Inflammatory Bowel Disease: Role of Vagus Nerve Stimulation.

Vagus nerve stimulation (VNS) is an accepted therapy for the treatment of refractory forms of epilepsy and depression. The brain-gut axis is increasingly being studied as a possible etiological factor of chronic inflammatory diseases, including inflammatory bowel diseases (IBD). A significant percentage of IBD patients lose response to treatments or experience side effects. In this perspective, VNS has shown the first efficacy data. The aim of this narrative review is to underline the biological plausibility of the use of VNS in patients affected by IBD, collect all clinical data in the literature, and hypothesize a target IBD population on which to focus the next clinical study.

Choroid Plexus Carcinoma in Adults: Literature Review and First Report of a Location into the Third Ventricle.

Choroid plexus carcinoma (CPC) is a rare intraventricular neoplasm originating from choroid plexus. CPC is the most aggressive choroid plexus tumor. Almost all the CPCs are detected in children, and the preferred location is the lateral ventricle. We reviewed the literature to evaluate the state of the art concerning the management of CPC in adults and report the first case described of the extremely rare localization into the third ventricle. A 38-year-old woman presented a medical history of Parinaud syndrome and occasional facial weakness. Brain magnetic resonance imaging revealed a mass lesion in the pineal region and posterior part of the third ventricle with obstructive hydrocephalus. She underwent subtotal resection through a supracerebellar infratentorial approach. After the histopathological diagnosis of CPC, the patient underwent a second surgery with gross total resection and adjuvant radiotherapy. CPC in adults, given its extreme rarity, does not have a standardized treatment. Gross total resection should be the first step of the treatment: however, according to the literature, gross total resection is achieved only in 40-75% of cases in CPC as opposed to 95% in choroid plexus papilloma, mainly due to the difficulty in managing a highly vascularized tumor in such a deep location. Chemotherapy has not an established role and adjuvant treatment is based on radiotherapy. In the case described hereby the gross total resection associated with surgical treatment of hydrocephalus and adjuvant radiotherapy has achieved a good clinical and radiological outcome.

Posttraumatic Middle Meningeal Artery Pseudoaneurysm: Case Report and Review of the Literature.

BACKGROUND: Intracranial pseudoaneurysm is a rare entity, with few cases described in the literature, and is mostly associated with a history of traumatic brain injury. Traumatic aneurysms comprise <1% of all intracranial aneurysms. In particular, middle meningeal artery (MMA) aneurysms are uncommon and usually caused by a skull fracture in the temporal region. About 40 traumatic MMA aneurysms are reported in the literature, and only 28 nontraumatic aneurysms are reported, usually related to high-flow conditions. The behavior of these aneurysms is largely unknown: both spontaneous resolution and aneurysm growth, leading to subsequent rupture, have been reported. Surgical and endovascular management are feasible for MMA aneurysms; however, the criterion standard treatment is not defined. CASE DESCRIPTION: We report the case of a traumatic pseudoaneurysm of the right MMA treated with an endovascular approach and provide a review of the literature. CONCLUSIONS: Aneurysms of the MMA are a rare entity that must be taken into account in the setting of a traumatic brain injury or predisposing factors. The diagnosis and aggressive treatment are mandatory, preventing the devastating consequences of their rupture. Endovascular and surgical techniques are well defined and available, even though there is not a demonstrated superiority in any of them.

Rare Case of Dumbbell-Shaped Spinal Cavernous Hemangioma and Literature Review.

BACKGROUND: Spinal epidural cavernous hemangiomas are rare vascular malformations. Exceptionally, they present with dumbbell-shaped morphology. When they happen, it's mandatory to include their pathology in the differential diagnosis because of their similarity to schwannomas. CASE DESCRIPTION: We report the case of a 72-year-old woman with a dumbbell-shaped thoracic epidural cavernous hemangioma. A literature review of diagnostic features and current treatment options are also discussed. CONCLUSIONS: Surgery is safe and effective in both improving patient condition and preventing acute hemorrhage that can worsen the outcome, causing neurologic and potentially irreversible deficits. The favorable result we obtained in our patient suggests that surgery should be evaluated as the first option, even in patients with large epidural cavernous hemangiomas.

Translaminar Approach for Treatment of Hidden Zone Foraminal Lumbar Disc Herniations: Surgical Technique and Preoperative Selection of Patients with Long-Term Follow-Up.

