Lateral lumbar interbody fusion via a unilateral true percutaneous approach associated with minimally invasive pedicle screw fixation for degenerative disc disease and lumbar instability. A technical note.

In recent years, minimally invasive surgical techniques for lumbar fusion and fixation procedures gained worldwide popularity. Herein we describe a personal technique for percutaneous lumbar interbody fusion associated with minimally invasive posterior fixation for patients affected by degenerative disc disease and lumbar instability. The procedure is described in a step-by-step way and early results are presented. Although the present data reflect only an early experience, we believe that this is a straightforward procedure which may be more advantageous in terms of surgical invasiveness, potentially saving operative and recovery time and reducing risks compared to posterior or anterior approaches for lumbar interbody fusion.

Anterior clinoidal meningiomas: report of a series of 33 patients operated on through the pterional approach.

Between 1985 and 1995, 33 cases of clinoidal meningioma were surgically treated by pterional approach. In 6 cases, according to the grading scale of Al-Mefty, the lesions were group I, having originated from the lower part of the clinoid; in 22 cases, the lesions were group II, having originated from the upper or lateral part of the clinoid process; and in 5 cases, the lesions were group III since they arose from the optic foramen. Postoperatively, 17 patients showed an improvement, 4 were unchanged, and 6 presented further deficits. Five patients died after surgery: two from pulmonary thromboembolism, one from myocardial infarction, one from hematoma of the operative field, and one from cerebral ischemia after severe vasospasm of the internal carotid artery (unresponsive to treatment). The mean follow-up was 53.7 months (range 12-108 months) and included 19 patients. During this period, there were five recurrences, and three patients underwent resection again and showed no signs of tumor regrowth 1 year later; one patient who did not undergo resection again due to his age and poor general conditions died 3 years after onset of the recurrence; the last patient has so far refused a second operation. The clinical, diagnostic, and therapeutic aspects of this not infrequent pathology are discussed in the light of our experience and the pertinent literature.

Lack of correlation between Ki-67 labelling index and tumor size of anterior pituitary adenomas.

AIMS AND BACKGROUND: The Ki-67 is a nuclear antigen detected by the monoclonal antibody MIB-1 and its Labeling Index (LI) is considered a marker of normal and abnormal cell proliferation. Pituitary adenomas are generally well differentiated neoplasms, even if in about one third of cases they are invasive of surrounding tissues. The aim of this study is to evaluate the correlation between Ki-67 labelling index and tumor size of pituitary adenomas extimated by means CT and MRI and confirmed at operation. METHODS: Using the monoclonal antibody MIB-1, we evaluated the expression of Ki-67 in 121 anterior pituitary adenomas consecutively operated on in a 48-month period. RESULTS: In relation to neuroradiological (CT and MRI) and surgically verified tumor size, we identified 24 microadenomas, 27 intrasellar macroadenomas, 34 intra-suprasellar macroadenomas, and 36 intra-supra-parasellar macroadenomas. The adenomas were non-infiltrating (76 cases) and infiltrating (45 cases) adenomas. The wall of the cavernous sinus (CS) was infiltrated in 18 cases. Forty-eight adenomas were non-functioning and 73 functioning. The overall mean +/- SD Ki-67 LI was 2.72 +/- 2.49% (median 1.6). It was 2.59 +/- 1.81 in microadenomas, 2.63 +/- 3.45 in intrasellar macroadenomas, 1.91 +/- 2.11 in intra-suprasellar macroadenomas, and 3.29 +/- 5.45 in intra-supra-parasellar macroadenomas (p = 0.27). It was 3.73 +/- 5.13% in infiltrating and 2.03 +/- 2.41% in non-infiltrating adenomas (p = 0.02), and 5.61 +/- 7.19% in CS-infiltrating versus 2.09 +/- 2.37% in CS-non-infiltrating adenomas (p = 0.0005). CONCLUSIONS: Our preliminary results seem to exclude significative correlations between Ki-67 LI and tumor size of anterior pituitary adenomas, even if this index can be considered a useful marker in the determination of the infiltrative behaviour of these tumors.

