Unilateral oculomotor nerve palsy: unusual sign of hydrocephalus.

We report an unusual case of hydrocephalus in which unilateral oculomotor nerve paralysis was the predominant sign. Misinterpretation of such an atypical clinical sign may lead to inappropriate therapy. We outline the role of intracranial pressure monitoring as an adjunctive diagnostic tool and we suggest a presumptive mechanism to explain the correlation between enlarged ventricles and 3(rd) nerve dysfunction. A 16-year-old boy presented with a complete left oculomotor nerve palsy associated with imaging findings of dilated ventricles and Dandy-Walker variant cystic malformation. Monitoring of intracranial pressure through a ventricular catheter was undertaken. In the first phase (no cerebrospinal fluid drainage [CSF] drainage) mean intracranial pressure (ICP) values were >0 mmHg. A second phase (with progressively longer CSF draining) further defined the diagnosis. A ventriculo-peritoneal shunt was then placed and the nerve function returned to normal within few days. Third cranial nerve dysfunction as a predominant sign of hydrocephalus is very rare and may raise doubts as to the real significance of the imaging findings of enlarged ventricles. In this ground, ICP monitoring is a safe and helpful diagnostic tool that can afford a more accurate evaluation and proper treatment. The supposed mechanism of 3(rd) nerve dysfunction was bending/stretching of the nerve.

Two-stage treatment of a tectal ganglioglioma: endoscopic third ventriculostomy followed by surgical resection.

Tumours of the quadrigeminal plate in adults are usually benign. Nevertheless, obstructive hydrocephalus due to compression of the Sylvian aqueduct is an almost invariable early finding. Whether or not direct excision is undertaken, temporary or permanent treatment of the hydrocephalus is warranted. Endoscopic third ventriculostomy is an alternative to insertion of a shunt and provides both acute and long-term relief of hydrocephalus-related symptoms. We chose a two-stage approach for treating a tectal ganglioglioma in an adult: endoscopic third ventriculostomy followed by surgical excision. The advantages and disadvantages of each therapeutic strategy are discussed.

Central neurocytoma of the fourth ventricle. Case history.

Central neurocytomas are low-grade tumours of neuronal origin, affecting mainly young patients and usually located in the lateral or third ventricle. We report a rare case of central neurocytoma at the fourth ventricle level. Magnetic resonance imaging showed a homogeneously enhancing mass lesion at the fourth ventricle. Gross-total surgical removal was achieved. The histological diagnosis was of central neurocytoma but the lesion showed a fairly elevated Ki-67 index (6%). Given this finding, close neuroimaging monitoring was performed and at the moment the patient is free of recurrence.

Isolated glossopharyngeal and vagus nerves palsy due to fracture involving the left jugular foramen.

This report describes a case of delayed post-traumatic glossopharyngeal and vagus nerves palsy (i.e. dysphonia and swallowing dysfunction). A high resolution CT study of the cranial base detected a fracture rim encroaching on the left jugular foramen. Treatment consisted in supportive measures with incomplete recovery during a one-year follow-up period. Lower cranial nerves palsies after head trauma are rare and, should they occur, a thorough investigation in search of posterior cranial base and cranio-cervical lesions is warranted. The presumptive mechanism in our case is a fracture-related oedema and ischemic damage to the nerves leading to the delayed occurrence of the palsy.

Neurological deterioration after head trauma in patients with colloid cysts of the 3rd ventricle. Two case histories.

The authors report 2 cases of colloid cyst of the 3(rd) ventricle (both patients previously asymptomatic) diagnosed after head trauma. Neurological deterioration due to biventricular hydrocephalus, rendering necessary an urgent bilateral CSF shunting, was observed. The possible relationship between clinical deterioration and head injury in these cases is discussed.

Spinal epidural hematoma following coronary thrombolysis. A case report.

A case of cervicothoracic spontaneous spinal epidural hematoma (SSEH) following coronary thrombolysis with r-TPA and intravenous heparin is reported. The clinical picture is discussed, as well as the importance of rapid neuroradiological diagnosis (with spinal MRI being the method of choice) and surgical treatment. Anyway, in these patients, thorough cardiac function evaluation and rapid correction of any clotting disorder is necessary prior to surgery. With the increasing use of fibrinolytic therapy this complication would be more frequent. This underlines the importance of prompt recognition and adequate treatment.

