Extracranial-intracranial bypass for giant aneurysms and complex vascular lesions: a clinical series of 10 patients.

AIM: The purpose of this clinical study is to evaluate the preventive bypass indications, the kind of bypass to use, and the timing of postoperative internal carotid artery (ICA) occlusion in the treatment of complex aneurysms. METHODS: This study enrolled 10 patients suffering from complex aneurysms treated using several kind of extra-intracranial bypass on the basis of preoperative careful assessment of cerebrovascular flow. This assessment is based on the balloon test occlusion (BTO), from which three different conditions emerge. According to the Department of Neurosurgery these three different conditions require three different kinds of bypass: in case of depleted flow a short STA-MCA bypass is necessary, in case of intermediate flow a long arterial graft bypass is required, whereas in case of high flow a long venous graft bypass is mandatory. RESULTS: Bypass patency was found in six out of seven patients who underwent surgery for giant ICA aneurysms, as well as in other patients. One of the patients died for a septic shock, another had a neck hematoma that required surgical evacuation. At mean follow-up no further neurological deficits were found. CONCLUSION: The severe complications due to the combined approaches can be reduced thanks to the indications obtained by BTO concerning the kind of bypass to perform and to the timing of the ICA occlusion.

A case of post-traumatic cervicogenic headache treated by cervical cord stimulation.

The case of a 26-year-old woman suffering from cervical trauma with disc herniation presenting with arm and neck pain is presented. She underwent cervical discectomy with fusion because the pain did not improve with medical therapies; as the neck pain resumed after surgery, a cervical cord neurostimulator was implanted, with improvement for cervicogenic headache. This report underlines the presence of two pathologies and the relationship between C2 and trigeminal pathways.

Pharmacological complications of the chronic baclofen infusion in the severe spinal spasticity. Personal experience and review of the literature.

AIM: To evaluate the pharmacological complications and side effects of the chronic intrathecal baclofen infusion in patients suffering from intractable spinal spasticity in our Department as well as in the literature. METHODS: The pharmacological complications and side effects observed at long-term follow-up in 25 patients with chronic intrathecal baclofen infusion are evaluated; the search of the literature complications was carried out in Medline and in Ingenta web sites. RESULTS: We have been able to observe in our series 3 (12%) patients with hypotonia, 2 with impairment on erection (8%) and 1 (4%) with constipation; 5 (20%) patients showed also tolerance but only 1 (4%) needed a ''drug holiday''. In the literature the side effects range from 4% to 16%. Moreover the tolerance is reported from 3% to 15%. The overdose has been reported from 0% to 14%, while the syndrome of withdrawal is reported in 16 patients with 6 fatalities. In our series these two last complications were not observed. CONCLUSIONS: Lethal pharmacological complications are rare and, if promptly diagnosed and treated, are reversible. Side effects of minor importance can impair the patient quality of live and needed to be adjusted to patient's requirements. This kind of therapy should be restricted to specialized centres.

Functional improvement in patients with severe spinal spasticity treated with chronic intrathecal baclofen infusion.

In this retrospective study we evaluated the efficacy and functional benefits of chronic intrathecal baclofen infusion in severe spinal spasticity. Twenty patients with a diagnosis of severe intractable spinal spasticity were evaluated prior to implantation of a programmable pump for chronic intrathecal baclofen therapy and at follow up, which ranged from 12 to 36 months (mean 22.4 months). The mean age of the patients was 39.1 years. The prevailing pathology was multiple sclerosis. All were unable to walk. Patient assessment was based on the Ashworth Scale, the Spasms Frequency Scale, self-reported pain and Functional Independence Measure (FIM) scores. The Wilcoxon test was used for statistical analysis. A statistically significant decrease in muscle tone, spasms and pain was observed in all the patients. The Ashworth score decreased from 4.4 to 1.8, the spasms frequency score from 2.5 to 0.5 and the self-reported pain score from 5.5 to 2.3. The FIM score also showed a statistically significant change (increasing from a mean of 33.8 to 58.7). Two patients in employment were able to return to work. No severe side effects were observed. Chronic intrathecal baclofen infusion was seen to produce a functional improvement in patients with severe spinal spasticity, particularly as regards bathing, comfortable wheelchair sitting and mobility.

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.

The association of cavernous and venous angioma. Case report and review of the literature.

We report the case of a patient with progressive seizures caused by a cavernous angioma in association with a venous angioma in the right parietal lobe. The radiological findings, the pathogenesis of this association and the importance of surgical treatment of a cavernous angioma with conservative treatment of a venous angioma are discussed.

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.

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.

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.

Intraethmoidal encephalomeningocele presenting with spontaneous cerebrospinal fluid rhinorrhea in an elderly man. Case report.

The case of a 63-year-old patient with spontaneous cerebrospinal fluid rhinorrhea from a intraethmoidal encephalomeningocele is presented. The patient was asymptomatic until the old age. The preoperative coronal CT-scan and the preoperative and postoperative MRI are shown. The rarity of this onset in an elderly man and the surgical indications of this disease are debated.

Associated cervical schwannoma and dorsal meningioma. Case report and review of the literature.

The association between spinal meningiomas and neurinomas without clinical signs of neurofibromatosis is very rare with only four cases reported in literature. A case of 70-year-old woman with a history of progressive paraparesis is presented. A cervico-dorsal magnetic resonance with contrast showed two tumors with different enhancement. The patient had examination negative for neurofibromatosis. At histological examination cervical schwannoma and a dorsal meningioma were found. The Authors debate the rarity of this association, the possible pathogenesis and the MR findings.

Intramedullary cervical cavernoma. Case report.

A rare case of intramedullary cervical cavernoma with complete neuroradiological examination is described. The Authors debate about clinical course, radiological examination and surgical indications.

Isolated aspergillosis of the sphenoid sinus. Case report.

The Authors report a rare case of isolated sphenoid sinus aspergillosis in a 69-year-old man. The patient had a complete recovery. The preoperative CT-scans and the preoperative and postoperative MRI are shown. The incidence, the pathology, the various clinical presentations, the prognosis and the management of this disease are debated.

Intraventricular subependymoma presenting as subarachnoid hemorrhage. Case report.

The Authors describe the case of an intraventricular subependymoma presenting as subarachnoid hemorrhage in a 42-year-old woman. The preoperative and postoperative CT-scans and Magnetic Resonance Images of this rare benign neoplasm are presented. The pathology, the clinical findings and the prognosis of this tumour are discussed.