Cognitive deficits in patients with low and high grade gliomas.

AIM: Studies in the literature with specific information concerning the neuropsychological alterations in patients with high and low grade gliomas are poor. The aim of the present study was to investigate and compare the cognitive functioning in patients with high and low-grade glioma pre- and postoperatively. METHODS: Between January 2009 and January 2011 27 patients with high-grade glioma (HG group) and 15 patients with low-grade glioma (LG group) were neuropsychologically assessed in the preoperative time, as well as 6 months and 1 year after surgery. During the examination, memory, visuo-constructive abilities, language and executive functions were tested. In addition in the preoperative time, the effect on cognition of lateralization, size and edema was analyzed for each group. RESULTS: Both in the HG and LG group statistical comparisons of the pre- and postoperative assessments of cognitive abilities showed a postoperative improvement in memory functions and in processing speed (P<0.05). In particular the analysis of the significance of clinical factors in the postoperative outcome of patients with glioma showed that lesion size, edema and lateralization affect cognitive functioning in varying degree. CONCLUSION: These findings demonstrated different levels of impairments in executive and memory domains and in processing speed in patients with low and high grade gliomas. These deficits may have a strong impact on quality of life. Psychiatric interventions may be useful for patients and their families; in particular for helping the patient to become aware of the illness, in bolstering coping strategies, and for facilitating their support at home.

Survival prognostic factors in patients with glioblastoma: our experience.

AIM: Approximate survival for glioblastoma is less than 1 year. Age, histological features and performance status at presentation represent the three statistically independent factors affecting longevity. The purpose of the study was to assess the role of surgery and to analyze prognostic factors in our patients operated for glioblastoma. METHODS: We evaluated in 56 patients operated for glioblastoma their depressive and performance status in the preoperative and postoperative time. Moreover we analyzed the extent of surgery, the site and the size of lesions. RESULTS: Median overall survival was 17 months. An age of ≥60 years (P<0.03), a preoperative Karnofsky Performance Status KPS≤70 (P=0.04), a subtotal tumor resection (P<0.001), a tumor size >5 cm (P=0.01), and no postoperative adjuvant treatment (P=0.01) were associated with the worst prognosis. Before surgery we found the presence of depression in 10 patients with a significative reduction of mean Back Depression Inventory scores after tumor resection (P=0.03). Finally, a KPS≤70 was significantly associated with an increased incidence of depression in the postoperative time. CONCLUSION: Tumor size, total resection and affective disorders were identified as predictors of survival in our series of patients with glioblastoma in addition to age and KPS score. In our opinion an early diagnosis and the use of specific safeguards in the operating room contribute to have an extension of the tumor progression time and median survival.

Reorganization of functional connectivity of the language network in patients with brain gliomas.

BACKGROUND AND PURPOSE: fcMRI measures spontaneous and synchronous fluctuations of BOLD signal between spatially remote brain regions. The present study investigated potential LN fcMRI modifications induced by left hemisphere brain gliomas. MATERIALS AND METHODS: We retrospectively evaluated fcMRI in 39 right-handed patients with a left hemisphere brain glioma and 13 healthy controls. Patients and controls performed a verb-generation task to identify individual BOLD activity in the left IFG (Broca area); the active region was used as seed to create whole-brain background connectivity maps and to identify the LN (including bilateral regions of the IFG, STS, and TPJ) following regression of task-evoked activity. We assessed differences between patients and controls in the pattern of functional connectivity of the LN, as well as potential effects of tumor position, histopathology, and volume. RESULTS: Global fcMRI of the LN was significantly reduced in patients with tumor compared with controls. Specifically, fcMRI was significantly reduced within seed regions of the affected hemisphere (left intrahemispheric fcMRI) and between the TPJ of the 2 hemispheres. In patients, the left TPJ node showed the greatest decrease of functional connectivity within the LN. CONCLUSIONS: The presence of a brain tumor in the left hemisphere significantly reduced the degree of fcMRI between language-related brain regions. The pattern of fcMRI was influenced by tumor position but was not restricted to the area immediately surrounding the tumor because the connectivity between remote and contralateral areas was also affected.

Less invasive approaches for the treatment of cervical schwannomas: our experience.

