Cognitive and linguistic outcomes after awake craniotomy in patients with high-grade gliomas.

BACKGROUND: Preservation of language and cognition is crucial in glioma surgery, as they are crucial aspects of daily life functioning. Several studies claimed that awake surgery in eloquent areas is demanded in low and high-grade gliomas. Cognitive and language outcome has been less investigated in high-grade gliomas compared to low-grade. METHOD: We analyzed the neuropsychological and neuro-oncological outcome of nineteen patients (from a cohort of forty patients) who underwent fully awake surgery for resection of malignant tumors located in eloquent areas. RESULTS: Post-surgery, linguistic functions were unchanged in 80 % of patients. Slight impairments in memory and executive functions were observed in about 50 % of patients. Survival rate at one year follow-up was 89 %. Results showed that awake procedure is safe, well tolerated and related with good linguistic outcome similar to low-grade gliomas. The majority of patients reported a good outcome in term of quality of life. CONCLUSIONS: Our results confirm that awake surgery is associated to good cognitive and linguistic clinical outcome also in malignant tumors.

Effectiveness of vagal nerve stimulation (VNS) in patients with drop-attacks and different epileptic syndromes.

PURPOSE: The effectiveness of VNS was evaluated in thirty-nine encephalopatic patients with drug-resistant epilepsy characterized by multiple seizures and drop attacks. Twenty-five patients were affected by severe epilepsy with multiple independent spike foci (SE-MISF) and fourteen patients by Lennox-Gastaut syndrome (LGS). METHOD: Changes in seizure frequency, cognition, adaptive behaviour and quality of life were assessed before and after VNS implant until three years. Outcome assessment for all seizure types included the number of seizures/month and the reduction in seizure frequency rate at each follow-up. Moreover, the effect of VNS on frequency, duration and intensity of drop attacks was separately addressed by a modification of McHugh scale. RESULTS: VNS produced a mean seizure rate reduction of 41% at six months, 50% at twelve months, and 54% at thirty-six months. After one year of stimulation, thirteen patients with SE-MISF (52%) and three patients with LGS (21%) showed a reduction above 50% in all seizures' frequency rate. As for drop attacks, eight patients (20%) gained a reduction above 50%, while seven patients (17%) showed a reduction only in intensity and duration. Cognitive level and adaptive behaviour were unchanged, while a better quality of life was reported in half out of the patients. CONCLUSIONS: VNS had a greater effect in reducing seizures frequency and drop attacks' intensity and duration in SE-MISF patients than LGS patients. An improved quality of life was observed also in those patients who only reduced the intensity and duration of drop attacks.

Cingulate epilepsy in a child with a low-grade glioma.

INTRODUCTION: Anterior cingulate epilepsy is a peculiar epileptic syndrome with a broad range of clinical manifestations, depending on the numerous projections of anterior cingulate into motor systems. Its diagnosis is often delayed, as seizures mostly occur during sleep and are typically misdiagnosed as parasomnias. Moreover, most focal anterior cingulate epilepsies are believed to be cryptogenic or idiopathic, even if there are some reports of anterior cingulate cortical dysplasia, while anterior cingulate neoplasms underlying epilepsy are rare. CASE REPORT: Here, we report a 30-month-old boy who developed, at the age of 20 months, cingulate epilepsy associated with a low-grade oligodendroglial tumor. It must outlined that the clinical presentation was characterized by very frequent and disabling seizures as the only symptom of the disease, while the results of several neuropsychological tests suggested intact intellectual and behavioral abilities. DISCUSSION AND CONCLUSION: Seizures disappeared completely after surgical removal of the lesion and neuropsychological child's performances remained completely normal. Long-term follow-up and observation are essential for evaluating the future clinical course.

