Endovascular treatment of primitive persistent trigeminal artery aneurysm associated with middle cerebral artery aneurysm.

We report the case of a primitive trigeminal artery aneurysm associated with an ipsilateral middle cerebral artery aneurysm. A 64-year-old Caucasian woman suffered from a severe acute headache. A head CT scan displayed subarachnoid hemorrhage and subsequent cerebral angiography showed right, wide-necked persistent trigeminal artery and ipsilateral middle cerebral artery aneurysms. The patient underwent embolization of both aneurysms with Guglielmi detachable coils. The association of a PPTA aneurysm and an ipsilateral MCA aneurysm has not been reported in the English literature.

Lumbar spinal osteoblastoma mimicking a dumbbell radicular schwannoma.

Spinal dumbbell tumors originate from nerve roots, usually growing within the spinal canal, the neural foramen and the extraforaminal compartment in the paraspinal region. We report a case of a 20-year-old man who presented with back pain radiating to his left lower limb mostly when in a supine position. Magnetic resonance imaging of the lumbar spine showed a dumbbell lesion at the L5-S1 neural foramen, with enlargement of the foramen and extension into the left paraspinal compartment. Although MR imaging studies were strongly suggestive of a dumbbell radicular schwannoma, the histological diagnosis was an osteoblastoma of the lumbar spine originating from the left L5 pedicle with intracanalicular, intraforaminal and extracanalicular extension. The presentation, imaging studies, intervention, pathology and differential diagnosis are described.

Endoscopic sinus surgery for a tension pneumocephalus after severe cranio-facial trauma.

Tension pneumocephalus is a rare form of pneumocephalus in which the air is under pressure; it is generally due to communication between the atmosphere and the intracranial cavity, and is an infrequent (0.88%) complication of cranial trauma. Tension pneumocephalus causes an increase in intracranial pressure with deterioration of the neurological situation and requires emergency treatment. Endoscopic surgery of the paranasal sinuses, which is generally applied in the diagnosis and treatment of fistulas with cerebrospinal fluid leakage, was here used to treat a case of pneumocephalus due to cranio-ethmoidal communication, in a patient we had treated previously for severe cranio-facial trauma.

Balloon-assisted endoscopic retroperitoneal gasless approach (BERG) for lumbar interbody fusion: is it a valid alternative to the laparoscopic approach?

OBJECTIVE: In the last years the use of interbody fusion devices with an anterior spinal lumbar approach has become a common procedure for the treatment of degenerative disc disease and spinal instability. We analysed our series of a simplified endoscopic approach to the anterior spine and made a review of the retroperitoneal endoscopically assisted approach to the anterior lumbar spine in the international literature. METHODS AND RESULTS: From 1999 through 2002, twenty consecutive "balloon-assisted endoscopic retroperitoneal gasless (BERG)" lumbar fusions were performed at San Filippo Neri Hospital in Rome, Italy. The surgical indications included patients with grade I or II spondylolisthesis and symptomatic degenerative disc disease with foraminal stenosis. Fourteen patients underwent a single level fusion (4 cases at L4-L5; 10 cases at L5-S1) and six patients underwent a double level fusion (L4-L5 and L5-S1). Mean operating time was 135 minutes (single level fusion), 175 minutes (double level fusion) and the mean intraoperative blood loss was 177 mL. No perioperative complications were observed and no procedure was converted to open surgical fusion. Patients were allowed to ambulate on the second postoperative day. Fusion was achieved in nineteen patients (fusion rate of 95%) 12 months after surgery. CONCLUSIONS: The BERG technique is a safe, effective, simplified, less technically demanding alternative approach when performing ALIF procedures, without the morbidity associated with laparoscopic or traditional approaches.

Epidermoid cysts of the fourth ventricle: very long follow up in 9 cases and review of the literature.

This study reports late surgical results obtained in 9 patients operated on for an epidermoid cyst of the fourth ventricle. They represent 19/9% of all cases of epidermoids treated at our Department over a period of 25 years (1975-2000). 7 cases were diagnosed with CT and 2 cases with MR. Duration of clinical history ranged from 2 months to 6 years (mean: 2,2 years). Preoperatively, 2 cases presented spontaneous remission of neurological symptoms and signs lasting about 1 year. 7 (77,8%) patients underwent subtotal removal of the cyst whereas in 2 patients the lesion was totally excised. 3 patients (33,3%) underwent a second operation for symptomatic recurrence diagnosed between 10 and 17 years from the first operation. At present, 7 (77,8%) patients are alive (mean follow up of 14,5 years, ranging from 5 to 23 years) without neuroradiological and clinical evidence of tumour recurrence. In this group, 6 have no neurological problems and 1 suffers from a light vestibulo-cerebellar syndrome. Fourth ventricle epidermoids have a good long-term prognosis even in the case of only subtotal removal. Follow-up clinical and MR controls allow an earlier diagnosis of recurrence. Surgery of recurrent cysts can be more demanding; nonetheless, long term prognosis can be quite good for patients in well preserved neurological condition.

Acoustic intrameatal meningiomas.