PURPOSE: The purpose of our paper is to illustrate our experience with minimally invasive approaches for the treatment of cervical schwannomas. Moreover, a brief review of the literature was conducted. METHODS: All data regarding patients treated for cervical schwannomas were retrospectively revised. Site, size and extension of the lesions and preoperative neurological status were obtained through re-examination of neuroimaging and clinical records. Postoperative clinical examinations and radiological images were available for all patients. The clinical course was documented using the visual analog scale (VAS), Karnofsky score (KPS) and the Klekamp-Samii score system. RESULTS: Sixteen patients harboring cervical schwannomas were treated from 2003 to 2009. Hemilaminectomy was performed in eight cases, subtotal hemilaminectomy in four cases, interlaminar fenestration in two cases, osteoplastic hemilaminotomy and laminoplasty in one case each. Postoperative neuroimaging revealed complete removal of the lesion and no signs of spinal instability. At discharge, neurological improvement was observed in 14 patients and all patients demonstrated reduction of VAS score and improvement of KPS and Klekamp-Samii's score. CONCLUSIONS: Minimal access procedures are increasingly gaining popularity but their use is poorly described in the treatment of cervical tumors. Less invasive approaches may effectively be used instead of traditional laminectomy in the treatment of cervical tumors, especially schwannomas, providing less iatrogenic traumatism and preventing postsurgical spinal instability. Modern neuroimaging allows adequate preoperative planning and microsurgical techniques provide adequate execution of the surgical act. The procedure has to be tailored case by case considering the specific lesional features and the individual anatomical situation.

A rare case of intracranial rosai-dorfman disease mimicking multiple meningiomas. A case report and review of the literature.

Rosai-Dorfman disease (RDD) was firstly described in 1969 as a benign proliferative disorder of histiocytes with systemic symptoms and lymphadenopathy. This disease is of uncertain pathogenesis and mostly occurs in children and young adults. The typical clinical features of RDD include bilateral painless cervical lymphadenopathy, but extranodal involvement may also be present. The most common extranodal sites include organs such as the respiratory tract, skin, nasal cavity, orbit and bone. Isolated central nervous system (CNS) manifestations are extremely rare. In case of CNS involvement, the commonest imaging findings are dural-based extra-axial enhancing masses. We describe a case of intracranial RDD mimicking multiple meningiomas both clinically and radiologically in a 57-year-old man presenting with a six-year history of progressive right visual and hearing loss and tinnitus. In cases of multiple extra-axial lesions it is worth bearing in mind the possible differential diagnosis for intracranial RDD and eventually propose to the patient further investigations.

IL-31 a Th2 cytokine involved in immunity and inflammation.

Cytokines are immunal regulatory proteins, however they also play a relevant role in inflammatory diseases. IL-31 is a newly discovered cytokine expressed primarily in TH2 cells, introduced by activated CD4+ T cells. IL-31 is capable of inducing chemokines and other cytokines in several inflammatory diseases via its surface receptor. This cytokine is also produced by mast cells and mast cell line, suggesting a role in allergic diseases. In this editorial we revisit the biological role of IL-31 in immunity and inflammation.

VEGF, substance P and stress, new aspects: a revisited study.

Mast cells play an essential role in diverse physiological and pathological processes, such as atherosclerosis, malignancy, asthma, pulmonary fibrosis and arthritis, directly interact with bacteria, and appear to play a vital role in host defense against pathogens. Mast cells could be recruited in the inflammatory site, by MCP-1, RANTES and SCF, to selectively secrete proinflammatory molecules; these could include growth factors, histamine, which is mitogenic (H1) and an immunosuppressant (H2), neovascularization agents, such as heparin, IL-8, and VEGF, as well as proteases that could permit new blood vessel formation. Neurogenic inflammation involves vasodilation and plasma protein extravasation in response to neural stimulation. Upon stimulation, sensory neurons release Substance P and other neuropeptides and activate neurokinin-1 receptors leading to plasma protein extravasation from post-capillary venules. Substance P is a neuropeptide that is released from nerve endings in many tissues and plays an important role in immunological and inflammatory states, and it is also a mediator of tissue injury, asthma, arthritis, allergy and autoimmune diseases. SP-positive nerve fibers and mast cell contacts are increased by acute stress in mice leading to dermal mast cell degranulation. VEGF is produced by flammatory cells. IL-33 is the newest inflammatory member of the IL-1 cytokine family and we show here that SP can induce VEGF secretion from mast cells and IL-33 augments the effect of SP in VEGF transcription and translation protein.

