Topical hemostatic agents in neurosurgery, a comprehensive review: 15 years update.

Hemostasis in neurosurgery is of utmost importance. Bleeding management is one of the crucial steps of each neurosurgical procedure. Several strategies, namely thermal, mechanical, electric, and chemical, have been advocated to face blood loss within the surgical field. Over time, countless hemostatic agents and devices have been proposed. Furthermore, the ever-growing recent technological innovation has made available several novel and interesting tools. Pursuant to their impact on surgical practice, we perceived the imperative to update our previous disclosure paper. Therefore, we reviewed the literature and analyzed technical data sheets of each product in order to provide an updated and comprehensive overview in regard to chemical properties, mechanisms of action, use, complications, tricks, and pitfalls of topical hemostatic agents.

Balloon kyphoplasty for pure traumatic thoracolumbar fractures: retrospective analysis of 61 cases focusing on restoration of vertebral height.

PURPOSE: The literature concerning the use of balloon kyphoplasty (BKP) for pure traumatic fractures is unclear. We report our experience about the treatment of a specific subgroup of traumatic vertebral fractures (AOSpine type A) with BKP through a retrospective analysis. METHODS: Sixty-one patients affected by AOSpine type A traumatic fractures of the thoracolumbar spine underwent BKP at our institution (2004-2008): 26 males and 35 females; mean age 52 ± 15 (18-75) years. At 6-12 and 60 months follow-up examinations, vertebral height restoration, sagittal spinal alignment and pain were recorded. RESULTS: Kyphoplasty proved to be a safe method to treat these fractures preserving a relative correct spinal sagittal balance with recovery of the morphology of the fractured vertebra, vertebral height and the angle of kyphosis. CONCLUSIONS: BKP used for traumatic fractures significantly alleviates pain, does not cause notable complications and enables patients to return to their normal lives in a short time.

[Management of children and adolescents with severe obesity]. / Il percorsi terapeutico del bambino e dell' adolescente con obesità grave.

Obesity is a complex public health issue. Recent data indicate the increasing prevalence and severity of obesity in children. Severe obesity is a real chronic condition for the difficulties of long-term clinical treatment, the high drop-out rate, the large burden of health and psychological problems and the high probability of persistence in adulthood. A staged approach for weight management is recommended. The establishment of permanent healthy lifestyle habits aimed at healthy eating, increasing physical activity and reducing sedentary behavior is the first outcome, because of the long-term health benefits of these behaviors. Improvement in medical conditions is also an important sign of long-term health benefits. Rapid weight loss is not pursued, for the implications on growth ad pubertal development and the risk of inducing eating disorders. Children and adolescents with severe obesity should be referred to a pediatric weight management center that has access to a multidisciplinary team with expertise in childhood obesity. This article provides pediatricians a comprehensive and evidence based update on treatment recommendations of severe obesity in children and adolescents.

Concomitant localization of a myxopapillary ependymoma at the middle thoracic part of the spinal cord and at the distal part of the filum terminale. Case report.

Myxopapillary ependymomas represent the most frequent type of ependymomas found at the conus medullaris-cauda equina-terminal filum level. In this article the authors describe the clinical presentation, radiographic findings, operative details, and pathological features of a patient with a concomitant presentations of a thoracic spinal cord myxopapillary ependymoma and a filum terminale myxopapillary ependymoma. A 16-year-old man presented to the Neurosurgery Department of the S. Maria delle Grazie Hospital (Naples, Italy) with an increased weakness of both the legs with great difficulties with walking and with bowel and bladder dysfunction. In a few minutes he becomes paraplegic. Magnetic resonance (MR) imaging revealed two ependymomas: the first one was localized in the middle thoracic part of the spinal cord and, the second one was localized in the cauda at sacral level. Two operations were performed for gross total resection of the masses. The first operation was performed at thoracic level and the second one was performed at the sacral level after two months. The examination demonstrated in both cases a myxopapillary ependymoma. The patient experienced complete resolution of her preoperative symptoms. This article reports an unusual case of a concomitant presentations of a thoracic spinal cord myxopapillary ependymoma and a filum terminale myxopapillary ependymoma myxopapillary. To the best of the authors' knowledge, this association has not yet been reported. This raises the interesting question of a possible associative or causative relationship between these pathologies. The authors considered dissemination to be the spread of tumor along the neuraxis to a location separate from the primary site. They do not believe that the lesion at the cauda level was a drop metastase. As the entire spinal cord and the brain were imaged, and as the tumor in the thoracic spinal cord area was we well capsulated, a disseminated ependymoma was confidently excluded.

