Third ventricle cavernoma associated with venous angioma. Case report and review of the literature.

A case of third ventricle cavernous angioma associated with venous angioma is reported. By a transventricular approach, the cavernoma was totally removed with successful preservation of the venous malformation. After review of the literature, the clinical characteristics and the surgical approach to third ventricle cavernous angioma are discussed; the importance of preservation of associated venous angioma is also underlined.

Carotid endarterectomy: a new technique replacing internal shunts.

BACKGROUND: Carotid endarterectomy has been reported to increase the time free from cerebral ischemic events in both symptomatic and asymptomatic patients with a high grade of stenosis of the internal carotid artery. In cases in whom the compensatory circulation during the carotid clamp time is not sufficient, the use of intraluminal shunts has been proposed. However, the use of intraluminal shunts present several problems, such as the technical difficulties in positioning the shunt, the variability of time requested for the placement, the inconstancy of the blood flow during surgery, and the need to clamp off the carotid to introduce and remove the shunt. For these reasons, most operators prefer not to employ intraluminal shunts, while others do use them only in selected cases. The purpose of this work is to present, for the first time, a new type of temporary extraluminal shunt, connecting the femoral to the internal carotid artery with the interposition of a roller pump to regulate the blood flow. This method allows one to perform carotid endarterectomy without interrupting the blood flow to the brain. METHODS: 407 consecutive patients, who underwent carotid endarterectomy between August 1992 and April 2000, were considered. 35 patients presented an absolutely insufficient collateral circulation, demonstrated by important modifications of the electroencephalographic monitoring during the carotid clamp time. In these patients the endarterectomy was performed using a new femoral-carotid extraluminal shunt. FINDINGS: In all the cases in whom the femoral-carotid extraluminal shunt was positioned, the normalisation of electroencephalographic monitoring was achieved by regulating the blood flow with the interposed roller pump. The use and the placement of the shunt was simple and easy. None of the patients showed postoperative complications, except for one who had a stroke two days after surgery. INTERPRETATION: The results obtained, although to be confirmed by further studies, seem to demonstrate the effectiveness of our femoral-carotid extraluminal shunt, which was simple to use and safe.

Subependymoma of the spinal cord: case report and review of the literature.

Spinal cord subependymoma is a rare tumour with only 39 reported cases in the literature. The authors report a further case of this neoplasm in a 53 year old man with a progressive paraparesis, paraesthesias of the lower limbs and sphincter disturbance. The tumour was partly removed, without progression 5 years after surgery. After a careful review of the literature, the optimal treatment of this spinal tumour is debated.

Cytogenetic and ultrastructural study of a pineocytoma case report.

The authors report a case of pineocytoma in a 44-year-old woman suffering from headache, vomiting and Parinaud syndrome. At histopathological examination the neoplasm showed a ill-defined lobulate pattern with some small pineocytomatous rosettes. The electron-microscopy revealed cells of moderate size and oval nuclei with smooth nuclear envelopes; well-developed organelles were found in the, abundant cytoplasm. The chromosome analysis revealed this kariotype: 58-59, XXX, -4, -5, -13, - 14, -15, + 19. This is the first report of a pineocytoma with ultrastructural and cytogenetic study; it confirms the literature findings of the electron-microscopy, whereas there is partial accordance with the previous cytogenetic studies.

Delayed post-traumatic cervical instability.

BACKGROUND: Cervical spine instability is a clinical entity whose biomechanical and radiological features have been widely discussed by many authors. On the other hand, the subject of delayed post-traumatic cervical instability is often surrounded by confusion due to its difficult nosologic framing; the aim of this study is to contribute to the matter. METHODS: A cooperative study was organized by the Study Group for Spinal Surgery of the Italian Society of Neurosurgery to evaluate cervical trauma patients surgically treated more than 20 days after the traumatic event. From a total number of 172 patients, twenty-five were admitted to the study, because neuroradiological investigations performed during the acute phase had shown either an absence of traumatic lesions or only minimal lesions judged to be stable. For this reason these 25 patients had not been treated by either surgery or immobilization in a halo vest. Some time after trauma, this group of patients clearly demonstrated evidence of unstable lesions requiring surgical treatment, following the appearance of new clinical signs or on neuroradiological follow-up. RESULTS: Re-examination of the neuroradiological investigations performed during the acute phase made it possible to identify elements that might have led us to suspect the presence of ligamental lesions: microfractures, dislocations less than 3 mm, and inversion of physiological lordosis. CONCLUSIONS: This review clearly indicates that patients with even mild cervical trauma must be scrupulously evaluated during the acute phase and that in some cases it is advisable to perform a more detailed neuroradiological investigation.