Combined endovascular and microsurgical approach in the treatment of giant paraclinoid and vertebrobasilar aneurysms.

AIM: The aim of this study is to present the application of endovascular intraoperative occlusion of the parent artery during the microsurgical treatment of giant paraclinoidal internal carotid artery aneurysms (ICA) and of complex vertebrobasilar junction aneurysms . METHODS: Five cases of giant paraclinoidal ICA aneury-sms were treated by direct surgical approach. In the operatory room any patient underwent angiography and balloon occlusion test using a mobile digital subtraction angiograph. Thereafter the catheter was left in the aortic arch. Through an extended pterional craniotomy, it was possible to evidentiate the aneurismal sac. The proximal control of the vessel was achieved inflating a double-lumen balloon; clipping of the aneurysm was achieved, because of pressure lowering inside the aneurysm. Also a giant vertebrobasilar junction aneurysm was treated by this combined technique: using a posterolateral approach the control of the omolateral vertebral artery was obtained by temporary clipping above PICA's origin; the control of controlateral artery was obtained inflating a balloon introduced through the femoral artery. These combined manoeuvres determined sac deflation, allowing an easier clipping. RESULTS: Aneurysm obliteration was achieved with preservation of the circulation without complications in all cases. CONCLUSIONS: The endovascular procedure allows safer and reliable proximal control of paraclinoidal ICA and vertebral artery during the microsurgical treatment of paraclinoid and vertebrobasilar junction aneurysms.

Supratentorial cavernomas in eloquent brain areas: application of neuronavigation and functional MRI in operative planning.

AIM: Cavernomas located in eloquent areas of cerebral hemispheres represent a challenge for the neurosurgeon. An accurate surgical approach is essential to completely remove the lesion with function preservation. Aim of this study was to evaluate the usefulness of integration between standard magnetic resonance imaging (MRI) for neuronavigation and functional MRI (fMRI) in preoperative planning and intraoperative removal of cavernomas. METHODS: Between June 2000 and December 2002, 21 patients underwent surgery for supratentorial subcortical cavernomas. Eleven lesions were located adjacent to eloquent brain areas. All the patients in the series underwent MRI for neuronavigation and, since January 2002, in 6 cases of lesions located in eloquent areas, fMRI was also performed, with subsequent images fusion. The surgical approach was performed via the transgyral route under conventional and ultrasound-guided neuronavigation. RESULTS: All the lesions were totally removed. No morbidity was seen in patients harbouring lesions in non eloquent areas. Four patients with lesions in critical areas suffered transient focal deficits, but only one patient of this series was operated on by the auxilium of image fusion. In 7 patients operated on by conventional image-guided surgery and affected by preoperative seizures, no further seizures were observed after surgery. In 3 patients more hosting lesions neighbouring critical areas, the perilesional ring was not removed, observing persistence of seizures pharmacologically treated. In 4 of the 6 patients (all affected by seizures), operated on by fMRI auxilium, lesion removal was associated to the removal of the perilesional ring. No further epilepsy was seen in these patients. CONCLUSIONS: In all the cases the use of neuronavigation allowed minimally invasive approaches and radical excision of the lesions. Moreover, fMRI seemed to provide important additional information in patients with lesions in eloquent brain areas, allowing a more aggressive approach on the perilesional tissue to the aim of resolving seizures, in absence of an increase in the morbidity rate.

The interhemispheric transcallosal-transversal approach to the lesions of the anterior and middle third ventricle: surgical validity and neuropsychological evaluation of the outcome.