BACKGROUND: Lumbar disc herniation is a common degenerative disease of the lumbar spine with a prevalence of 1%-3% in some population studies. In 10% of patients, there is a fragment migrated cranially in Macnab's "hidden zone." In selected cases, this fragment can be removed with a translaminar approach that was described in 1998. We provide a detailed description of the technical advantages and pitfalls of the translaminar approach in a consecutive series of 32 patients treated at our institution. METHODS: Patients were divided preoperatively and postoperatively into 5 classes based on the Oswestry Disability Index (ODI): class 1, ODI 0%-20% (minimal disability); class 2, 20%-40% (moderate disability); class 3, 40%-60% (severe disability); 60%-80% (crippled); 80%-100% (bedridden or disabling symptoms). RESULTS: Four (12.5%) patients were upgraded 1 ODI class after the operation; 6 (18.7%) patients were upgraded 2 classes, 8 (25%) patients were upgraded 3 classes, and 11 (34.4%) patients were upgraded 4 classes. In 3 (9.4%) patients, ODI class did not change after the operation. After surgery, 7 (21.9%) patients developed mild low back pain. Mean follow-up was 25 months. CONCLUSIONS: When performed by dedicated spinal neurosurgeons, the translaminar approach is safe and effective in patients with long-term follow-up. Most patients showed an improvement in ODI. Major pitfalls were related to surgical selection and the narrow working space.

Postoperative Care of Patients with High-grade Glioma: Is There a Real Need for the Neurocritical ICU and Early CT Scan?

BACKGROUND: Pressure on economic resources now requires a careful rationalization of services. For adult patients with supratentorial gliomas, there is no consensus on the real need for care in a postoperative neurocritical intensive care unit (NICU) and on the timing of a postsurgical computed tomography (CT) scan. In this retrospective nonrandomized study, we assessed if and when there is a real need for NICU and if an early CT scan could be justified in the absence of neurologic worsening. METHODS: Of 264 patients, 21 were admitted to the NICU after the procedure as planned before the surgery for their clinical features (Karnofsky performance status < 70, American Society of Anesthesiologists score > 2, or Charlson Comorbidity Index > 5). RESULTS: The mean stay in the NICU was 19.7 hours. One of these patients had developed a postoperative hematoma that was subsequently removed, and died afterward. The other 243 patients were followed clinically after the procedure: 219 underwent a cerebral CT scan 24 hours after the procedure and were discharged in good condition. The other 24 patients had a cerebral CT scan within 24 hours after the procedure. The early CT showed the presence of a local edema in five cases and a hematoma surgically treated with a subsequent admission to the NICU in two cases. CONCLUSION: Considering our data, we suggest that NICU should not always be used after craniotomy for supratentorial gliomas. Clinical observation was sufficient to predict early postoperative complications. A CT scan before 24 hours after surgery is not recommended in the absence of clinical worsening.

Identification of residual tumor with intraoperative contrast-enhanced ultrasound during glioblastoma resection.

OBJECTIVE: The purpose of this study was to assess the capability of contrast-enhanced ultrasound (CEUS) to identify residual tumor mass during glioblastoma multiforme (GBM) surgery, to increase the extent of resection. METHODS: The authors prospectively evaluated 10 patients who underwent surgery for GBM removal with navigated ultrasound guidance. Navigated B-mode and CEUS were performed prior to resection, during resection, and after complete tumor resection. Areas suspected for residual tumors on B-mode and CEUS studies were localized within the surgical field with navigated ultrasound and samples were sent separately for histopathological analysis to confirm tumor presence. RESULTS: In all cases tumor remnants were visualized as hyperechoic areas on B-mode, highlighted as CEUS-positive areas, and confirmed as tumoral areas on histopathological analysis. In 1 case only, CEUS partially failed to demonstrate residual tumor because the residual hyperechoic area was devascularized prior to ultrasound contrast agent injection. In all cases CEUS enhanced B-mode findings. CONCLUSIONS: As has already been shown in other neoplastic lesions in other organs, CEUS is extremely specific in the identification of residual tumor. The ability of CEUS to distinguish between tumor and artifacts or normal brain on B-mode is based on its capacity to show the vascularization degree and not the echogenicity of the tissues. Therefore, CEUS can play a decisive role in the process of maximizing GBM resection.