BACKGROUND: The sporadic finding of an acoustic intrameatal meningioma stimulated the authors to the present study. An analysis of the cases previously reported in the literature aimed to outline a preliminary account about biological, radiological and surgical specific hallmarks of these tumours. METHODS: Eight previous cases of meningiomas, meeting the prerequisite of origin and situation within the internal acoustic canal, have been discovered in the known literature since 1975. A further case was recently observed in our experience. The cases in the series showed no sex prevalence and in most of them the age of incidence was comprised between the fifth and sixth decade of life. Hearing loss was the prevalent symptom, lasting 1 month to 7 years before presentation. Myelocisternography, myelo-CT or high resolution CT/MR revealed no specific radiological features to distinguish small intrameatal meningiomas from the more frequently occurring vestibular schwannomas, while CT scan with bone algorithm could point out valuable indirect details for differential diagnosis. Various surgical approaches, i.e. middle fossa, translabyrinthine and retromastoid, were utilized by the different authors. RESULTS: Basing on apparent individual surgical preference, one of three different surgical routes (translabyrinthine, middle fossa, retromastoid) was chosen for 10 procedures in 9 patients. In all, except two cases the impression at surgery was of complete tumour removal. CONCLUSIONS: The possibility for meningiomas to recur and invade the surrounding bone requires a differential diagnosis from vestibular schwannomas. In the absence of intrinsic distinctive signs, radiological evaluation of peritumoral bone alterations could help diagnosis. Although the various surgical routes have often proved effective, temporal bone invasion justifies more extensive approach even in small tumours.

Conservative management of C5-C6 fracture-luxation in the elderly. Case report.

The case of a 86-year-old female victim of cervical trauma with C5-C6 fracture-luxation and bilateral locked facets is hereinafter described. The case was reputed representative of the complexity in deciding between conservative and surgical treatment in spine surgery. Conservative management would have been dictated by the additional risks linked to the age of the patient, whereas the surgical treatment would have been favored by the easy access to the anterior cervical spine for reduction and fixation. On the way to plan the definitive treatment, the patient died by pulmonary embolism. The controversial aspects and the indication to anticoagulant therapy in spinal surgery, frequently faced in the treatment of spine trauma in patients of this age group, are discussed in this case report.

Spinal cord stimulation for the treatment of refractory angina pectoris: a two-year follow-up.

Twenty-three patients affected by severe, refractory angina were submitted to permanent spinal cord stimulation (SCS) and then followed in our outpatient clinic for 24 months. During the follow-up period, the number of weekly angina episodes drastically dropped from 9.2 (preimplant) to 1.8 in the 3rd, 2.5 in the 6th, 4.5 in the 12th, and 4.2 in the 24th month, with a statistically significant difference (P < 0.01) between the first and last values. A significant increase in the average exercise time from 320 +/- 120 seconds (in baseline condition) to 410 +/- 115 seconds (during SCS) was observed at the treadmill stress test (P < 0.01). SCS was well tolerated by all the patients. However, 7 patients died during follow-up (3 myocardial infarctions, 2 noncardiac deaths, and 2 sudden deaths). Three generators were replaced because of battery depletion after 15, 17, and 21 months. No serious complication was observed. In conclusion, in patients with otherwise intractable angina or already submitted to myocardial revascularization, SCS is very effective in reducing the number of angina episodes. The time of the work during exercise stress test is also significantly prolonged.

Stereotactic-guided microsurgical removal of lesions without cortical appearance planned by three-dimensional CT reconstruction: limits and advantages of the frame-based technique.

Intraoperative positioning still constitutes a basic problem in the microsurgical removal of intracerebral lesions, either deep-seated or without cortical appearance. We treated different types of lesions (cavernous angiomas, intraventricular tumors, gliomas, and metastases), by combining stereotactic targeting with the standard microsurgical technique. The dedicated software for the three-dimensional reconstruction of stereotactic CT images allowed us to determine the least traumatic surgical trajectory and the exact location of the lesion intraoperatively, with minimum manipulation of healthy cerebral tissue. We believe that the main indication for this technique is the removal of small, encapsulated or well-defined lesions without cortical appearance or in critical areas, while a direct inspection of the area is still essential in order to evaluate surgical removal in the case of infiltrating tumors.

Neuroma of the spinal accessory nerve disclosed by a subarachnoid hemorrhage: case report.

OBJECTIVE AND IMPORTANCE: Neuroma of the 11th nerve disclosed by subarachnoid bleeding is a very rare condition. Clinical diagnosis is almost impossible, but previous episodes of muscle spasm and mild signs of subarachnoid hemorrhage with a hematoma in the cisterna magna should suggest magnetic resonance imaging as well as angiography. CLINICAL PRESENTATION: We present a case of an 11th nerve neuroma disclosed by subarachnoid bleeding. Previous episodes of muscle spasm and neck pain treated with nonsteroid anti-inflammatory drugs had been overlooked, preventing the neuroma from being diagnosed at that time. The computed tomographic scan showed an intracisternal hematoma spreading into the subarachnoid space. The hematoma appeared heterogeneous on the magnetic resonance image, and a tumor mass growing into the cisterna magna against the brain stem was also revealed. INTERVENTION: The tumor was totally removed by a suboccipital craniectomy and C1 laminectomy. It originated from the spinal root of the 11th nerve, from which it was able to be dissected without damage to the nerve. CONCLUSION: To our knowledge, this is the first reported case of an 11th nerve neuroma disclosed by a subarachnoid hemorrhage. Furthermore, this is the seventh documented case of an 11th nerve neuroma developing in the cisterna magna. We emphasize the importance of a high index of suspicion for the rare instances of hematic density limited to the cisterna magna, especially if associated with recurring episodes of localized neck pain and muscle spasm treated with nonsteroid anti-inflammatory drugs.

