Brain location and tumor biological markers in high- and low-grade gliomas.

BACKGROUND: Recent studies suggest gliomas location may be correlated with specific biological signatures. Our purpose was to focus on the possible correlation between MGMT metilation status and Ki67 positivity with patient age, glioma location and lateralization. METHODS: We performed a retrospective evaluation to assess the correlation between MGMT metilation status and Ki67 index positivity with patient age, glioma location and lateralization. RESULTS: The study included 174 supratentorial gliomas. Of these, 144 tumors were high grade gliomas (HGGs), and 30 tumors were low grade gliomas (LGGs). In HGG group we detected an association between tumor location and MGMT status. Those GBMs located in the frontal lobe were significantly associated with MGMT methylated status (MGMT+) and Ki67<30% than those GBMs located in other sites; while those GBMs located in the temporal lobe were associated with MGMT unmethylated (MGMT-) status. In anaplastic gliomas, we found an association between the involvement of the frontal lobe with MGMT+ status and Ki67<30%. In LGG group, our results showed that both frontal and temporal lobe were associated with a Ki67<30% and there was a predictive value for MGMT methylation status when patient age increased. CONCLUSIONS: Our findings suggest there is a high variability in anatomical distribution of biological glioma markers and this high heterogeneity may have a clinical role. Moreover, our study supports the idea that frontal lobe HGGs may be biologically favorable. Considering that as all glioma with lobar location are more amenable to radical surgical resection, it may be assumed that frontal tumor can have a better prognosis, and we have shown, to our knowledge for the first time, this is true both for HGG and for LGG.

Parasagittal meningiomas: Our surgical experience and the reconstruction technique of the superior sagittal sinus.

BACKGROUND: The radical resection of parasagittal meningiomas without complications and recurrences is the goal of the neurosurgeon. Nowadays, different managements are proposed. This study describes our surgical technique during the lesional excision and the reconstruction of the superior sagittal sinus (SSS). METHODS: The total removal (Simpson I and II) of parasagittal meningiomas (WHO grade I and II) was obtained in 75 patients from September 2000 to January 2010. The indocyanine green videoangiography was used before the dural opening and, when necessary, to identify and preserve the cortical veins. The surgery of the SSS was performed in accordance with Sindou's classification, and its reconstruction was achieved through the use of a patch of galea capitis. RESULTS: We had no cases of recurrence and thrombotic occlusion of the SSS in 5 years after the reconstruction. No complications were observed in 65 patients, and no cases of mortality were reported. Neurological focal deficits were observed in 5 patients. A brain swelling and a venous infarction were observed in 1 patient. Only one case of thrombotic occlusion was observed. A cerebrospinal fluid leak was observed in 2 patients, and a systemic complication was found in 1 patient. CONCLUSION: Several factors contribute to the success of the parasagittal meningioma surgery. We consider the preservation of the cortical veins to be important, and, when possible, we recommend the reconstruction of the anterior third of the SSS. Our experience has led us to believe that until now surgery is a winning choice if practiced by expert hands.

Dural repair using autologous fat: Our experience and review of the literature.

BACKGROUND: Various materials have been proposed to obliterate dead spaces and to reconstruct dural defects during a neurosurgical approach. This study describes our technique of using the abdominal autologous fat graft and evaluates the complications and characteristics related to the use of this tissue during cranial procedures. METHODS: Autologous fat grafts were used in 296 patients with basicranial and convexity extraaxial tumors from April 2005 to January 2015. The adipose tissue was removed from the paraumbilical abdominal region and was transformed into a thin foil. When possible, a watertight suture was made between the dural or bone edge with a fat graft. We always used fibrin glue to reinforce the dural closure. RESULTS: Complications occurred between 2 days and 1 year following procedure. Cerebrospinal fluid leaks were found in 11 cases. No case of mortality, pseudomeningoceles, fistula, infections, bacterial meningitides, or lipoid meningitides was reported. No patient required removal of the graft. No adhesion was observed between the brain and the autologous fat. Other fat-related complications observed were 2 cases of fat necrosis in the abdomen and 2 cases of abdominal hemorrhage. CONCLUSION: The technique of harvesting and applying fat grafts is fairly simple, although it must be performed meticulously to be effective. Our experience has led us to believe that the use of fat grafts presents low morbidity and mortality. However, a neurosurgeon should never forget the possible late or early complications related to the use of fat grafts.