Role of nitric oxide and mechanisms involved in cerebral injury after subarachnoid hemorrhage: is nitric oxide a possible answer to cerebral vasospasm?

Cerebral vasospasm represents the most critical event that could occur after subarachnoid hemorrhage (SAH). Therapy is only partially effective because cerebral arterial constriction is not fully understood yet. One of the most important biological messenger associated to SAH is nitric oxide (NO), that is considered local regulator of cerebral blood flow. Different nitric oxide synthase (NOS) forms play a role in different biological processes, one of which is to link neuronal activity to blood flow in cerebral cortex. We performed a reassessment of the literature to summarize the role of NO as the main inflammatory pathway activated after SAH to clarify its importance for treatment of vasospasm.

Glioma Surgery: Technological Advances to Achieve a Maximal Safe Resection.

Glioblastoma multiforme (GBM) is the most frequent primary central nervous system (CNS) tumor. Despite the best treatment and advances in therapy, prognosis remains poor. One of the mainstays of therapy in GBM is surgical excision. Several studies have confirmed that the extent of resection (EOR) positively influences overall survival (OS) in patients with high-grade gliomas (HGGs). A literature search was performed using PubMed to assess the useful neurosurgical tools to achieve the best neurosurgical performance. In order to achieve the major extent of resection, preserving neurological function, many tools are now available, especially neuronavigation, intraoperative fluorescence, intraoperative ultrasound, and neuromonitoring. In addition to the maximal excision of tumor, the neurosurgeon can use photodynamic therapy (PTD) and local drug delivery (LDD) to improve the local control and bridge conventional radio and chemotherapy. EOR improves OS in patients with HGGs. There are technological possibilities for achieving a complete resection preserving neurological function, and it is not acceptable to perform only biopsy of these lesions.

Intraoperative Navigated Angiosonography for Skull Base Tumor Surgery.

BACKGROUND: One of the main challenges during skull base tumor surgery is identifying the relationships between the lesion and the principal intracranial vessels. To this end, neuronavigation systems based on preoperative imaging lack accuracy because of brain shift and brain deformation. Intraoperative navigated B-mode ultrasonography is useful in defining the extent of brain tumor. Doppler imaging adds information regarding flow entity in neighboring vessels. Second-generation ultrasound contrast agents improve the signal-to-noise ratio of B-mode imaging and permit the study of the vessel's course, blood flow, and perfusion characteristics of focal lesions. We report our experience using intraoperative navigated contrast-enhanced ultrasound to perform a navigated angiosonography (N-ASG) for the visualization of vessels in a series of 18 skull base tumors. METHODS: We performed N-ASG in a series of 18 skull base tumors (10 meningiomas, 3 craniopharyngiomas, 2 giant pituitary adenomas, 1 posterior fossa epidermoid, 2 dermoid cysts). N-ASG was obtained after craniotomy before resecting each lesion and during tumor removal, after intravenous injection of ultrasound contrast agent. RESULTS: In all 18 cases, major vessels and their branches were simultaneously identified (both high and low flow) using N-ASG, which allowed to visualize the whole length of each vessels. N-ASG was also useful in highlighting the lesion, compared with standard B-mode imaging, and showing its perfusion patterns. CONCLUSIONS: N-ASG can be applied to skull base tumor surgery, providing helpful information about the relationship between principal intracranial vessels and tumors. This technique could be of assistance in approaching the tumor and avoiding vascular damages.

Cerebrovascular diseases in the elderly: the challenge of multiple aneurysms.

OBJECTIVE: The worldwide population aging and the nowadays medical advances impose to consider new management guidelines for elderly. Aim of this study was to assess the best treatment in elderly with multiple intracranial aneurysms (MIA). METHODS: From 1994 to 2011, we admitted 1462 patients with ruptured cerebral aneurysm. Among those aged ≥65 years, 43 had MIA (15% of elderly). Size and aneurysm location, timing and type of treatment were analyzed. Patients were thus stratified according to Hunt-Hess grade on admission and evaluated at 6 months using the Glasgow Outcome Scale (GOS). RESULTS: We had 87 aneurysms in the final series. Three patients died because of the impossibility to treat the ruptured aneurysm. No new bleeding from untreated aneurysms was observed; no retreatment after previous coiling was performed. CONCLUSIONS: MIA lead to significantly poorer outcomes, especially in elderly, because of their general clinical condition, presence of risk factors and lower capacity of reaction to stressful events. In patients without large hematomas, coiling of the ruptured aneurysm represents the procedure with high effectiveness. The clinical conditions on admission represent the most important factor for the treatment results. To reduce the treatment-related risks we do recommend a conservative approach for the unruptured aneurysms.