Treatment of the failed back surgery syndrome due to lumbo-sacral epidural fibrosis.

The failed back surgery syndrome (FBSS) is a severe, long-lasting, disabling and relatively frequent (5-10%) complication of lumbosacral spine surgery. Wrong level of surgery, inadequate surgical techniques, vertebral instability, recurrent disc herniation, and lumbo-sacral fibrosis are the most frequent causes of FBSS. The results after repeated surgery on recurrent disc herniations are comparable to those after the first intervention, whereas repeated surgery for fibrosis gives only 30-35% success rate, and 15-20% of the patients report worsening of the symptoms. Computerized tomography (CT) with contrast medium and, in particular, Gd-DPTA enhanced MRI have recently allowed a differentiation between these two pathologies permitting us to adopt different therapies. In 1982-92 we applied spinal cord stimulation (SCS) as a first therapy of FBSS with proven lumbo-sacral fibrosis. Fifty-five patients underwent percutaneous trial SCS with a mono/multipolar electrode placed at the level of Th9-12. In the 36 patients who had a positive response to the trial stimulation, the electrode was connected to an implantable neurostimulator. On January '94 a third party, not involved in the treatment of the patients, controlled 34 of the 36 patients with a mean follow-up of 55 months. We classified the patients reporting at least 50% pain relief and satisfaction with result as successful, and 56% of the patients fell in that category. 10 out of 34 patients were able to resume their work. The success rate was significantly higher in females (73%) than in males, and in radicular rather than axial pain. Our data have led us to consider SCS as a first choice treatment in FBSS due to lumbo-sacral fibrosis.

Extra-foraminal prolapsed lumbar disc: a possible cause of recurrent sciatica in failed low-back surgery patient. Case report.

The present report describes the case of a 48 year-old woman who had undergone two separate lumbar laminectomies for a L4-L5 disc. She was admitted for a recurrent sciatica of 6-months duration, which failed to respond to conservative treatment. Myelogram on admission was negative. However CT showed a far laterally placed bulging L4-L5 disc. The patient was successfully reoperated on using a paramedian posterolateral approach on the side of the lesion. The rationale for this approach is discussed.

Epidermoid cysts of the fourth ventricle.

Epidermoid tumors located in the fourth ventricle are exceedingly rare. Seven cases of this pathological condition were observed during a 10-year period. Patients were mostly middle-aged men, with a clinical history of relatively short duration (5 months). Clinical symptoms consisted of vertigo and ataxia, followed by incoordination, dysmetria, and tremor at a later stage. Computed tomography scanning represented the main diagnostic technique for these lesions, and typically showed a highly hypodense, round-shaped area within the fourth ventricle, occasionally accompanied by hydrocephaly. Subtotal surgical removal of the cysts produced excellent results in 86% of the cases. The implications of these findings are discussed.

Association of two saccular aneurysms of the posterior inferior cerebellar artery with a cerebellar arteriovenous malformation fed by the same artery. Case report.

Coexistence of posterior fossa aneurysms and AVMs on the same feeding artery is very rare; the case of an association of two saccular aneurysms of the posterior inferior cerebellar artery with a cerebellar arteriovenous malformation of the same artery is reported. Theories concerning etiology are reported as well.

[Giant carotid-cavernous aneurysm treated by balloon catheter]. / Aneurisma gigante carotido cavernoso trattato con balloon catheter.

The AA. report the case of a giant carotid cavernous aneurysm; clinical onset was a VI cranial nerve paralysis, and diagnosis was based upon CT and angiographic findings. They describe balloon catheter technique used to exclude aneurysm, followed by carotid ligature. They eventually emphasize radiologic and neurophysiologic studies, and clinical follow up months later.

[Aneurysm of the anterior inferior cerebellar artery (AICA). 18th case in the literature]. / Aneurisma dell'arteria cerebellare anteriore inferiore (AICA). XVIII caso della letteratura.

The AA. report the case of an anterior inferior cerebellar artery aneurysm (XVIIIth in world literature). Reviewing literature on the subject, they recall anatomical and clinical variations of AICA aneurysms, and report surgical techniques usually employed.

[Computerized tomography in the diagnosis of carpal tunnel syndrome]. / La tomografia computerizzata nella diagnosi della sindrome del tunnel carpale.

The AA. have employed CT scan in studying the latest 10 cases in a series of 50 carpal tunnel syndromes; CT scans have then been confronted with EMGs and surgical findings. Usefulness of CT scan is enhanced in pre and postoperative study of this pathology.