Management of "critical" aneurysms of the anterior circulation: technical suggestions.

This paper first goal is to establish what "critical" aneurysm means. We decided to consider as "critical" aneurysms those whose correct clipping-treatment would be particularly difficult; this particular difficulty could concern the malformation intrinsic characteristics as well as extrinsic factors (the patient's clinical conditions as well as insufficient organizational or technical facilities). We thus reviewed 277 aneurysms operated in the Neurosurgical Department of Varese from 1988 to 1994. We excluded 18 vertebro-basilar system aneurysms; the clinical and surgical charts of the 259 remaining aneurysms were reviewed and informations regarding their last clinical conditions were gathered. In this way it was possible for us to distinguish different categories of critical aneurysms: critical for their anatomical position, morphology, size and for their number; unpredictably critic aneurysms and aneurysms associated with the patient's critical conditions were also considered. After describing our technical solutions and those suggested by the current literature we concluded that what is required to treat these critical aneurysms is not an extraordinary surgical skill, but a good organizational and technical facility at the surgical-team's disposal.

Subtemporal suboccipital transpetrosal transsigmoidal approach to aneurysm of the basilar artery fenestration.

The aneurysm arising from the lower third of a basilar artery fenestration is a rare event. The traditional suboccipital or subtentorial transtentorial or transoral approach to this vascular malformation can be problematic. We report the case of a 52-year-old woman who suffered a Grade 4 subarachnoid hemorrhage from an aneurysm located at a fenestration of the proximal third of the basilar artery. This aneurysm was successfully clipped through a left subtemporal suboccipital translabyrinthine transsigmoidal approach. In the aneurysms of the proximal third of the basilar artery the transpetrosal approach with its variants (translabyrinthine and transsigmoidal) related to patient's clinical condition can be useful with undoubted advantages.

Carotid Sinus Syndrome: a review of the literature and our experience using carotid sinus denervation.

BACKGROUND: The Carotid Sinus Syndrome (CSS) is a rare condition causing spontaneous syncopal attacks or marked dizziness. METHODS: We studied 28 patients affected by CSS from January 1991 to October 1996. Eleven patients affected by cardioinhibitory type were treated by pace-maker (PM) implant. Seventeen patients had mixed type and all, but one who refused any treatment, entered this study. Carotid Sinus Denervation (CSD) was first performed in 2 of 10 patients who remained symptomatic after PM and in 6 patients as first choice therapy. RESULTS: At a mean follow-up of 30 months no patient submitted to CSD had recurrent syncopal attacks or dizziness. CONCLUSIONS: CSD is a safe and simple technique to abolish either the cardioinhibitory or the vasodepressor response in CSS.

Intrathecal administration of different drugs by programmable infusion device in chronic pain. A case report.

Objective and Importance. The subarachnoid infusion of narcotics by programmable devices in patients with chronic non-malignant pain can be a useful therapeutic method. However, certain side-effects, opioid tolerance or changes in the nature of the pain can lead to failure of the therapy. Clinical Presentation. We present a case report of a woman with both chronic perineal pain and sciatic pain with radiation to her lower limbs caused by failed back surgery syndrome. The pain proved to be resistant to common medical therapy and to spinal cord stimulation. Technique. After surgical implantation of a programmable infusion pump, the patient's leg pain improved with an intrathecal infusion of morphine and bupivacaine. The perineal pain was treated with an infusion of clonidine. The patient therefore needed alternative infusions of both drugs with changes of infusional parameters. Conclusion. The possibility of varying the infusion method of mixed drugs or alternating the drugs is fundamental for successful therapy since neuropathic pain must be considered a dynamic state.

Iatrogenic intracranial aneurysm. Case report and review of the literature.

A case of a 56-year-old woman that developed subarachnoid haemorrhage from iatrogenic post-traumatic aneurysm of the cortical middle cerebral artery due to a ventricular tap for hydrocephalus is presented. Previous reported cases of postsurgical aneurysms of the cerebral vessels are discussed and the pathogenesis, the clinical course, the outcome and the advisable treatment of this condition are debated.

