The subchoroidal approach to the third ventricle: surgical anatomy according to Galen.

THE SUBCHOROIDAL APPROACH has taken its place among the surgical access routes to the third ventricle. Eighteen centuries ago, in his major anatomic work, Galen detailed with astonishing accuracy the anatomy of the structures around the third ventricle and the procedure for exposing this cavity by entering the lateral ventricles and elevating its roof. Even more surprising is Galen's pioneering description of surgical maneuvers of the third ventricle in living animals in a way that anticipated the modern subchoroidal approach.

Association of aneurysm and arteriovenous malformation on the posterior inferior cerebellar artery. Report of three further cases and review of the literature.

As far as we know, only 20 patients with association of aneurysm and arteriovenous malformation (AVM) on the posterior inferior cerebellar artery (PICA) have been reported so far. Further three personal cases are presented here and the pertinent literature is reviewed, the coexistence of aneurysm(s) and AVM on the PICA district increases the risk of intracranial bleeding compared with patients harbouring this association in the cerebral hemispheres. The direct approach of both lesions (excision of the AVM and clipping of the aneurysm) in one-stage operation is the treatment of choice.

Subsequent bleeding from ruptured intracranial aneurysms treated by wrapping or coating: a review of the long-term results in 47 cases.

Forty-seven patients, who underwent surgery over a 34-year period by the wrapping or coating of ruptured intracranial aneurysms, have been retrospectively evaluated. The following materials were used in the surgical procedures: muscle with gelatin sponge (7 cases), gauze (2 cases), oxidized cellulose with Biobond (28 cases), Histoacryl with gauze or fascia (10 cases). The patients were monitored for up to 37 years (mean, 13.7 +/- 8.2 yr). One or more subsequent bleedings occurred in eight patients (17%). Three patients had additional bleeding and died in the early postoperative phase (within 1 mo after surgery). In five patients, the subsequent bleeding occurred between 1 and 15 years postoperatively, with two fatalities. One patient experienced two recurrences. Therefore, the mortality rate for postoperative bleedings was 10.6% (five patients) in the whole series, and the incidence of early (within 1 mo after surgery) fatal bleedings was 6.4%. After the first month from the initial hemorrhage, the global risk of subsequent bleeding was 0.93%/yr. Among the nine patients whose aneurysms were wrapped with muscle, gelatin sponge, or gauze, four additional bleedings occurred, whereas four relapses were observed among the 38 cases treated by employing bioadhesive agents (P < 0.04; Fisher's exact test). The rate of further bleeding was higher (25%) in patients undergoing surgery in the premicrosurgical era compared with that (8.7%) recorded in patients treated by microsurgery (difference statistically not significant).

Neuropsychological evaluation in a series of 17 cases operated on for craniosynostosis.

In a study of patients suffering from craniosynostosis various pre- and post-operative parameters were identified that may affect subsequent intellectual capacity. In particular, facial malformations appeared to be closely correlated with impaired intellectual development. Other parameters included measurement of cranial circumference and volume; their subaverage values correlated with slight mental insufficiency. However, in the pre-operative period they cannot be used as prognostic indices because these relations were statistically not significant. The remaining parameters (neurological and electroencephalographic findings, post-operative re-ossification of the skull, pre-operative digital impressions, CT findings) did not seem to be related to intellectual development.

Extrusion of peritoneal catheter through a thoracic skin fistula: report of a rare complication of ventriculoperitoneal shunt.

A very rare complication of ventriculoperitoneal shunt is presented. The tip of the distal catheter extruded through a skin fistula in the right subclavian region. After the replacement of a new catheter in the peritoneal cavity, inflammation of the overlying scar occurred. Then, a ventriculoatrial shunt was carried out. The authors suggest a possible mechanism of this complication.

Penetrating craniocerebral missile injuries in civilians: a retrospective analysis of 314 cases.

