Spontaneous ("erosive") cerebrospinal rhinorrhea, with pneumococcal meningitis from anterior optic glioma. Case report.

A 6-year-old girl, operated upon for an optic nerve astrocytoma (resection limited to the intraorbital portion of the nerve), developed 3 years later symptoms and signs of chiasmatic invasion. Nine years after surgery (1980), she suffered from pneumococcal meningitis, due to cerebrospinal rhinorrhea that had been present in the last few years. A repeated neuroradiological investigation showed the site of the fistula and cerebral ventricles of normal size. The case is argued for bulb-to-chiasm resection of an optic nerve glioma: a spontaneous cerebrospinal rhinorrhea with its potential dangers of meningitis seems to be one more complication of a limited resection of these tumors. It is felt that this is an unusual instance of spontaneous rhinorrhea from direct tumoral erosion. The diagnostic value of metrizamide cisternography for the assessment of presence and site of the fistulous leak is confirmed.

Opto-chiasmatic arachnoiditis in the young.

14 young patients, operated upon for opto-chiasmatic arachnoiditis by craniotomy are presented. 2 main etiopathogenetic forms (and their respective clinical equivalents) of the disease could be recognized. Only 1 postoperative death occurred, in a patient with a dominant clinical picture of intracranial hypertension. Results of surgery (craniotomy and lysis of adhesions) could be distinguished as positive (functional improvement) in 5 cases, indifferent or negative in the others, with a follow-up duration of up to 23 years. The role of the diagnostic value of the pneumoencephalogram as a basis for surgical indication is discussed: it is felt that this examination, when reported as negative, is not of sufficient value to rule out the diagnosis, which must essentially rely upon clinical data.

[Computerized tomography in diffuse post-traumatic brain damage]. / La tomografia computerizzata nel danno cerebrale diffuso post-traumatico.

Among 851 patients admitted following a head injury at the Neuroradiological Service and Neurosurgical Department of the University Hospital of Padua from January 1979 to June 1981, 51 presented a diffuse damage of the white matter of the brain. The CT scan, the only neuroradiological method able to show such a lesion, does never reveal large lesions but only minimal alterations of the cerebral parenchyma, opposite to the severity of clinical picture. We discuss the etiopathogenetic, anatomopathologic and neuroradiologic aspect of diffuse brain damage, emphasizing, the technical difficulties in the demonstration, on CT scan, of some lesions, particularly at the level of the brainstem.

Cervical rib syndrome: a neurosurgical experience with a series of 38 cases.

A series of 38 patients with thoracic outlet syndrome caused by a cervical rib is reviewed after a postoperative follow-up period of 3 to 24 years. The outcome of the operation (anterior scalenotomy and partial to subtotal removal of the cervical rib) is not considered wholly satisfactory; three causes for this were identified: excessive duration of symptoms (mean almost 6 years), insufficient patient work-up and inadequacy of the incomplete removal of the cervical rib. In the presence of a cervical rib, other possible causes of compression of the neurovascular supply to the upper limb should always be considered.

Long-term immunological investigation of malignant intracranial gliomas.

In this study, 118 consecutive adult patients with supratentorial gliomas underwent preoperative immunological monitoring, with particular regard to B-lymphocyte and T-lymphocyte markers. Most patients were treated surgically and with radiotherapy. Three months later, they were readmitted for postoperative immunological investigation and follow-up control. A total of 76 cases could thus be completely investigated and were statistically eligible for evaluation. A pronounced failure of T-cell-mediated immunity was observed: "E-active" rosette-forming cells and mitogen-induced blastogenesis tests turned out to be markedly depressed, with a slight postoperative recovery. Spontaneous cell-mediated cytotoxicity was significantly (p less than 0.01) increased both in preoperative and postoperative findings. The main immunodiagnostic patterns (immunoglobulins assay, surface immunoglobulins, "mouse" rosettes) concerning the B-cell-dependent "pool" were found to be within normal limits.

[The CT-scan and hypocycloidal cysternography with water soluble non ionic contrast media (metrizamide and iopamidol) in sellar and parasellar lesions (author's transl)]. / La cisternografia opaca computerizzata ed ipocicloidale con mezzi di contrasto non ionici (metrizamide e iopamidolo) nelle lesioni sellari e parasellari.

A group of 30 patients with sellar or parasellar lesions were investigated by CT-scan and hypocycloidal tomography after lumbar injection of water-soluble non ionic contrast media. The combination of the 2 techniques (CT-scan and tomography) allowed very satisfactory diagnostic results and the excellent tolerance of non-ionic contrast was confirmed in this patient series.

Gliomas of the optic nerve and chiasm. A clinical review.

A series of 24 children with anterior optic gliomas, observed and for the most part operated upon in a neurosurgical service, is reviewed. A low incidence of unilateral nerve tumors and of associated neurofibromatosis, and a rather high frequency of precocious or pseudoprecocious puberty were noted in comparison with other series. Most tumors were low-grade growths. The results of surgical treatment reflect a good prognosis for unilateral tumors and an increasing prognostic ominousness for the posterior neoplastic development. Cerebrospinal fluid shunts and radiation treatment do have a role as adjuncts to surgical exploration and biopsy, which are generally indicated since no preoperative test seems to grant an absolute diagnosis. The opinion that chiasmal tumors should not be treated at all is not shared. When the treatment of an illness falls as far short of the ultimate, as does the therapy of neoplastic disease, then it is necessary to reconsider frequently the principles upon which it is based and the results it achieves. These results are two-fold, curative and palliative and, while our efforts are directed toward the former, we realize only too frequently that the best results will sometimes lie in palliation. The disappointment in accepting this lesser goal must not allow us to underestimate its importance or neglect the help it may give.