Balloon kyphoplasty in traumatic fractures of the thoracolumbar junction. Preliminary experience in 12 cases.

AIM: The purpose of this study was to assess the effectiveness and safety of Ballon Kyphoplasty as a new method of treatment for traumatic fracture of the thoracolumbar junction. METHODS: We treated twelve patients 8 patients male and 4 female. The average age was 47,3 years (22-75 years). The interested vertebrae and therefore the procedures have been 13 since in a patient two vertebrae have been treated. In 9 cases the interested vertebra was L1, in 2 cases L2 and one case D11 and D12. Following the classification of Magerl 9 fractures were of A1.2 fractures and one fracture respectively of type A1.3, A2.2, A2.3, A3.1. We have never placed indication to Balloon Kyphoplasty in the fractures of the type B and C, neither in the complete burst fractures (A3.2 and A3.3), neither in the fractures of the A1.1 type. Balloon Kyphoplasty has been carried out using the Kyphon system (Kyphon Inc. Sunnyvale, CA, USA). In the patients older than 50 years (7 cases) we have used polymethylmethacrylate (PMMA), as filling material, while in the patients younger than 50 years (5 in total), we have used Calcibon (Biomet, Inc.Warsaw, Indiana) in 4 cases and in one case a new material called KyphOs (Kyphon Inc. Sunnyvale, CA, USA). These last two types of material are made up of tricalcium phosphate that, although less manageable of the PMMA and less resistant initially, in the time it will be reabsorbed and osteointegrated. RESULTS: The method demonstrated swift pain relief associated with an evident augmentation in the resistance and restoration of the vertebral body's physiological shape. No patient has worn a postoperative orthesis. In all the cases we obtained an optimal stabilization in the follow-up minimal to 4 months. In no case we observed a structural yielding of the vertebra. CONCLUSIONS: Kyphoplasty is an effective, alternative, simple and safe treatment of traumatic fracture of the thoracolumbar junction.

Endoscope-assisted microneurosurgery for anterior circulation aneurysms using the angle-type rigid endoscope over a 3-year period.

INTRODUCTION: The use of the endoscope (fiberscope) to assist the microsurgical clipping of cerebral aneurysm was first reported by Fischer and Mustafa in 1994. The rigid endoscope has been increasingly used during aneurysm surgery in which structures around the aneurysm can be detected with high quality imaging. Our 3 years of its use now allows us to assess the endoscope's efficacy and limits in standard surgery with a pterional approach in aneurysms of the anterior circulation. The endoscope can carry out a supportive role in planning surgical manoeuvres and in verifying whether clipping has been performed correctly or not. In our view, among the aneurysms of the anterior circulation, the endoscope is particularly useful in those of the internal carotid and the anterior communicating arteries. In many cases of these aneurysms the posterior communicating artery, choroidal artery or one of the distal cerebral arteries is hidden behind the aneurysm dome. Dome retraction is often required in order to see these vascular structures with the microscope. Thus an endoscope with a 30 degrees view angle becomes very useful. The concealed areas are identified without retraction, which prevents the possibility of the aneurysm being ruptured and also reduces the use of temporary clipping. From its early use as a supportive measure that is sometimes useful in surgery for "easy" aneurysms, the endoscope has now become almost indispensable for the "difficult" aneurysms, including the large and giant ones before and after clipping. Thus, the endoscope should be kept ready for use in the operating theatre for any eventuality. OBJECTIVE: We assess the advantages and disadvantages of the use of the endoscope in the microsurgical treatment of intracranial aneurysms. METHODS: During our 3 years of experience, 52 patients with 48 ruptured and 10 unruptured aneurysms of the anterior circulation (including 6 cases of two-fold aneurysms) underwent clipping with endoscope support through a pterional approach. All ruptured aneurysms produced a Hunt and Hess Grade I or II subarachnoid haemorrhage. The endoscope was inserted before and after clipping in order to observe the conditions surrounding the aneurysm and to receive immediate confirmation that clipping had been performed correctly. RESULTS: In all cases general anatomy visualization was provided by the endoscope, and the correct clip positioning and vessel conditions were easily checked. In 4 cases the endoscope showed that the clip had been positioned incorrectly. Additional clipping was performed in these cases: in 2 cases the clip was re-applied correctly and in another case a clip was added. Only the fourth patient with a large communicating artery died (1.9%) of cerebral infarction. This was due to post-clipping stenosis of one distal cerebral artery in which it was not possible to re-position the clip correctly because of the presence of arteriosclerotic calcific plaque near the aneurysm neck. In 3 cases there was an intraoperative ruptured aneurysm dome that was not caused by the endoscope insertion. No further complications were caused by the endoscope. CONCLUSION: In certain cases endoscopic-assisted microsurgery is an exceptional aid to the surgeon and must become part of the operating theatre equipment and kept on hand ready for use. The endoscope is, in our opinion, particularly useful in certain aneurysm localisations (internal carotid artery-anterior communicating artery [ICA-ACOMA]).