Analysis of 314 cases of penetrating craniocerebral missile injuries in civilians revealed a high rate of early mortality, with 228 victims having died at the scene and a further 38 dead within 3 hours. Surgery was performed in 44 patients who had a preoperative Glasgow Coma Score of at least 4. Out of the 26 survivors, all operated upon, 19 had an adequate recovery (score of 0-3 on the expanded Glasgow Outcome Scale). Vigorous resuscitation and early surgery often resulted in useful survivals and occasionally in spectacular recoveries. However, the high mortality rate on the scene or soon after the injury restricted the possibility of effective management to a minority of cases.

Regional cerebral blood flow after omental transposition to the ischaemic brain in man. A five year follow-up study.

Regional cerebral blood flow, recorded by the 133Xenon inhalation method, was measured preoperatively and over a five years postoperative period in six patients with completed stroke and stabilized neurological deficits, who had undergone omental transposition for revascularization of the ischaemic brain. Comparisons of the preoperative blood flow values with those recorded following surgery demonstrate a postoperative increase of blood flow in five patients, with a high statistical degree of significance in four of them at the final examination. The flow increase was noted over the infarcted areas of the brain, upon which the omentum had been placed, as well as areas of the ischaemic hemisphere without omental placement and the contralateral hemisphere. Out of the five patients who demonstrated preoperative flow values below the expected norm for age, four showed final postoperative cerebral blood flow within the normal limits for their age. The results are consistent with the assumption that the transposed omentum played a role in postoperative blood flow increase, by adding collateral circulation to the ischaemic brain.

Long-term follow-up of the surgical treatment of intracranial coenurosis.

Intracranial infestation by the coenurus of the tapeworm Taenia multiceps is a rare occurrence in humans, with about 55 cases having been reported so far. Although most of these cases were observed in African or South American countries, the illness was occassionally found also in sheep-raising areas of Western Europe and the United States. Out of 4 personal cases, who were operated upon over an 18-year-period, 2 were neurologically intact respectively 20 and 3 years following surgical treatment. CT scans confirmed the absence of a progression of the disease. One patient was able to work 6 years after surgery, when he was killed in a road accident. A further, severely impaired patient remained unchanged and died with intercurrent infection 10 years following the operation.

Post-traumatic subarachnoid pneumocephalus. A case report.

We present a case of subarachnoid pneumocephalus fed through a basal bony breach and confined to the cysterns of the Willis circle in a traumatized patient. The peculiar configuration of the pneumocephalus is attributed to the partial obliteration of the subarachnoid space due to the increased intracranial pressure.

The value of some clinical and computer tomographic parameters in the prognosis of surgically treated patients with intracerebral hematoma.

The six-month follow-up of 83 surgically treated cases for intracerebral hematoma (ICH) was examined in relation to some clinical and computer-tomographic parameters (age, sex, accompanying diseases, clinical features, localization, ventricular involvement, time elapsed between stroke and surgery). Clinical and laboratory pre-requisites for admittance to the study were: 1) ICH with subcortical major component greater than 3 cm. in diameter, 2) a Glasgow Coma Scale (GCS) score at/or superior than 5, 3) any evidence of trauma, aneurysm, A-V malformation and tumor and 4) surgery not later than 96 hrs. after onset of bleeding. The role of the clinical picture and the ventricular involvement of ICH was strinkingly significant on both mortality as well as recovery rates while sex, some accompanying diseases and left localization influenced the recovery rate. Time elapsed between bleeding and surgery was not considered an objective parameter due to the variability of some organizatory and human factors. Age was an uninfluential factor.

Spinal cord dysfunction from lumbar disk herniation.

Two patients with a herniated disk respectively at the level of the L4-L5 and of the L5-S1 intervertebral spaces presented with pyramidal signs, bladder paralysis and radicular impairment. The symptoms subsided immediately following surgical removal of the prolapsed disk. The role of transient ischemia in the lower segments of the spinal cord as possible cause of this uncommon clinical picture is discussed, and the pertinent literature is reviewed.

Parkinsonism in the presence of intracranial extracerebral haematomas.

Bilateral Parkinsonism has been observed in a 60-year-old female with a chronic subdural intracranial haematoma. Scattered, poorly marginated, hypodense areas within the ipsilateral pallidus and putamen were evident on the preoperative CT scans. The rapid neurological improvement following the surgical drainage of the subdural clot and the evolution of the densitometric features of the nuclear lesions, which became clear-cut, though smaller, in the following months, suggest a cause-and-effect relation between the haematoma and the clinical symptomatology. To the best of our knowledge this is the first case in which anatomical lesions within the basal ganglia could be detected neuroradiologically.