Ki-67 labelling index and invasiveness among anterior pituitary adenomas: analysis of 103 cases using the MIB-1 monoclonal antibody.

AIMS: To investigate the relation between proliferative activity of anterior pituitary adenomas, quantified by the Ki-67 labelling index, and their invasive behaviour. METHODS: Expression of Ki-67 was evaluated in 103 anterior pituitary adenomas consecutively operated on in a 36 month period and correlated with surgical evidence of invasiveness. RESULTS: Non-invasive (n = 65) and invasive (n = 38) adenomas were identified from surgically verified infiltration of sellar floor dura and bone. The wall of the cavernous sinus was infiltrated in 16 cases. Forty one adenomas were non-functioning and 62 functioning (24 prolactin, 21 growth hormone, 10 ACTH, seven mixed). The overall mean (SD) Ki-67 labelling index was 2.64 (3.69) per cent (median 1.5). The mean index was 3.08 (4.59) per cent in functioning and 1.97 (1.78) per cent in non-functioning tumours; 5.47 (9.52) per cent in ACTH adenomas and 2.33 (2.42) per cent in others (p = 0.01); 3.71 (5.17) per cent in invasive and 2.01 (2.45) per cent in non-invasive adenomas (p = 0.027); and 5.58 (7.24) per cent in cavernous sinus infiltrating v 2.10 (2.39) per cent in cavernous sinus non-infiltrating adenomas (p = 0.0005). To identify a value of labelling index beyond which adenomas should be considered invasive and another beyond which cavernous sinus infiltration should be suspected, normality Q-Q plots were obtained: a threshold labelling index of 3.5% for invasive adenomas and of 5% for cavernous sinus infiltrating adenomas was defined, with statistically significant differences (p = 0.02 and p = 0.004, respectively). CONCLUSIONS: The Ki-67 labelling index can be considered a useful marker in determining the invasive behaviour of anterior pituitary adenomas.

Proposal of a clinico-histological "glioma score" as a prognostic index in high-grade glioma patients. Preliminary observations in a series of 80 cases.

BACKGROUND: Despite of several multimodal treatments, malignant gliomas still have a poor outcome. In order to identify subgroups of patients with different prognosis, we propose a clinical and histological score (GS). METHODS: Eighty consecutive patients operated on for a high-grade glioma and treated with adjuvant therapy entered the study. In relation to age at diagnosis, preoperative Karnofsky Performance Status (KPS), and MIB-1 index, patients have been splitted in 4 groups (GS 0-III). RESULTS: The overall mean survival of the entire cohort was 18.2 months (median 12). Patients with GS 0 have a mean survival rate of 30.0 months, with GS I 23.1 months, with GS II 12.1 months, and with GS III 9.0 months (p=0.0001). Moreover, mean survival with a KPS = or >70 was 29.0 in GS 0, 26.0 in GS I, 10.0 in GS II, and 0 in GS III patients (p<0.0001). CONCLUSIONS: On the basis of these preliminary observations, we discuss the utility of our "glioma score" as a prognostic indicator for patients operated on for cerebral malignant gliomas and treated postoperatively with adjuvant therapy.

Magnetic resonance imaging findings of Kernohan-Woltman notch in acute subdural hematoma.

OBJECTIVE AND IMPORTANCE: We report the case of a 73-year-old patient who presented a right motor deficit caused by an ipsilateral acute subdural hematoma. A magnetic resonance imaging (MRI) demonstration of Kernohan-Woltman notch phenomenon was obtained. CLINICAL PRESENTATION: The woman sustained a major head injury at home, followed by loss of consciousness. On admission to the emergency room, she was comatose, anisochoric (left > right), and showed a reaction to pain with decerebrating movements of left limbs (Glasgow Coma Scale (GCS) 4/15). A right severe hemiparesis was observed. Cerebral computed tomography scan showed a large right hemispheric subdural hematoma. INTERVENTION AND POST-OPERATIVE COURSE: A wide right craniotomy was performed and the subdural hematoma evacuated. During the post-operative period, the level of consciousness gradually improved. A MRI performed about 2 weeks after operation showed a small area of abnormal signal intensity in the left cerebral peduncle. On discharge, the woman was able to communicate with others, but her right hemiparesis was still severe.