Objective pulsatile tinnitus: case report.

Anomalies in the vascular structures of the neck, cranial base, temporal bone, and intracranial circulation may give rise to pulsatile tinnitus. If the anomalous sound is perceived also by others, then it is defined as objective tinnitus. Herein, the case is reported of right pulsatile tinnitus of one year's duration, which appeared after cranial trauma. Magnetic resonance angiography showed that the jugular bulb was dominant on the same side as the tinnitus. The tinnitus was recorded with a high-sensitivity microphone, while otoacoustic emissions were measured by distortion products during follow-up.

Preliminary experience with anterior cervical microdiscectomy and interbody titanium cage fusion (Novus CT-Ti) in patients with cervical disc disease.

BACKGROUND: Although the use of intervertebral fusion after anterior microdiscectomy in cervical disc disease remains controversial, a new surgical device is proposed for use in intervertebral fusion instead of bone graft. METHODS: This retrospective study at the Department of Neurosurgery, Cardarelli Hospital, Naples, from January 1993 to December 1998, compares the results of surgery on 58 patients with anterior microdiscectomy and intervertebral bone graft fusion (Group A) (ADIBG) with a group of 52 patients who underwent anterior microdiscectomy and intervertebral titanium cage fusion (Group B) (ADITC) in cervical radiculopathy and spondylotic myelopathy. In both groups a "radical discectomy" was performed under the operating microscope. In group A, interbody fusion was performed with autologous tricortical bone graft. In group B, a new type of titanium device (Novus CT-Ti) was used (Sofamor Danek Group). RESULTS: There was no collapse or extrusion of the device and no complications at the donor site (the bone fragments used to fill the cage were taken from osteophytes or vertebral body fragments). The use of this device provides immediate stabilization, reduces or eliminates pain, promotes bone fusion between the vertebrae adjacent to the cage by allowing bone growth through the cage, reestablishes and maintains the intervertebral space, reduces the average hospitalization time, and allows a quicker return to work. CONCLUSIONS: Patients who underwent ADITC did well and benefited from the surgery. Those who underwent ADITC did better than those who underwent ADIBG in regard to function, relief from pain, and complications. Early and good stability of the cervical spine seems to be the main advantage of using titanium cages.

"Ultraearly" aneurysm surgery.

