Myelomeningocele: Long-Term Neurosurgical Management.

Open spina bifida, also known as myelomeningocele (MMC), is the most challenging and severe birth defect of the central nervous system compatible with life and it is due to a failure in the dorsal fusion of the nascent neural tube during embryonic development. MMC is often accompanied by a constellation of collateral conditions, including hydrocephalus, Arnold - Chiari II malformation, brainstem disfunction, hydrosyringomyelia, tethered cord syndrome and scoliosis. Beyond early surgical repair of the dorsal defect, MMC requires lifelong cares. Several additional surgical procedures are generally necessary to improve the long-term outcomes of patients affected by MMC and multidisciplinary evaluations are crucial for early identification and management of the various medical condition that can accompany this pathology. In this chapter, the most common pathological entities associated with MMC are illustrated, focusing on clinical manifestations, treatment strategies and follow up recommendations.

Extracranial-intracranial bypass for giant aneurysms and complex vascular lesions: a clinical series of 10 patients.

AIM: The purpose of this clinical study is to evaluate the preventive bypass indications, the kind of bypass to use, and the timing of postoperative internal carotid artery (ICA) occlusion in the treatment of complex aneurysms. METHODS: This study enrolled 10 patients suffering from complex aneurysms treated using several kind of extra-intracranial bypass on the basis of preoperative careful assessment of cerebrovascular flow. This assessment is based on the balloon test occlusion (BTO), from which three different conditions emerge. According to the Department of Neurosurgery these three different conditions require three different kinds of bypass: in case of depleted flow a short STA-MCA bypass is necessary, in case of intermediate flow a long arterial graft bypass is required, whereas in case of high flow a long venous graft bypass is mandatory. RESULTS: Bypass patency was found in six out of seven patients who underwent surgery for giant ICA aneurysms, as well as in other patients. One of the patients died for a septic shock, another had a neck hematoma that required surgical evacuation. At mean follow-up no further neurological deficits were found. CONCLUSION: The severe complications due to the combined approaches can be reduced thanks to the indications obtained by BTO concerning the kind of bypass to perform and to the timing of the ICA occlusion.

Pharmacological complications of the chronic baclofen infusion in the severe spinal spasticity. Personal experience and review of the literature.

AIM: To evaluate the pharmacological complications and side effects of the chronic intrathecal baclofen infusion in patients suffering from intractable spinal spasticity in our Department as well as in the literature. METHODS: The pharmacological complications and side effects observed at long-term follow-up in 25 patients with chronic intrathecal baclofen infusion are evaluated; the search of the literature complications was carried out in Medline and in Ingenta web sites. RESULTS: We have been able to observe in our series 3 (12%) patients with hypotonia, 2 with impairment on erection (8%) and 1 (4%) with constipation; 5 (20%) patients showed also tolerance but only 1 (4%) needed a ''drug holiday''. In the literature the side effects range from 4% to 16%. Moreover the tolerance is reported from 3% to 15%. The overdose has been reported from 0% to 14%, while the syndrome of withdrawal is reported in 16 patients with 6 fatalities. In our series these two last complications were not observed. CONCLUSIONS: Lethal pharmacological complications are rare and, if promptly diagnosed and treated, are reversible. Side effects of minor importance can impair the patient quality of live and needed to be adjusted to patient's requirements. This kind of therapy should be restricted to specialized centres.

The microvasculature of the lateral choroid plexus in the rat: a scanning electron microscopy study of vascular corrosion casts.

The three-dimensional microvascular structure of many organs can be adequately investigated only using the corrosion casting technique. We applied this method, consisting of an injection of low viscosity acrylic resin through the major vessels and the subsequent digestion of the organic component with strong alkali or acids, to the choroid plexus of the lateral ventricles in the rat, focusing on its structural vascular features. This approach allowed a qualitative morphological description of the choroid plexus of the lateral ventricles, revealing several aspects of their capillary architecture as well as the morphological details underlying its main functional activity, essential to cerebrospinal fluid turnover. Observation of the casts with scanning electron microscopy gave a detailed picture of the choroid plexus of the lateral ventricles of the rat and enabled us to distinguish four different regions, depending on the site that the lateral ventricles occupied: the anterior olfactory region, the main central region, the longer branch and the inferior horn. Each region mostly consisted of spiral capillaries and had specific characteristics. At high magnification, the casts revealed distinctive vascular specializations, such as numerous bulges regularly placed on the capillaries. This morphological investigation underpins a better comprehension of the pathological mechanisms involving the choroid plexus in the lateral ventricles.