Papilledema in childhood for diagnosis of pseudotumor cerebri or late hydrocephalus: a case report.

Abstract: A case of hydrocephalus is presented in a 13-year-old female with transient loss of vision from 1 week and papilledema, previous ophtalmological history was negative. Visual field was performed, and neurogical examination proved to be hydrocephalus. In literature few cases of Papilledema in adolescent children with hydrocephalus has been reported. The aim of this case report is to decode the signs, symptoms and factors associated with papilledema in children with hydrocephalus at an early stage in order to prevent a poor visual-functional residual (permanent low vision).

Consensus statement from the international consensus meeting on post-traumatic cranioplasty.

BACKGROUND: Due to the lack of high-quality evidence which has hindered the development of evidence-based guidelines, there is a need to provide general guidance on cranioplasty (CP) following traumatic brain injury (TBI), as well as identify areas of ongoing uncertainty via a consensus-based approach. METHODS: The international consensus meeting on post-traumatic CP was held during the International Conference on Recent Advances in Neurotraumatology (ICRAN), in Naples, Italy, in June 2018. This meeting was endorsed by the Neurotrauma Committee of the World Federation of Neurosurgical Societies (WFNS), the NIHR Global Health Research Group on Neurotrauma, and several other neurotrauma organizations. Discussions and voting were organized around 5 pre-specified themes: (1) indications and technique, (2) materials, (3) timing, (4) hydrocephalus, and (5) paediatric CP. RESULTS: The participants discussed published evidence on each topic and proposed consensus statements, which were subject to ratification using anonymous real-time voting. Statements required an agreement threshold of more than 70% for inclusion in the final recommendations. CONCLUSIONS: This document is the first set of practical consensus-based clinical recommendations on post-traumatic CP, focusing on timing, materials, complications, and surgical procedures. Future research directions are also presented.

Cambios metabólicos corticales y resultado clínico en la hidrocefalia normotensiva después de la derivación ventrículo-peritoneal: nuestros resultados preliminares / Cortical metabolic changes and clinical outcome in normal pressure hydrocephalus after ventriculoperitoneal shunt: our preliminary results

INTRODUCCIÓN: Nuestro objetivo fue evaluar los cambios metabólicos corticales y el resultado clínico en los pacientes afectados por la hidrocefalia idiopática de presión normal (iNPH) después de la colocación de una derivación ventriculoperitoneal (VP). MATERIALES Y MÉTODOS: Diez pacientes afectados por la sospecha de iNPH se sometieron a una evaluación de la hidrodinámica del LCR basada en una prueba de infusión lumbar. El principal criterio de selección para la cirugía se basó en la elasticidad intracraneal (EI)>0,30. Todos los sujetos con una EI> 0,30 se sometieron a una exploración PET con 18 fluorodesoxiglucosa (18F-FDG) en la línea de base (PET1) y un mes después de la cirugía (PET2). Además, los mismos pacientes fueron sometidos a una evaluación clínica antes y un mes después de la cirugía mediante pruebas neuropsicológicas y análisis de la marcha. RESULTADOS: Se realizó un número total de 20 exploraciones de PET 18F-FDG en todos los pacientes reclutados. En comparación con la PET1, la PET2 mostró un aumento en el consumo de glucosa en el lóbulo frontal izquierdo y el lóbulo parietal izquierdo en la PET2 en comparación con la PET1 (p < 0,001). Todos los pacientes reclutados presentaron un aumento significativo en las puntuaciones neuropsicológicas (i.e. Batería de evaluación frontal y Evaluación cognitiva de Montreal) y han mejorado clínicamente en el análisis de la marcha. Se encontró una correlación significativa entre el aumento del consumo de glucosa cortical en el área parietal izquierda y la mejoría cognitiva detectable por la evaluación neuropsicológica. CONCLUSIONES: La mejora en 18F-FDG PET del metabolismo de la glucosa podría considerarse un marcador de imagen útil para la evaluación de la respuesta de la iNPH a la derivación ventriculoperitoneal