Multiple cavernomas of the brain: simultaneous hemorrhage of two lesions in a non-familial form.

BACKGROUND: Cavernomas of the brain are congenital lesions clinically divided into hereditary and a sporadic forms. Multiple lesions are usually observed in the familial form, whereas the sporadic variant generally shows a single cavernoma. In this case we describe the simultaneous bleeding of two lesions in a patient with a non-familial cavernomatosis. CASE DESCRIPTION: A 46-year-old woman presented with slight hyposthenia involving the left arm and cervical stiffness. Examinations revealed two cavernomas with recent signs of bleeding. The lesions were surgically removed achieving a total excision. The patient was discharged after 10 days with slight left hyposthenia. DISCUSSION: Simultaneous hemorrhage of multiple cavernomas is rare. To the best of our knowledge, this is the first case showing a sporadic form presenting with two hemorrhagic lesions. We suggest an aggressive approach in order to avoid the risk of rebleeding, which is particularly high in case of hemorrhagic cavernomatosis.

Subarachnoid hemorrhage in elderly: advantages of the endovascular treatment.

AIM: Subarachnoid hemorrhage (SAH) from aneurysm rupture accounts for approximately 3% of all strokes. A significant improvement in surgery and endovascular procedures has reduced mortality and morbidity. Nowadays, endovascular treatment is a viable alternative to conservative treatment in elderly patients. We designed a retrospective observational study on all endovascular procedures carried out in our department in order to evaluate the outcome in elderly patients compared with a younger cohort. METHODS: A total of 378 patients with aneurysmal SAH were treated with detachable platinum coils in our department (1994-2009). Of these, 310 patients were aged 20-69 years and 68 were aged over 70 years. Data were stratified according to Hunt-Hess (H-H) grade at admission. The mean follow up was 4.8 years. The final outcome was evaluated through the Glasgow Outcome Scale (GOS). RESULTS: We observed a favorable outcome (GOS 5-4) in both groups of patients admitted with moderately good clinical conditions (H-H 1-3), with no statistically significant difference. In contrast, in the case of H-H grade at admission > 3, we observed a statistically significant poor outcome in elderly patients. CONCLUSIONS: We consider the endovascular treatment as first choice for elderly patients presenting with a good H-H grade at admission. Quick functional recovery and reduced hospitalization time were observed. Unlike young patients, a chance of recovery in elderly patients with H-H 4-5 is more difficult to achieve. Therefore, a conservative approach should be considered.

Interleukin-1 cluster gene polymorphisms and aneurysmal subarachnoid hemorrhage.

BACKGROUND: Emerging data indicate that proinflammatory cytokines may be involved in the pathogenesis of intracranial aneurysms. Interleukin (IL)-1 is a proinflammatory cytokine that plays a pivotal role in both acute and chronic central nervous system injuries. OBJECTIVE: To investigate whether select polymorphisms in the IL-1alpha, IL-1beta, and IL-1 receptor antagonist genes are associated with both susceptibility to and clinical characteristics of subarachnoid hemorrhage due to intracranial aneurysm rupture. METHODS: Allelic and genotypic frequencies of the IL-1alpha (-889), IL-1beta (-511), and IL-1 receptor antagonist (VNTR) genes were determined in 215 patients and 155 healthy controls. Patient files were reviewed for the clinical characteristics at hospital admission and at 6-month follow-up. RESULTS: No association between aneurysmal subarachnoid hemorrhage susceptibility and the examined cytokine gene polymorphisms was found. Haplotype analysis did not show any significant difference between cases and controls. However, aneurysmal subarachnoid hemorrhage patients carrying the T/T genotype of the IL-1beta gene showed a significant (P = .034) increase in the Hunt and Hess scores at hospital admission and a significant (P = .026) reduction in 6-month Glasgow Outcome Scale scores. The remaining polymorphisms showed no effect on the clinical features examined. CONCLUSION: Our results do not support the hypothesis that genetic variation in select polymorphisms of the IL-1 cluster genes is associated with aneurysmal subarachnoid cerebral hemorrhage. However, the IL-1beta gene may modify disease severity and may be regarded as disease severity gene.