Intracerebral hematoma following removal of chronic subdural hematoma. Report of two cases.

Two cases of intracerebral hemorrhage consequent to surgery planned for homolateral chronic subdural hematoma are reported. Both patients were treated conservatively and made a satisfactory recovery. The pathological events leading to the formation of an intracerebral hematoma following the evacuation of a chronic subdural hematoma still remain undefined.

Computed tomography and magnetic resonance imaging of cerebral coenurosis.

A case of Coenurus cerebralis involving both cerebral hemispheres and the interpeduncular cistern is presented to illustrate the computed tomography (CT) and magnetic resonance imaging (MRI) features. In CT scans viable cysts appear as lucent lesions surrounded by a contrast-enhanced peripheral rim. By using multiple echo sequences the cyst content is characterized in magnetic resonance images by a cerebrospinal fluid-like intensity pattern.

Computed tomography and magnetic resonance imaging in spinal hydatidosis.

Computed tomography and magnetic resonance imaging in patients with spinal hydatidosis provide comprehensive evaluation of the actual extent of the disease. Paravertebral uncalcified cysts, hardly recognizable by conventional radiologic examinations, are clearly shown by both methods. Initial involvement of the spongy bone is evident in computed tomography scans, in contrast to what usually appears to be normal in plain films or tomograms. Occurrence of cysts within the spinal canal is revealed by both types of computed scans, with magnetic resonance imaging being able to provide further information on the involvement of the spinal cord.

Long term follow-up of the surgical treatment of the intracranial hydatid disease.

Long term results of the surgical treatment of intracranial hydatid disease ist reported in 11 personal cases. Nine patients are alive 9 to 15 years following the operation, only one of them being disabled. The remaining two patients died respectively 6 months and 2 years after the first operation.

Iatrogenic lumbar pseudomeningocele.

The authors describe two cases of pseudomeningocele after surgery for herniated lumbar disc. In order to prevent this rare complication, they suggest to suture the dura and to put on it oxycel or gelfoam every time there is a fluid leakage. The patient has to be placed in Trendelenburg's position for about seven days.

[Echinococcosis of the spine]. / Uber die Echinokokkose der Wirbelsäule.

21 patients with hydatid disease of the spine were operated on upon a 30-year period. The follow-up ranged up to 24 years. 12 cases underwent one or more reoperations, due to recurrences. 8 patients died between 1 and 21 years after the first operation. The surgical treatment usually allows only a transient remission and does not avoid recurrence or progression of the illness. Although the parasite cannot be wholly eradicated surgically, a prolonged and acceptable life with the disease can result from repeat surgical interference.

Clinical and electrophysiological investigation of the results of operation for lumbar disc hernia. Preliminary results.

The long-term results of operations to remove disc hernias were assessed clinically and electrophysiologically in two groups of patients treated by different surgical techniques. The electrophysiological parameters determined were the motor conduction speed of the sciatic nerve, the H reflex, the minimum latency of the F wave and quantitative analysis of the EMG by the Willison method. The preliminary results reported in the present paper are related to two comparable samples of patients who underwent hemilaminoarthrectomy or hemilaminectomy for disc hernia at L5-S1. They show that the incidence of after effects was lower in the patients treated by simple hemilaminectomy.

Cerebral blood flow in minor cerebral contusion.

Seventeen patients with minor cerebral contusion were selected from a series of patients with head injuries of various severity, who had undergone repeat evaluations of the regional cerebral blood flow. The mean global flow (expressed as mean global initial slope index) on early examination was found to be significantly lower, compared with that recorded in healthy volunteers. A tendency towards the recovery of higher flow values was apparent in repeat evaluations that were performed several weeks after the injury. Interhemispheric asymmetries of flow were a common occurrence, with lower perfusion and reduced attenuation values on computed tomography scans being, however, in good agreement only in approximately half of the cases.