INTRODUCTION: Our objective was to evaluate the cortical metabolic changes and clinical outcome in patients affected by idiopathic normal pressure hydrocephalus (iNPH) after a placement of ventriculoperitoneal (VP) shunt. MATERIALS AND METHODS: 10 patients affected by suspected iNPH underwent a CSF hydrodynamics evaluation based on a lumbar infusion test (LIT). The main selection criterion for surgery was based on intracranial elasticity (IE)>0.30. All subjects with an IE>0.30 underwent a PET scan with 18 fluorodeoxiglucose (18F-FDG) at baseline (PET1) and 1 month after surgery (PET2). Furthermore, the same patients were submitted to clinical evaluation before and 1 month after surgery through neuropsychological tests and gait analysis. RESULTS: An overall number of 20 18F-FDG PET scans were performed in all the enrolled patients. As compared to PET1, PET2 showed an increase in glucose consumption in the left frontal and left parietal lobe in PET2 as compared to PET1 (P<.001). All the enrolled patients presented a significant increase in neuropsychological scores (i.e Frontal Assessment Battery and Montreal Cognitive Assessment) and have clinically improved at gait analysis. A significant correlation was found between the increase of cortical glucose consumption in the left parietal area and the cognitive improvement as detectable by neuropsychological assessment. CONCLUSIONS: Improvement in 18F FDG PET glucose metabolism could be considered a useful imaging marker for the assessment of iNPH response to VP shunting

Cortical metabolic changes and clinical outcome in normal pressure hydrocephalus after ventriculoperitoneal shunt: Our preliminary results. / Cambios metabólicos corticales y resultado clínico en la hidrocefalia normotensiva después de la derivación ventrículo-peritoneal: nuestros resultados preliminares.

INTRODUCTION: Our objective was to evaluate the cortical metabolic changes and clinical outcome in patients affected by idiopathic normal pressure hydrocephalus (iNPH) after a placement of ventriculoperitoneal (VP) shunt. MATERIALS AND METHODS: 10 patients affected by suspected iNPH underwent a CSF hydrodynamics evaluation based on a lumbar infusion test (LIT). The main selection criterion for surgery was based on intracranial elasticity (IE)>0.30. All subjects with an IE>0.30 underwent a PET scan with 18 fluorodeoxiglucose (18F-FDG) at baseline (PET1) and 1 month after surgery (PET2). Furthermore, the same patients were submitted to clinical evaluation before and 1 month after surgery through neuropsychological tests and gait analysis. RESULTS: An overall number of 20 18F-FDG PET scans were performed in all the enrolled patients. As compared to PET1, PET2 showed an increase in glucose consumption in the left frontal and left parietal lobe in PET2 as compared to PET1 (P<.001). All the enrolled patients presented a significant increase in neuropsychological scores (i.e Frontal Assessment Battery and Montreal Cognitive Assessment) and have clinically improved at gait analysis. A significant correlation was found between the increase of cortical glucose consumption in the left parietal area and the cognitive improvement as detectable by neuropsychological assessment. CONCLUSIONS: Improvement in 18F FDG PET glucose metabolism could be considered a useful imaging marker for the assessment of iNPH response to VP shunting.

Intraventricular versus intravenous colistin for the treatment of extensively drug resistant Acinetobacter baumannii meningitis.

BACKGROUND AND PURPOSE: Reports on the safety and efficacy of intraventricularly administered (IVT) colistin for the treatment of Acinetobacter baumannii ventriculomeningitis in adults are limited and no comparative studies of IVT colistin versus intravenous (IV) therapy alone have been published. This study compared outcomes of patients with postneurosurgical ventriculomeningitis caused by extensively drug-resistant A. baumannii treated with IV colistin or IV plus IVT colistin. METHODS: In an 11-year period, information on 18 consecutive patients with extensively drug-resistant A. baumannii ventriculomeningitis was collected. Infection was defined on the basis of (i) isolation of A. baumannii from the cerebrospinal fluid (CSF); (ii) laboratory evidence of CSF infection; (iii) signs/symptoms of central nervous system (CNS) infection. Patients were divided into group 1 (nine patients, IV colistin alone) and group 2 (nine patients, IV plus IVT colistin). RESULTS: Cerebrospinal fluid sterilization was documented for 12 of 18 patients (66.6%). The CSF sterilization rate was 33.3% in group 1 and 100% in group 2 (P = 0.009). The mean time to CSF sterilization was 21 days (range 8-48). Five patients died due to A. baumannii CNS infection (all in group 1), and five deaths were unrelated to A. baumannii ventriculomeningitis. Intensive care unit mean length of stay was shorter in group 2 (20.7 vs. 41.6 days, P = 0.046). Crude relative risk ratio of cumulative incidence of persistent CNS infection in group 1 versus group 2 was 13. No cases of chemical meningitis due to intrathecal colistin administration were encountered. CONCLUSIONS: Intraventricular colistin administration is much more effective than IV therapy alone and does not seem to add further toxicity.