Angiolymphoid hyperplasia with eosinophilia and entrapment of the ulnar nerve.

BACKGROUND: The angiolymphoid hyperplasia with eosinophilia (ALHE) is a sporadic vasoproliferative lesion of uncertain etiology involving the skin and the subcutaneous tissue. Occasionally, it involves also the large arteries compressing the near nerves. ALHE is commonly confused with Kimura's disease because of their clinical and histological similarities. CASE DESCRIPTION: We report a case of a 52-year-old female suffering from a 6-month pain and paresthesias in the fourth and fifth finger of the right hand. The angiography showed a pseudoaneurysm in the proximal third of the right ulnar artery. A complete surgical excision of the vascular lesion was undertaken. The lesion forced the right ulnar nerve. The histopathological diagnosis deposed for ALHE. CONCLUSION: Up to now, literature has described 8 cases of ALHE involving the arteries, and only one case originating from the ulnar nerve. The authors report a case of a female with ALHE involving the ulnar artery that compressed the ulnar nerve. Clinical aspects, radiological features, surgical treatment, and operative findings are discussed reviewing the pertinent literature.

Cavernous hemangioma of the dura mater mimicking meningioma.

BACKGROUND: Cavernomas are benign lesions that most commonly occur intra-parenchymally, but occasionally they have been described as arising from the dura mater. Extra-axial cavernous angiomas (or hemangiomas) account for 0.4-2% of all intracranial vascular malformations, and they usually occur in the middle cranial fossa, associated with the cavernous sinus. Other possible localizations (e.g. tentorium, convexity, anterior cranial fossa, cerebellopontine angle, Meckel's cave, sella turcica and internal auditory meatus) are rare, and they account only for 0.2-0.5%. CASE DESCRIPTION: We report a case of a 30-year-old female presenting with a 2 years history of headache unresponsive to drug therapy. The magnetic resonance imaging showed a dural-based lesion in the left frontal region; the lesion size was: 1.5 cm × 3.5 cm. The appearance suggested a convexity meningioma. A left frontal craniotomy was performed, and the histopathological diagnosis deposed for a cavernous hemangioma of the dura mater. The follow-up at 1-year was good without any neurologic deficit. CONCLUSIONS: Dural-based cavernous hemangiomas of the convexity are uncommon lesions. Up to now, only 13 cases have been described in the literature. The authors have discussed clinical aspects, radiological features, surgical treatment, and operative findings.

The usefulness of intraoperative mobile computed tomography in severe head trauma.

With modern technology, intraoperative computed tomography scans are being used in neurosurgical operative rooms. A case of severe head trauma is reported to underline how intraoperative computed tomography can improve the treatment of traumatic lesions, without changing the operative setup, with safety for patients and surgeons. The ability to perform an intraoperative computed tomography scan rapidly, at any surgical step, and with no need of any change in the operative room set or of moving the patient from the operative table improves safety both for the patient and surgeon. Intraoperative computed tomography is a very helpful tool during surgery for complex cases when a rapid evaluation of surgical manoeuvres is required.

Brain Metastasis From Prostate Adenocarcinoma: Case Report and Review of Literature.

It is rare for prostate carcinoma to metastasize to the central nervous system. It often represents a terminal event with death in one year frequently due to the advanced systemic disease. Starting by a case report, we also reviewed the relevant literature to focus on this uncommon entity from epidemiology to clinical manifestation and therapeutic strategies. In this article, a case of multiple brain prostate metastasis is reported and a review of relevant literature is also discussed. Treatments available for intracranial metastasis include neurosurgery, external beam radiation and hormonal manipulation. Surgery associated with whole brain radiotherapy seems to be effective in the control of brain lesions both relieving neurological symptoms and prolonging survival, even if prognosis remains dismal. From this case, we concluded that brain metastasis from prostate carcinoma is a rare, terminal event with death in one year frequently due to the advanced systemic disease. A better understanding of the biology of prostate carcinoma will help clarify the basis for its metastasis to the brain.