Intracranial meningioma associated with cerebral artery aneurysm. Report of two cases and review of the literature.

Two cases of association between intracranial meningioma and cerebral artery aneurysm are reported. A 50-year-old woman had a petroclival meningioma with a carotid-ophthalmic artery aneurysm; the surgery was performed first for the aneurysm then for the meningioma with good results. The second patient, a 67-year-old woman, had an olfactory meningioma with a carotid-posterior communicating artery aneurysm treated successfully in the same procedure. The pertinent literature is reviewed and the localization of meningiomas and aneurysms, the surgical treatment and the results at distance are discussed. It seems advisable, when possible, the contemporaneous treatment of the two lesions.

Associated olfactory groove meningioma and acoustic neurinoma.

The authors describe the case of a 71-year-old man without signs of phacomatosis with a history of progressive psychomotory lowering and two simultaneous tumors of the olfactory groove and of the cerebellopontine angle, as demonstrated by CT scans. Histologic examinations showed the lesions to be a meningioma and a neurinoma. The rarity and the possible pathogenesis of this association are discussed.

Intracranial meningioma and astrocytoma in the same patient. Case report and review of the literature.

The authors describe the case of a 58-year-old man with an history of seizures because of right parietal parasagittal meningioma. Twenty-two months after complete removal of this neoplasm, the patient showed progressive mental deterioration and at CT-scans revealed a right temporal anaplastic astrocytoma which was operated. In literature the association between intracranial meningioma and astrocytoma is reported in 41 cases. After a brief review of the previous cases, the authors debate the clinical presentation, the diagnostic problems, the aetiopathogenetic hypotheses and the best surgical treatment of this association.

Percutaneous cervical diskectomy: preliminary experience.

We assessed the feasibility of percutaneous treatment of a cervical herniated disc. In the lumbar region, the surgical instrument for percutaneous diskectomy passes only through the paravertebral muscles, while in the cervical region there is considerable risk of nervous, parenchymal and vascular lesions. Moreover, open surgery for cervical herniated nucleus pulposus is a well-established, low-risk procedure, with little risk of epidural fibrosis, the main complication of lumbar open surgery; a percutaneous procedure should therefore have a low morbidity rate. A safe percutaneous approach to cervical discs could be useful for biopsy and for treatment of high-risk patients for general anaesthesia. We treated 15 patients with cervical herniated nucleus pulposus; all gave informed consent and refused or were not eligible for open surgery. We used the Nucleotome described for treatment of lumbar herniated discs; except for the first three cases, we used colour Doppler sonography to detect hazardous structures in the path of the probe. We had one complication, a cervical haematoma due to damage to the inferior thyroid artery, prior to the use of ultrasound.

Intracranial cavernous angioma. Report of two cases in the same family.

We report two cases of intracranial cavernous angioma in members of one family and discuss our clinical and surgical findings in a further 10 cases of this lesion seen in the past five years. We stress the value of RNM, which supplies a precise diagnosis of nature, site and size, especially when the lesion is surrounded by a recent hematoma. NMR is especially indicated in suspected familial cavernous angioma, as in the cases reported.

Lumbar neurinoma associated with hydrocephalus. Case report.

The authors describe the rare case of a 50-year-old man with lumbar neurinoma associated with hydrocephalus. The complete neuroradiological study is presented. The various explanations about the pathogenesis of the hydrocephalus and the management of this condition are debated.

Associated chronic subdural haematoma and meningeal neoplasm. Two case reports.

The authors present two cases of non-traumatic subdural haematomas associated with a meningioma. Relevant literature is reviewed and the pathogenesis of this rare condition is discussed.

Saccular aneurysm associated with proximal basilar artery fenestration. Case report.

When an aneurysm arises from a limb of an arterial fenestration at the vertebrobasilar junction or in the proximal third of the basilar artery, its surgical management can be an intriguing problem. We report here a case of such an aneurysm successfully clipped through a right subtemporal transtentorial approach.

Intracranial aneurysm associated with cerebral cavernous angioma. Case report.

The very rare case of association of anterior communicating artery aneurysm and a right frontal cavernoma not visualized by CT-scan and angiography in a 37-year-old man is described. The rarity and the possible pathogenesis of this association are discussed.