Relationship between Ki-67 labeling index and survival in high-grade glioma patients treated after surgery with tamoxifen.

BACKGROUND: The Ki-67 is a nuclear antigen expressed in the G1, S, G2, and M phases of the cell cycle recognizable by the monoclonal antibody MIB-1. The Ki-67 labeling index (LI) is considered as a marker of proliferation (growth fraction rate), even if its use as prognostic indicator of cerebral high-grade gliomas is still debated. The aim of this study is to correlate the Ki-67 LI with survival in patients operated on for a malignant glioma and treated postoperatively with tamoxifen. METHODS: Using the MIB-1 antibody, the Ki-67 antigen staining of surgical specimens was obtained in 26 patients operated on for a malignant cerebral glioma. After operation, 9 patients started to receive 40 mg/day, 8 patients 80 mg/day, and 9 patients 120 mg/day of tamoxifen. In 20 cases one or more cycles of i.v. carboplatin was administered. All patients received radiotherapy (4500-6000 cGy). RESULTS: The overall mean survival rate was 19.8 months and the median 12 months; the 12-month and 24-month survival rates were 47% and 23%, respectively. The Ki-67 LI ranged from 2.3% to 62% (mean 24.1%, median 20.5%). Excluding 2 patients who died during the postoperative period, we analyzed the survival rates of the remaining 24 patients in relation to the value of Ki-67 LI. In relation to the index, patients have been divided into 3 groups, with different survival rates: L) Ki-67 LI < or =10%, with mean survival rate of 30.7 months, M) from 10.1% to 30%, with mean survival rate of 15.8 months, and H) >30%, with mean survival rate of 20.2 months. CONCLUSIONS: Our preliminary observations seem to confirm the efficacy of TAM in modifying the survival of malignant gliomas and seem to indicate that tumors with a lower LI and those with a LI >30% could be associated, if treated with TAM, with a better survival than gliomas belonging to group M, who could have a higher tumor proliferation rate in comparison to group L and a lower response to protein-kinase-C antagonists than group H.

Intramedullary increased MR signal intensity and its relation to clinical features in cervical myelopathy.

BACKGROUND: Areas of intramedullary hyperintensity in patients with cervical spondylogenetic myelopathy (CSM) have been described and studied by several authors. METHODS: In the present study, 100 patients were reappraised and divided into 2 groups according to whether or not MRI detected areas of hyperintensity on T2-weighted images. RESULTS: Statistical analysis demonstrated that intramedullary hyperintensity is most frequently associated with severe impairment of deambulation, muscular hypotonus-hypotrophy and hypoesthesias of the upper limbs. CONCLUSIONS: These radiological findings probably correspond to various types of lesions which, when irreversible, may influence postoperative neurological recovery.

Tamoxifen modulation of carboplatin cytotoxicity in a human U-138 glioma cell line.

Glioma cells express high protein kinase C (PKC) activity, which may represent an important therapeutic target. Tamoxifen (TAM) has moderate PKC-inhibiting activity, blocking DNA synthesis and cellular proliferation in human glioma cells at concentrations that can be achieved therapeutically. Carboplatin (CBDCA), a second-generation platinum derivative, induces intra- and interstrand DNA-protein crosslinks producing inhibition of tumor-cell growth. In the present study, the effect of TAM, CBDCA, and the combination of both was evaluated against the human established U-138 glioma cell line during the exponential growth phase (48-72 h) by means of both the Biorad protein assay (BPA) method and Trypan blue exclusion study (TBES). Both TAM and CBDCA reduced the cellular growth rate, with a median 50%-inhibiting concentration (IC50) of 12.5 microM for TAM and 350 microM for CBDCA. The U-138 glioma cell line showed a moderate response to 100 microM of CBDCA, with < or = 10% reduction of the growth rate. The association of both chemotherapeutic agents induced a 98% reduction of the IC50 dose of TAM (0.1 microM), and a 71% reduction of the IC50 dose of CBDCA (100 microM). During the combinational TAM CBDCA exposure we observed a cytotoxic effect of TAM at concentrations lower than 0.1 microM, not recognized using it as a single drug. The differences observed among the IC50 doses (TAM, CBDCA, TAM-CBDCA) and among treated and untreated matched control cells were statistically significant (P < 0.01). Our results confirm previous observations about the efficacy in vitro of TAM against human glioma cell lines and show a marked enhancement of this activity by CBDCA.