237 ACoA aneurysms clipped or embolized. Outcomes measurement using the De Santis-CESE assessment tool.

AIM: The aim of this retrospective study was to demonstrate the difference in patient outcomes after treatment for bleeding endocranial aneurysms when evaluated with methods based on different assessment criteria. METHODS: The outcome of 237 patients, 141 of which were operated on for anterior communicating artery aneurysm and 96 embolized, was assessed by a new method developed by De Santis. The patients operated on were assessed by the Glasgow Outcome Scale (GOS) and Rank Disability Scale (RDS) and the results of the latter were compared with the new method, the De Santis-CESE (Clinical Emotional Social Evaluation) method, which consists of a clinical evaluation and a numeric scoring system based on seven standard points. Comparison between the three methods showed significantly different outcomes. Patients who underwent surgical operation showed changes in character and behaviour, whereas the others showed cognitive, emotional and sexual habit changes. CONCLUSION: Compared with the GOS and RDS instruments, the CESE method showed significant differences in patient outcome assessment, particularly regarding best outcomes. These differences may be due to the greater sensitivity of the CESE method over the other two scales. Furthermore, surgical patients seemed to achieve a better outcome than endovascular patients. The authors intend to conduct a prospective study to test the results obtained in this retrospective study.

Complications of vagal nerve stimulation for epilepsy in children.

Vagal nerve stimulation (VNS) is a surgical option to treat drug-resistant epilepsy. A few side effects have been described, mainly as anecdotal reports. We analysed our material concerning a juvenile population to identify the most common and most important complications, discussing them with the literature. Thirty-six patients were studied (18 months-18 years old). The children were assessed before the VNS implant and 3, 6, 12, 24 and 36 months after surgery. The mean follow-up was 30 months. Four patients required a second surgery: two for changing the device 3 years after implant; one for revision of an imperfect implant; one for removing a non-functioning device. In one patient a transient vocal cord paralysis was observed. Hoarseness was the main complaint (38.8%). More infrequent was mild sleep apnoea (8.3%), sternocleidomastoid muscle spasm, drooling and snoring in one patient each. Skin scars were reported with a different frequency according to the surgical technique. At variance with the literature reports, we did not observe infections. Side effects of VNS can be minimised, but not avoided completely, with a correct technical procedure, which in turn depends upon a thorough knowledge of vagus nerve anatomy.

Anterior cervical epidural abscess treated by endoscopy-assisted minimally invasive microsurgery via posterior approach.

This is a report of clinical manifestation, physical findings, neurophysiological data, magnetic resonance imaging, and results after surgery in a 71-years-old man with cervical abscess. Magnetic resonance imaging after two weeks of empiric antibiotic therapy demonstrated the persistence of an anterior cervical epidural collection and signs of spondylodiscitis at the C5-C6 and C6-C7 levels. Surgery was performed by posterior endoscopy assisted key-hole approach at the C2-C3 level to drain the abscess and to decompress the spinal cord. Postoperative specific medical treatment was then administered. A successful outcome, at 24 months follow-up, was achieved by surgery with complete clinical recovery, resolution of the abscess and healing of the spondylodiscitis. After unsuccessful blind medical therapy the minimally invasive microsurgical technique allowed us to keep the surgical injury of the healthy tissue to a minimum while producing the maximum therapeutic effect.

Intrathecal chemotherapy for treatment of overt meningeal leukemia: comparison between intraventricular and traditional intralumbar route.

BACKGROUND: Despite advances in the treatment of acute lymphoblastic leukemia (ALL), overt meningeal leukemia remains a dire condition. The role of intraventricular chemotherapy (IVC) in its treatment is still a matter for debate. Data suggesting benefit from it have been countered by statements of concern regarding the potential complications associated with its use. This report details our results from using IVC. PATIENTS AND METHODS: We compared two groups of adult patients with ALL at their first meningeal involvement. Twelve of them were submitted to ILC and 9 to IVC. RESULTS: Our data showed that IVC yielded a higher rate of complete response (88% vs. 33%) and a lower incidence of second CNS relapse than did ILC (none vs. 50%). Even though there were more long-term disease-free survivors (33% vs. 8%) among the IVC patients, the difference in median event-free survival was not significant (120 vs. 80 weeks; p = 0.66). IVC was associated with a longer overall survival (p = 0.005) and CNS remission time (p = 0.046). Two cases refractory to ILC were later fully responsive to IVC. There were 22% device-related and 11% drug-related complications. CONCLUSIONS: The results are promising, but the small series does not allow for any definite conclusion. In our opinion, the hazards inherent in the placement and operation of the device do not outweight the benefits of IVC for the treatment of overt meningeal leukemia and should not preclude its use. Accurate neurosurgical technique, meticulous care in drug administration and experience with this form of therapy can all contribute to minimizing complications so that full advantage can be taken of IVC's potential.