Meningioangiomatosis Without Neurofibromatosis Type 2.

Meningioangiomatosis (MA) is a rare, benign hamartomatous lesion found in cerebral cortex and leptomeninges. It occurs mostly in 5 - 15 year old children in form isolated or diffuse; the diffuse form may be associated with neurofibromatosis type 2 (NF2). The sporadic type in the adults is less common.The patient was a 37 year-old man with a long history of frontal headache. In suspected sinusitis, the patient underwent cerebral MRI that showed hypointense lesion in the right frontal lobe with heterogeneous contrast enhancement after gadolinium administration. There were no stigmata or family history of neurofibromatosis. A right pterional approach with a supraorbital craniotomy was performed. The lesion was removed with complete remission of the headache in the postoperative time. MA enters into differential diagnosis with several other diseases and a correct diagnosis is mandatory. The total surgical removal is the treatment of choice, and the prognosis after surgery is usually excellent for the absence of recurrence in sporadic cases.

A rare case of greater petrosal nerve schwannoma.

BACKGROUND: Facial nerve schwannomas include only 0.8% of all intrapetrous mass lesions, and schwannomas originating exclusively from the greater petrosal nerve (GPN) are extremely rare. To date, only 13 reports have been described. In this case, the tumor was thought to originate from the GPN on the basis of clinical, radiological, and operative findings. CASE DESCRIPTION: A 23-year-old girl presented an acute left facial palsy, a disturbance in tear secretion of the ipsilateral eye, and a left-sided conductive hypoacusia. Computed tomography (CT) scan and magnetic resonance imaging (MRI) showed an extradural mass in the left middle fossa. A subtemporal approach was performed and the lesion, originating from the proximal portion of the GPN, was excised. The post-operative course was satisfactory, except for a xerophtalmia, which was treated with artificial teardrops. CONCLUSION: GPN schwannomas can originate anywhere alongside the course of the nerve, from its proximal segment near the facial hiatus to its distal segment near the foramen lacerum. For these reasons, it requires differential diagnosis with trigeminal nerve schwannomas or with injuries arising from the geniculate ganglion, because it can be easily confused with those lesions. However, in less severe cases, an early diagnosis can be able to preserve the function of the facial nerve by reducing iatrogenic injuries caused by surgical maneuvers.

Laparoscopy-assisted ventriculoperitoneal shunt surgery: personal experience and review of the literature.

Ventriculoperitoneal shunting is a widely accepted technique for the treatment of hydrocephalus. The standard procedure to insert the peritoneal catheter requires an abdominal incision, muscle dissection, and opening of the peritoneum. A number of complications related to the abdominal surgical phase have been reported. Laparoscopy-assisted ventriculoperitoneal shunting is a valid alternative procedure that reduces surgical trauma. We describe our experience and review the literature. A total of 30 laparoscopically guided ventriculoperitoneal shunting procedures were performed between January 2007 and June 2008, in collaboration with a general surgeon experienced in laparoscopy. Of these procedures, 25 were new shunt placements and 5 were revisions. Data about operative time, outcome, and complications were registered and compared with a group of 30 patients treated by means of standard laparotomy in the period 2005-2007. Laparoscopic shunt placement was successful in all patients. Operative duration, complications, and postoperative pain were all lower in patients treated by laparoscopy as compared to the laparotomy. In the laparoscopic group, an earlier peristalsis, quicker mobilization, and better cosmetic results were also noted. Laparoscopy in both ventriculoperitoneal shunt placement and revision is a safe, effective, and minimally invasive technique. It ensures proper abdominal placement of the distal catheter under direct vision allowing confirmation of its patency.