Clinical and radiographic stabilization of intracranial glioblastoma. Report of a case treated after surgery with tamoxifen.

We report the case of a patient with a left temporal-parietal glioblastoma treated with subtotal surgical excision, radiotherapy and chemotherapy, with a single intravenous administration of carboplatin and continuous oral administration of tamoxifen (40 mg/daily). Two years after the patient presents a stabilization of clinical and CT picture. We discute the possible role of tamoxifen in prolonging the survival of selected patients with intracranial high-grade glioma.

Malignant cerebellar astrocytomas: clinico-pathological remarks on 10 cases.

BACKGROUND: Malignant glioma represent the 3rd¿4th most frequent cause of death from cancer. The cerebellar site is rare and life expectancy with cerebellar anaplastic astrocytoma is still dismall. The growth and clinical-pathological remarks of the tumor, is similar to the others gliomas of the central nervous system. MRI with Gd is the most useful diagnostic approach but lacks of specificity in detecting highly differentiated neoplasia areas. METHODS: Between 1980 and 1994 10 cases of malignant cerebellar astrocytomas were operated at the Neurosurgical Institute, Department of NeuroSciences, of Roma "La Sapienza" University. All patients were investigated pre-and postoperatively by CT scan with i.v. administration and/or MRI with Gd when possible. RESULTS: Of the 10 patients who followed various protocols, 7 died. Average survival was 13.7 months (range 5-21 months). 3 patients were still alive 12, 15 and 18 months after surgery. In 3 cases (50%) there was also radiological evidence of spinal cord spreading. CONCLUSIONS: Like cerebral lesions, malignant cerebellar astrocytoma still a pathology with a real unsatisfactory prognosis. Our experience probably showed that spinal spreading is underestimated. For this reason we believe that, despite the limited number of cases treated so far, it is important to extend postoperatively the radiotherapy to the entire spinal cord in all patients.

Actinomycosis of the central nervous system: surgical treatment of three cases.

Three cases of actinomycotic brain infection are described, 2 of which manifested as cerebral abscess, the third as epidural empyema. Complete resolution of the infection was always achieved by means of surgical treatment and prolonged antibiotic therapy. The cases reported emphasize the importance of a combined approach in the treatment of this unusual cause of brain infection.

Relationships among DNA Index, S-Phase, and invasive behavior in anterior pituitary adenomas. A cytometric study of 61 cases with Feulgen-positive DNA analysis.

BACKGROUND: Pituitary adenomas are usually well differentiated neoplasms, although in about 1/3 of cases they invade the surrounding dura mater and bone, as confirmed by surgical findings, resulting in a long-term possibility of relapse. METHODS: To identify the cellular growth rate and to correlate it with surgical evidence of invasiveness, we performed the analysis of DNA with static cytometric quantitation on fresh surgical specimens, using a computer-assisted image processor. The DNA index and the percentage of cells in S-phase (%SPh) were obtained in 61 pituitary tumors consecutively operated on. In relation to surgically verified infiltration of dura and bone, we identified 39 noninvasive and 22 invasive adenomas. The cavernous sinus (CS) was infiltrated in 13 cases. On the basis of immunohistochemical staining and endocrine activity we recognized 27 nonsecreting and 34 secreting adenomas. RESULTS: The DNA content was aneuploid in 33 cases (11 nonfunctioning, 22 functioning; p = 0.05); there was no correlation with the invasive behavior of the adenomas. The DNA index ranged between 0.93 and 2.50 (median 1.13); the range of %SPh was 0-12.00% (median 2.54%). In invasive adenomas the mean DNA index was 1.33 (p not significant) and the mean %SPh was 4.03% (p = 0.05). In CS-infiltrating pituitary adenomas, the mean DNA index was 1.44 (p = 0.04) and the mean %SPh was 4.52% (p = 0.05). CONCLUSIONS: Our preliminary results seem to reveal a correlation between DNA index, %SPh, and invasive behavior of pituitary adenomas, encouraging the use of DNA analysis in the prognostic evaluation of these tumors.