Successful treatment of multidrug-resistant Acinetobacter baumannii ventriculitis with intrathecal and intravenous colistin.

Acinetobacter baumannii (AB) nosocomial infections, especially those due to multi-drug resistant (MDR) strains, are increasingly detected. We report a case of a 42-year-old male patient affected by low-grade ependymoma who developed AB-MDR post-neurosurgical ventriculitis. Initially, because of in vitro susceptibility, we used a combination of intravenous colistin and tigecycline. This treatment resulted in the improvement of the patient's initial condition. However, soon after, the infection relapsed; tigecycline was stopped and treatment with intrathecal colistin was initiated. Cure was achieved by continuing this treatment for approximately three weeks, without adverse effects.

Intracranial meningiomas associated with non-traumatic chronic subdural hematoma.

BACKGROUND: Non-traumatic subdural hematomas are very rarely associated with intracranial meningiomas. Pathophysiological mechanisms of such an association are not yet fully understood. CASE DESCRIPTION: We report on two patients harboring an intracranial meningioma and ipsilateral non-traumatic chronic subdural hematoma. Their history was negative for risk factors for subdural hematoma. Both patients were submitted to surgery for evacuation of the subdural collection. The presence of the meningioma was discovered during surgery. A second operation was necessary in our first case. CONCLUSIONS: We retrospectively analyzed our radiological data and the literature to provide some features that may help in the pre-operative diagnosis of a meningioma in patients presenting with a chronic subdural hematoma. Furthermore the mechanisms responsible for this association are discussed on the basis of our pathological evidence.

Gliomatosis cerebri and pituitary adenoma: case report and literature review.

The diagnosis of Gliomatosis cerebri (GC) is known to be difficult and is still a matter of debate. We describe an in vivo case of GC associated with a pituitary tumor. A 47-year-old woman presented with short-term memory loss. A MRI revealed the presence of a pituitary enhancing tumor and a diffuse lesion involving the brain. A left pterional craniotomy with partial temporal lobectomy and removal of the pituitary lesion were performed in order to obtain diagnosis. The histological analyses showed a pituitary non-functioning tumor and a GC consisting of neoplastic oligodendrocytes and astrocytes. Both lesions showed nuclear immunoreactivity for progesterone receptors (PGr) and estrogen receptors (EGr). This result could suggest there is a common receptor substrate in these tumors. In this case hormones could constitute a common step in tumorigenesis of both lesions.

Rosette-forming glioneuronal tumour of the fourth ventricle: report of a case with clinical and surgical implications.

A 32-year-old woman presented with a 2-month history of episodic headache, cervical pain and neck rigidity. Neurological examination showed a moderate dysmetria. Magnetic resonance imaging (MRI) revealed a mass occupying the fourth ventricle. The patient underwent median sub-occipital craniotomy with total excision of the lesion well demarcated except for a portion infiltrating the right side of the IV ventricle wall. In the post-operative course the patient developed VI and VII right cranial nerves palsy and worsening of dysmetria. MRI confirmed the complete removal of the tumour without signs of recurrence. The pathological diagnosis was rosette forming glio-neuronal tumour (RGNT). At present this is the 13th RGNT reported in literature. These lesions are considered low-grade tumours (WHO I). Nevertheless, the case here reported, like in 6 of the 12 cases in literature, developed disabling post-operative deficits. To establish the therapeutic choice long-term follow-up studies are needed.

Open-door laminoplasty for cervical stenotic myelopathy: surgical technique and neurophysiological monitoring.

OBJECT: A modified technique of open-door laminoplasty for cervical stenotic myelopathy (CSM) is described, and the role of evoked potential monitoring in selecting patients for surgery and evaluating results is discussed. METHODS: Between October 1992 and October 1996, 33 patients with CSM underwent open-door laminoplasty. After surgery, in 27 patients (81.8%) different levels of clinical improvement were demonstrated, and in five of them (15%) full recovery was observed. The Japanese Orthopaedic Association score increased from 5 to 12 (mean 9.8) preoperatively to 8 to 14 (mean 11.6) postoperatively. At 1-year follow up, the N13 cervical response was restored in nine (75%) of 12 patients with isolated presurgical abnormality and in 57.1% of those with combined abnormalities of both N13 and P14 response. Although significant clinical improvement was observed in 82% of the cases, in 24 of 33 patients motor evoked potential abnormalities persisted at least at one explored level. CONCLUSIONS: Of several laminoplasty techniques, the one described here offers some advantages: preservation of biomechanical function of posterior muscular-ligamentous complex, prevention of laminar collapse, smaller degrees in reduction of range of cervical motion, stabilization of the spine with no postoperative malalignment, and maintenance of decompressive effect that avoids recurrent stenosis. Neurophysiological studies sometimes clarified neurological disorders that were only suspected on the basis of history and/or clinical examination, leading to early diagnosis.