Three hundred and twenty-seven patients with intracranial aneurysm were managed at the Neurosurgical Division of Emergency Department of the Cardarelli Hospital of Naples. Of the 327 patient, 231 (70.6%), (I group), were operated on after 72 hours and 96 patients (29.4%), (II group), were operated on within 72 hours of subaracnoid hemorrhage. The patients operated on within 72 hours of hemorrhage (II group) were divided in two subgroups: 29 patients operated on within 72 hours formed the IIa group ("ultraearly" surgery) and 67 patients operated on between 24-72 hours formed the IIb group. Poor clinical grades (IV and V Hunt and Hess grades) were excluded from this study. Glasgow outcome scale (GOS), simplified in three grades was used to evaluate the results (GOS 1 good recovery; GOS 2 moderate or severe disability, and GOS 3 dead). The outcome was evaluated at the dimission and at 6 months. The best results seem to be for the patients in group IIb (24-72 hours), but if we consider that 31.2% of the patients operated on within 24 hours (IIa group) were in grade III of Hunt and Hess classification, also for these patients the surgical results seem to be good. The clinical presentation, treatment and outcome are discussed in this report.

A new instrumentation for posterior stabilization of cervical traumatic instability.

BACKGROUND: Twenty-six patients underwent application of a new posterior plating system (CIDEF SYSTEM) for the alignment and the stabilization of C3-C7 cervical unstable fractures from January 1992 to December 1993. METHODS: The osteosynthesis apparatus employs posterior articular screw fixation and plate application. Indications for surgery were the presence of neurological damage and cervical column instability. Operative techniques included decompressive and exploratory laminectomy in 20 cases and an articular resection in six cases of posterior superior articular fractures. A one-stage operation with an anterior approach, designed to remove anterior compression from herniated discs, or bone fragments, was also performed in four cases. Three cervical motion segments were immobilized in 15 of the treated cases; four in nine; and five in two. All patients were studied pre- and postoperatively with plain radiographs and computed tomography. Pre- and postoperative examinations demonstrated no alteration in neurological status. RESULTS: At a mean follow-up period of 47 months, no evidence was found of infection, rejection of the materials used, or mechanical failure of the plates and screws; all patients with incomplete lesion showed improvement in neurological function. Four patients tetraplegic at admission expired from systemic complications (one from pulmonary embolism; one from Disseminated Intravascular Coagulopathy; one for sepsis; and one from myocardial infarction). All patients were immobilized for at least 4 months with a Philadelphia collar. No injury to the neural or vascular structures contiguous to the cervical spine has occurred. CONCLUSIONS: The authors' experience suggests that the new system offers ease and versatility of application, restoration of vertebral alignment, enhanced spinal stability and is useful in the treatment of urgent and rather complex traumatic lesions of the lower cervical spine.

[Reasons against lumbar puncture diagnosis with cerebrospinal fluid drainage in subarachnoid hemorrhage]. / Le ragioni "contro" la rachicentesi diagnostica ed il drenaggio liquorale nell'ESA.

The necessity of cerebral angiography or angio-MRI was assessed in patients with thunderclap headache in whom subarachnoid haemorrhage had been ruled out on CT findings. In this cases the cerebrospinal fluid examination could be dangerous because could reduce the intracranial pressure with consequent risk of aneurysm rupture. CSF drainage, although, improves the clinical conditions and the symptoms of the patients, seems to not reduce the incidence of permanent neurological deficits caused by vasospasm; on the contrary, it increases the incidence of hydrocephalus requiring shunt procedures. We conclude that routine ventriculostomy with external ventricular drainage should be considered for all patients with altered sensorium and acute hyrocephalus following subarachnoid haemorrhage, with improvement in outcome.

The postero-lateral approach in the treatment of post-traumatic canalar stenosis of the thoraco-lumbar spine.

METHODS: Twenty-four cases of unstable thoraco-lumbar fractures with significant canalar stenosis were operated in the Emergency Neurosurgical Unit of the Cardarelli Hospital from November 1989 to October 1991. The surgical technique was the combined transpedicular (TPA) and transarticular (TAA) postero-lateral approach, posterior osteosynthesis and arthrodesis. The average follow-up was 20 months. RESULTS: No evidence of implant breakage or pseudoarthrosis was detected. CONCLUSIONS: The authors affirm recalibration of the posterior wall by direct impaction, epidural hemostasis, removal of extruded disc fragments and dural repair are the advantages offered by this technique without compromise the contsrist stability. This approach represents an alternative to single posterior and combined anterior-posterior approaches in the management of the thoraco-lumbar fractures with severe canal stenosis.