High-dose radiation-induced meningiomas.

BACKGROUND: Numerous neoplasms within the CNS have been reported as radiogenic in origin; radiation-induced meningiomas are at least five times more numerous than gliomas or sarcomas in the world literature. METHODS: The authors review 10 cases of cerebral meningiomas following high-dose radiotherapy in patients operated for neoplasm of the nervous system. The pathologic and clinical aspects of this unusual complication are analyzed in all cases in the world literature. RESULTS: There is a female predominance (F-M ratio: 3:2) and the patients are young (mean age: 33.1 years; median: 29 years). The average latency period is 14.4 years (range: 9-21 years). The first disease is acute lymphocytic leukemia (ALL) in 40% of cases. Radiation induced meningiomas are atypical in four cases. Recurrence was observed in one case without malignant transformation. CONCLUSION: High-dose radiation-induced meningiomas have the following characteristics: (1) children appear particularly sensitive to the development of this tumor; (2) there is a female predominance, otherwise than is observed in low-dose meningioma; (3) these tumors present a peak frequency in the third decade of life; and (4) frequently, these tumors are atypical and recur. Finally, it is essential that every new case be reported to throw light on this particular pathologic correlation with its many grey areas.

Post-radiation gliomas.

AIMS AND BACKGROUND: Radiotherapy is important in the treatment of neoplasm of the central nervous system, but various side effects, particularly neoplastic, have been described. Recently, post-radiation gliomas have been reported. METHODS: The authors review 88 cases of cerebral glioma following radiotherapy in patients operated for neoplasms of the nervous system, including 6 personal cases of post-radiation gliomas treated in the Neurosurgical Division of the Department of Neurological Sciences, "La Sapienza" University, Rome. The criteria used to define this unusual pathologic association are discussed. RESULTS: There was a male predominance. Post-radiation gliomas were particularly malignant, the average dose was 33 Gy, and average free latency was 9.6 years. The first disease was most frequently acute lymphatic leukemia. CONCLUSIONS: Post-radiation gliomas have particular features but do not present a histologic or clinical behavior different from analogous spontaneous gliomas. The fact that 88 cases have been reported in recent years suggests that a thorough biological, clinical studies be carried out on this association.

Solitary eosinophilic granuloma of the calvaria.

AIMS AND BACKGROUND: Histiocytosis X is a condition characterized by an abnormal proliferation of histiocytes with a variable granulomatous and inflammatory component; bone involvement is almost always present. The aim of this study was to define the management of solitary eosinophilic granuloma (EG) of the calvaria in adult patients, in relation to the size and site of the lesion. METHODS: Fourteen patients, ranging in age from 7 to 45 years, with solitary eosinophilic granuloma of the calvaria were surgically treated by craniectomy or curettage and cranioplasty. We subgrouped the lesions into two types: A) lesions localized inside the diploë and/or compressing the cerebral parenchyma below but without dural infiltration; B) lesions with mainly intracranial growth, compressing the cerebral parenchyma and infiltrating the dura. The infiltrated dura mater in type B lesions was replaced with a dural patch. Cranioplasty was performed in lesions with a diameter of 4 cm or more and/or located in aesthetically exposed areas of the skull. RESULTS: None of the patients died during the study and no local or systemic recurrences were observed during follow-up (min. 3 yrs, max. 8 yrs). CONCLUSIONS: Surgical treatment of patients with isolated EG of the calvaria not only is simple and quick but also allows histological diagnosis of the osteolytic lesion. These patients do not require further adjuvant treatment. Cranioplasty should be performed when the lesion has a diameter of 4 cm or more, when it is located in aesthetically exposed areas of the skull such as the frontal or temporal bones, or when it produces alterations of the normal skull morphology.