Cerebral arteriovenous malformations in children (56 cases).

A survey of 56 patients aged less than or equal to 16 years, admitted (1954-1979) for cerebral arteriovenous malformations, is presented. The clinical manifestation was mostly related to hemorrhage, less frequently to epilepsy or to a cerebral 'steal' syndrome. The most frequent site was the parietal lobe, with supply from the middle cerebral artery. Deep malformations were not uncommon and most lesions were of medium or large size. 38 patients were operated upon, and 18 were given treatment other than surgical (including radiotherapy). 23 malformations were completely excised, in 4 patients only a partial excision could be carried out, and in 10 patients surgery consisted of occlusion (clipping or coagulation) of feeding vessels. In 1 patient, surgery had to be limited to removal of an intracerebral hematoma. The immediate and long-term results of treatment are much better in the surgical than in the nonsurgical group.

Diagnosis of cerebral venous angioma by rapidly enhanced CT scan.

A case is presented of cerebral venous angioma demonstrated by cerebral angiography and by CT scans in the axial and coronal projections after contrast enhancement with high, rapidly administered doses of contrast medium. The respective advantages of the two examinations in the diagnosis of cerebral vascular hamartomas with a slow blood flow are discussed.

4-Demethoxy-4-hydroxydaunorubicin 6-methyl ether and 11-methyl ether, two active isomers of daunorubicin.

The preparation of two isomers of daunorubicin, one having a completely chelated dihydroxyanthraquinone chromophor (III) and one have having such a chromophor in a emichelated form (IV), is reported. The former is as active as daunorubicin, the latter shows a considerable activity, however at much higher doses.

Intracranial aneurysms of childhood.

15 cases of cerebral aneurysms in children between 8 and 15 years of age, all operated upon in a 20-year span (1956--1976), are reported. 7 of them were the carriers of large aneurysms (3 'giant'). Surgical mortality was limited to 2 patients with aneurysms of the middle cerebral artery and large intracerebral hematomas. All other patients are in satisfactory conditions, with a follow-up ranging from 2 to 22 years. A direct approach to the aneurysm was used in all but 3 cases. Certain features of cerebral aneurysms in children are discussed pertinently to this series.

Exophthalmos from aneurysmal bone cyst of the orbital roof.

An aneurysmal bone cyst of the orbital roof, causing a monolateral exophthalmos in a 15-month-old child with no previous history of head injury, was operated upon and histologically misdiagnosed as a giant cell tumor. Radiation treatment in a dosage (3,740 rad) appropriate for the latter diagnosis apparently caused a massive calcification of the residual mass with persisting exophthalmos. At a second operation the lesion was removed completely and a radical change in the histopathological features was found. 12 years after surgery, there is no evidence of residuals upon roentgenographic and CT scan examinations and the exophthalmos has practically disappeared, while there is a normal visual function in the affected eye. Some points of histopathological and gross pathological differential diagnosis between aneurysmal bone cysts and giant cell ("myeloplaxis") tumors are discussed.

Anterior optic gliomas with precocious or pseudoprecocious puberty.

5 patients with gliomas of the anterior optic pathways, histologically assessed or with strong diagnostic evidence, who developed precocious or pseudoprecocious puberty (2 cases) before the operation or after radiation treatment, are presented. Only 2 patients presented familial and/or personal evidence of neurofibromatosis. The production mechanism of these sexual changes is discussed.

Combined treatment of pediatric medulloblastoma. A review of an integrated program )two-arm chemotherapy trial).

29 out of 34 consecutive patients of pediatric age, operated upon for posterior fossa medulloblastoma, were divided into 2 groups according to the chemotherapeutic treatment (intrathecal methotrexate or intravenous cyclophosphamide) received at random after surgery and radiation treatment. The modalities of irradiation and chemotherapy are described. 9 patients have not yet shown a local recurrence and are alive at varous intervals after surgery. Only 1 patient with local recurrence is still alive 31 months after the primary operation. The mean actuarial survival of the whole series of patients is about 38 months. Differences between the two groups, concerning either the survival rate till local recurrence, or the general and neurologic conditions of survival, are not statistically significant. Hematologic toxicity was more pronounced in the group treated with cyclophosphamide, whereas late neurologic sequelae were a more prominent feature of the intrathecal methotrexate trial.

Tuberculoma of the anterior optic pathways. Case report.

A tuberculoma, encasing the anterior optic pathways in a neoplastiform growth, was found in a 25-year-old man complaining of severe visual loss, diabetes insipidus, and sexual impotence following tuberculous meningitis. Following biopsy and anti-tuberculosis treatment, a satisfactory restoration of sight in one eye allowed the patient to resume an almost normal life.