Factors of surgical outcome in tumoural epilepsy.

OBJECTIVES: The purposes of the study were the assessment of the role of surgery in the suppression of epilepsy due to low-grade primitive cerebral tumours and the search for factors relevant to the surgical outcome. PATIENTS AND METHODS: Forty-eight patients with epilepsy due to low-grade supratentorial cerebral tumours were considered. They presented drug-resistant daily to monthly seizures since for least one year (mean 7 yrs). Twenty-four patients underwent a combined tumour and epileptogenic zone resection ("epilepsy surgery") and 24 tumour resection alone ("lesionectomy"). The surgical outcome was evaluated two years after surgery. Several variables related to the characteristics of the epilepsy, the tumour and surgery, were considered for a possible association with the outcome. Statistical analyses were performed. RESULTS: Seizure freedom, including aura, was obtained in 35 patients (72.9%). Mild permanent complications occurred in 6 cases. Seizure suppression was significantly associated with complete tumour resection (post-surgical CT or MRI) and relatively low presurgical seizure frequency; it was also related, though not significantly, to small tumour size and histological grade I. The surgical outcome was only slightly better following "epilepsy surgery" than "lesionectomy". However: i) the extent of tumour resection was not relevant regarding the "epilepsy surgery" outcome, while significantly influencing the outcome after "lesionectomy"; ii) the presurgical frequency of seizures and, to a less extent, the tumour size, had a higher influence on the outcome after "lesionectomy". CONCLUSION: Long-lasting and drug-resistant epilepsy due to cerebral tumours can be suppressed surgically in the majority of cases. The extent of tumour resection and the frequency of the seizures are the most relevant prognostic factors. Both "epilepsy surgery" and "lesionectomy" can provide good results. However, the two approaches should not be regarded as interchangeable: a choice of the approach based on the characteristics of seizures and of the tumour appears relevant to improve the surgical prognosis.

Anterior cervical epidural abscess treated by endoscopy-assisted minimally invasive microsurgery via posterior approach.

This is a report of clinical manifestation, physical findings, neurophysiological data, magnetic resonance imaging, and results after surgery in a 71-years-old man with cervical abscess. Magnetic resonance imaging after two weeks of empiric antibiotic therapy demonstrated the persistence of an anterior cervical epidural collection and signs of spondylodiscitis at the C5-C6 and C6-C7 levels. Surgery was performed by posterior endoscopy assisted key-hole approach at the C2-C3 level to drain the abscess and to decompress the spinal cord. Postoperative specific medical treatment was then administered. A successful outcome, at 24 months follow-up, was achieved by surgery with complete clinical recovery, resolution of the abscess and healing of the spondylodiscitis. After unsuccessful blind medical therapy the minimally invasive microsurgical technique allowed us to keep the surgical injury of the healthy tissue to a minimum while producing the maximum therapeutic effect.

Modification of the Talairach stereotactic system for CT-compatibility: technical note.

A modification of the Talairach stereotactic system is described which is able to incorporate CT data and provides both co-ordinate calculations, directly from the CT console screen and by a fiducial reference system. The device maintains the original base plate, thus allowing its interfacing with all the accessories of the early apparatus and its direct use in the stereotactic operating room. The instrument has shown great reliability in the localisation of brain lesions and considerable flexibility in many stereotactic operations such as biopsy procedures, brachytherapy, radiosurgery and stereotactically assisted resections.

Callosotomy for drug resistant generalized seizures.

We report our series of drug resistant epileptic patients submitted to callosotomy. The 25 patients were affected by severe epilepsy with invalidating generalized seizures with fall, lacking of indication for ablative surgery. Nineteen patients, with at least 1 year of follow-up, were considered for this study. The surgical outcome was classified as: class A), seizure disappearance; class B) 80%, class C) 80-50%, class D) less than 50% seizure reduction; E) increase of seizure frequency. The follow-up analysis shows that the better results are obtained with the generalized seizures, in particular the GTA. Our surgical results are discussed considering the data of the literature: about the functional anatomy of the Corpus Callosum, the experimental studies and the clinical series published on callosotomized epileptic patients.