Overlap among neurocutaneous syndromes. Observations on encephalocraniocutaneous lipomatosis.

The authors report a case of encephalocraniocutaneous lipomatosis (ECCL) in a female infant. Clinical manifestations in this case showed significative overlap with another neurocutaneous syndrome, namely oculocerebrocutaneous (OCC) Delleman's syndrome. This may support the theory of somatic mosaicism. The patient underwent a cerebrospinal fluid (CSF) shunt procedure due to marked tetraventricular hydrocephalus that was not present at birth. The need for close and multidisciplinary follow-up of these patients is stressed.

Síndrome de moyamoya unilateral hemorrágico: descripción de un caso / Hemorrhagic unilateral moyamoya: report of one case

Se presenta el caso de una paciente de 29 años con derrame cerebral hemorrágico. La angiografía puso de evidencia un cuadro de moyamoya unilateral. El tratamiento fue conservador y la paciente fue dada de alta con indicación de realizar angiografías cerebrales periódicas. El diagnóstico de moyamoya, aunque raro, tiene que ser tomado en consideración en casos de derrame isquémico o hemorragia cerebrovascular. La historia natural en los casos de moyamoya unilateral no ha sido bien aclarada en cuanto a la progresión hacia una forma bilateral y en cuanto al riesgo de un nuevo ataque. En el estado actual una estrategia de controles radiológicos periódicos (con angiografía convencional o angiografía de resonancia magnética) parece la más razonable (AU)

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Hemorrhagic unilateral moyamoya: report of one case.

A 29 year old woman presented with an intracerebral hemorrhage. Angiographic findings were consistent with unilateral moyamoya. The patient was managed non-surgically and discharged with the indication of periodical followup angiography. Moyamoya is a rare entity that must be considered in the differential diagnosis of ischemic or hemorrhagic cerebrovascular events. At present, the natural history of unilateral moyamoya is not well established in relation to the progression to a bilateral form and to rebleeding risk. Periodical follow-up angiography (conventional or MRI) seems a reasonable management strategy.

Integration of image transmission into a protocol for head injury management: a preliminary report.

Neurosurgical care is limited in many parts of the world to one or two hospitals serving a large geographic area. The quality of neurosurgical response to emergencies depends on the reliability and completeness of the information received from referral hospitals. The aim of this study is to show how application of guidelines for head injury management in an entire area can be usefully combined with transmission of images from the peripheral to the central hospital. From January 1998 to December 2000, 1665 CT examinations were sent via image transfer to the Neurosurgical Unit; 637 first examinations (47%) and 206 second examinations (70%) were related to acute trauma cases. Out of 637 first examinations, 150 patients were actually transferred to the Neurosurgery Unit (23%), whereas of 206 second examinations, only 10 patients were secondarily transferred (5%). In the absence of the outcomes of patients located outside the Neurosurgical Unit, we studied in detail these 10 patients. They are, in fact, the only way for us to partially measure the impact of our system. Only in a single case could the death be attributed to a delay in transferring the patient. We then studied the factors influencing the decision of patient transfer. Mean GCS was 11 both for transferred and non transferred cases. The mean age of all patients was 52 years (median 48, SD 20.5 years); mean age of non-transferred patients was 54 years and for transferred patients it was 41 years (p < 0.01). The same statistically significant difference concerning age applied to any type of pathology sent via image link. In conclusion our data show that it is feasible to co-ordinate in an entire area the treatment of head injured patients. Available systems for CT images link are reliable and mostly useful. Unnecessary transfers can be avoided and the neurosurgeons can evaluate the images of a number of patients who have always been treated outside our Units. This results in more work for the neurosurgeons on duty, but also in a better quality service for the whole area. The lack of follow-up for patients not admitted to Neurosurgery is the limitation on a quality assessment of the system.

Growing-fracture of the orbital roof with post-traumatic encephalocele in an adult patient. Case report.

Growing fractures are a rare entity, usually occurring in paediatric age. Localisation at the orbital region is even rarer. We report the case of a growing fracture of the orbital roof with post-traumatic encephalocele in an adult patient, the 1(st) similar case in adulthood at our knowledge. Clinical and neuroimaging aspects are described, underlining the role of MRI in displaying intraorbital encephalocele. Surgical treatment with relevant technical notes is discussed as well.