Surgical treatment of subdural empyema: a critical review.

Between 1990 and 1992 six cases of subdural empyema were surgically treated at the Neurosurgical Division of Emergency Department of Cardarelli Hospital in Naples. Three cases were associated with paranasal sinusitis and three cases with otitis media. Headache and fever were the presenting symptoms in all cases; in only two cases they were associated with seizures and altered mental status. CT scans showed convexity low density collections in five cases and multilocalized pus collection in one; concurrent paranasal or mastoid infections were visualized as well. The organisms responsible for the subdural empyema were Peptococcus in four cases, Streptococcus and anaerobius in the other two cases. In five cases surgical treatment consists in pus drainage by selective burr hole and placement of a subdural small silicon tube for local antibiotic therapy. In one case with a loculated diffuse empyema, craniotomy was performed in order to provide a better access to all the localizations. In all cases drainage of the wound and intravenous antibiotic therapy were used. Paranasal sinus drainage or mastoidectomy performed by the otolaryngologist when a localized collection of pus was present, grave a quicker regression of symptoms. A full recover of the original neurological status was achieved in all cases; a 20 months mean followup confirms the results.

Non invasive recording of CO2 cerebrovascular reactivity in normal subjects and patients with unilateral internal carotid artery stenosis.

CO2 cerebrovascular reactivity has been recorded in 12 healthy volunteers and 10 patients with unilateral > 70% extracranial internal carotid artery (ICA) stenosis, using non invasive techniques. The relative changes of middle cerebral artery blood flow velocity (VMCA) and velocity waveform pulsatility (PIMCA) after that hypocapnia was induced by spontaneous hyperventilation were recorded. 35.5% average VMCA reduction and 63% PIMCA increment of basal values was produced in healthy subjects after hyperventilation. The percentage variation of CO2 Reactivity Index (RI), expressed in terms of VMCA (V-RI) and PIMCA (PI-RI), per mmHg change in pCO2, presents a good right-left side correlation (r = 0.82 and r = 0.83 respectively) in healthy subjects, while a dissociation between V-RI and PI-RI was found in our patients. A significant reduction of PI-RI was also recorded in the group of patients on the side of ICA stenosis. From our data CO2 reactivity index recorded in terms of PI seems to allow a better separation between pathology and normality, without the need to assume a close relationship between velocity and blood flow under the condition considered. Furthermore, PI-RI seems to be a valid index in the evaluation of some attribute pertaining to the distal vascular bed.

A new instrumentation system for the reduction and posterior stabilization of unstable thoracolumbar fractures.

An innovative instrumentation and stabilization system was used for the treatment of unstable thoracolumbar fractures. The new osteosynthesis apparatus employs pedicle screw fixation, plate application, and a mechanical device for dynamic reduction in stable posterior fixation. Sixteen patients were treated with this operative technique that included a decompressive laminectomy, an arthropedunculectomy, and the removal of vertebral canal bone fragments. In most patients, three vertebral bodies, rather than four or five, were immobilized. All patients were studied pre- and postoperatively with plain radiographs and computed tomography. Pre- and postoperative examinations demonstrated no alteration in neurological status. All patients, however, with incomplete lesions showed improvement in neurological function at a mean follow-up period of 12 months. The authors' experience suggests that the new system offers ease and versatility of application, restoration of vertebral alignment through mechanical reduction, and enhanced spinal stability. The new system, moreover, enables the reduction of lateral dislocation.

Memory performances after anterior communicating artery aneurysm surgery.

10 patients operated on for anterior communicating artery aneurysm (ACoA) underwent to neuropsychological examination one year after surgery, in order to detect eventual behavioural and/or amnestic disorders, already described by others in a wide percentage of such patients. Even if after accurate neurological examination the therapeutic results were defined as "good", 60% circa of our patients present amnestic and/or behavioural disturbances. Possible correlations between neuropsychological tests finding and intraoperative occurrences (early aneurysm rupture, gyrectomy etc.) are considered and discussed.