Based on the observation of the course of callosal fibres and of their artero-venous support as appearing in a microanatomic study, the Authors propose a variant of standard callosotomy procedure by the introduction of the transverse section of callosal fibres. This technique would allow the surgeon to spare a larger number of callosal fibres by the combined effect of a lower direct mechanical traction on fibres and a lower impact on artero-venous microcircle. The neuropsychological outcome of the patients who underwent this kind of procedure was evaluated. Fourteen patients affected by occupying-space lesions involving the anterior and middle third ventricle were included in the study. Ten patients underwent transverse callosotomy, four subjects received standard sagittal callosotomy. A control group was also included in the study. All patients underwent a pre-operative and six months post-operative neuropsychological evaluation focused on performance at cognitive and attentional tasks. No disturbances in executive function were observed in either group. Patients receiving transverse callosotomy performed as well as control group subjects in attentive tasks, which is not the case of patients undergoing sagittal callosotomy who show a marked deficit in selective attention for left side visual field. The observed more favourable neuropsychological outcome supports transverse callosotomy as a valid alternative method to standard longitudinal callosotomy in third ventricle surgery.

[Combined surgical treatment of pulmonary neoplasms with single brain metastasis]. / Trattamento chirurgico combinato delle neoplasie polmonari con metastasi cerebrale unica.

The combined surgical treatment of primitive lung cancer with single brain metastasis is a frequently debated but still controversial problem. Up to day several therapeutic approaches are generally integrated (surgery, radiotherapy, chemotherapy) according to the clinical patterns and the technical possibilities. In general, the combined surgical operation (thoracotomy + craniotomy) when it is possible to be done, followed or proceeded by chemo-radiotherapy, has allowed to achieve a prolonged survival in these patients, maintaining an acceptable quality of life. The authors analyze 10 cases treated by thoracotomy and craniotomy at the Chair of Thoracic Surgery of University of L'Aquila. Although consisting of a small number of cases, this experience allows to detect the particular problems concerning these patients. The indications to the combined surgical treatment are considered, evaluating the surgical operation which is to be performed as first on the basis of lung cancer staging and of the location and size of the brain metastases. Finally the patients survival and their quality of life are considered.

Parailiac ectopic bone complicating the removal of a bone graft for cervical disc surgery.

A case of symptomatic parailiac ectopic bone neoformation, following the removal of a bone plug for cervical disc surgery, is reported. The pathogenesis of this rare complication is discussed and some technical hints to avoid it are given.

Cerebral abscesses: topic treatment with antibiotics.

The Authors, after a brief discussion of current therapies used in the treatment of cerebral abscesses, present a series of 10 cases treated topically with antibiotics (through drill-hole and puncturing of the abscess). The determining role of CT scan in this technique is emphasised.

Bilateral anomalous course of the ulnar nerve at the wrist causing ulnar and median nerve compression syndrome. Case report.

The case of a patient with a bilateral compression syndrome of the ulnar and median nerves at the wrist is described. Both ulnar nerves, which were surgically explored at different times, followed an anomalous course and passed into the canalis carpi side by side with the median nerve. This variation in the course of the ulnar nerve is extremely rare and causes a unique syndrome with characteristic electromyographic patterns.

Spontaneous intraorbital hemorrhage caused by cavernous angioma of the orbit.

The authors present three cases of orbital angioma (two with serious spontaneous hemorrhage) and discuss the symptomatology, the diagnostic procedures and operability. The pertinent literature is reviewed.

Giant anterior lumbosacral meningocele associated with intracranial meningiomas and multiple congenital malformations.

A case of anterior meningocele arising through a thin fistulous tract in the intervertebral disk space of L5-S1 is described. This lesion was giant, and almost completely filled the abdominal and pelvic cavities. Furthermore, it was associated with two separate intracranial meningiomas, a pleuropericardial cyst, and numerous developmental malformations. Pathogenetic factors, clinical and radiological features, and surgical treatment are discussed.

Spinal intradural arachnoid cyst.

A case of spinal intradural arachnoid cyst is presented, and the literature dealing with this rare lesion is surveyed. The etiological and pathological features are discussed; emphasis is placed on the importance of correct interpretation of clinical and radiological findings that may be diagnostically misleading.

Hemangioma calcificans.

Two cases of intraparenchymal hemangioma calcificans, an extremely rare variety of cavernous angioma, are reported. These lesions, well demonstrated on roentgenographic films of the skull and on computerized tomography scans, appeared avascular during the course of cerebral angiography. Clinical features, as well as macroscopic and microscopic evaluation, are discussed. The differential diagnosis from other intracranial calcified lesions is difficult. The literature describing this rare lesion is briefly reviewed, with special regard to the surgical indications.