmacological tocolytic control seems an essential step before a routine surgery is established. In the meanwhile miniinvasive endoscopic surgery holds out the best promises, minimizing fetal and maternal stress. There are many convincing experimental evidences that endoscopic surgery may prevent secondary neurological damage of spinal cord in the myelomeningocele. Vascularized latissimus dorsi muscle flap or skin graft were effectively used, with endoscopic techniques, to create a protective patch to preserve the nervous tissue from mechanical and/or chemical damage. Endoscopic implant of neurons-rich grafts in damaged cerebral sites, with beneficial behavioural effects and increased learning capacity in the recipient animal with respect to controls, disclose further perspectives to fetoscopic surgery.

1897--celebrating the centennial--Hermann Moritz Gocht and radiation therapy in the treatment of trigeminal neuralgia.

Among German radiologists and orthopaedic surgeons Hermann Moritz Gocht (1869-1938) is one of the most prominent figures. In addition to his noteworthy contributions to the progress of orthopaedic surgery, in 1897 he introduced the use of radiotherapy for the treatment of trigeminal neuralgia. Subsequently the value of this technique was widely recognized by radiologists and neurosurgeons, and it is still acclaimed as the most brilliant intuition of this famous pioneer of radiology. Gocht made also important contributions to the technical development of X-ray apparatus and to the definition of the radiological anatomy of the skeleton, as well as to orthopaedic surgical pathology. The aim of this paper is to celebrate the centennial of Gocht's introduction of radiotherapy in the treatment of neuralgic syndromes and to express our appreciation of the work of this eminent scientist.