Long-term survival in cerebral glioblastoma. Case report and critical review of the literature.

Glioblastoma multiforme is the most malignant tumor of the glial series. The average survival of patients with this tumor ranges from 6 to 12 months. The case of a patient who survived for more than 11 years after diagnosis of a temporal-occipital glioblastoma which was treated with surgery, radiotherapy and chemotherapy is described. The authors deduce that among patients with glioblastoma multiforme (GM), those with a long disease-free interval after initial diagnosis who undergo multimodal therapy, including aggressive tumor removal, are the most likely long-term survivors (LS). Other factors which appeared to be related to longer survival were younger age and high Karnofsky scores.

Adrenocorticotropic hormone secreting pituitary adenomas: analysis of growth fraction using the MIB-1 antibody.

AIMS AND BACKGROUND: Pituitary adenomas are usually considered well differentiated tumors, even if in about one third of cases they invade surrounding tissues, with the possibility of postoperative relapse after complete surgical removal. Adrenocorticotropic hormone (ACTH) secreting adenomas seem to be the most infiltrating subtype, with a higher incidence of recurrence. Ki-67 is a nuclear antigen which is easily detectable by means of the MIB-1 monoclonal antibody, and the labeling index (LI) obtained can be considered a marker of tumor proliferation. METHODS: In order to identify the growth fraction of these tumors we used the MIB-1 antibody to evaluate the expression of Ki-67 antibody in 11 ACTH secreting pituitary adenomas and to compare it with the LI obtained in 98 other hormone secreting or non-functioning pituitary adenomas consecutively operated on during a 40-month period. RESULTS: In relation to surgically verified infiltration of the sellar floor dura and bone, we identified eight non-invasive and three invasive ACTH secreting pituitary adenomas. All invasive tumors infiltrated the wall of the cavernous sinus (CS). The mean Ki-67 LI was 5.88 +/- 9.13% versus 2.33 +/- 2.40% in non-ACTH secreting adenomas (P = 0.0025). It was 13.27 +/- 15.42% in invasive and 3.11 +/- 4.37% in non-invasive ACTH adenomas, and 18.40 +/- 17.82% in patients over 50 years versus 3.10 +/- 4.09% in younger subjects (P = 0.02). CONCLUSIONS: Ki-67 LI is a useful marker in the determination of proliferative activity and invasiveness of anterior pituitary adenomas. Our data seem to confirm that ACTH secreting adenomas have a higher growth fraction than other pituitary adenomas and this observation presumably explains the higher incidence of relapse of these tumors even after macroscopically total removal.

Primary eosinophilic granuloma invading the skull base: case report and critical review of the literature.

A case of eosinophilic granuloma of the lesser wing of the sphenoid bone is reported. The patient was a 5-year-old white male, with left temporal-frontal headache, left III cranial nerve palsy, left exophthalmos and ptosis caused by an osteolytic lesion of the anterior clinoid process extending to the left optic canal and cavernous sinus. The patient underwent surgical resection of pathologic tissue. Pathologic diagnosis was eosinophilic granuloma of the sphenoid bone. Surgical management, postoperative prognosis and differential diagnosis of eosinophilic granuloma of the skull base are discussed along with a review of the literature.

Multicentric gliomas. Report of seven cases.

Multifocal gliomas fall into four main categories: diffuse, multiple, multicentric and multiple-organ. Multicentric gliomas are uncommon lesions of the central nervous system. Even more so are multicentric gliomas lying both above and below the tentorium (16 cases to date, as far we know). We report a clinical series of 7 cases, including 3 supra-infratentorial tumors. The distinctive features of multicentric gliomas are mainly the absence of gross or microscopic connections and absence of seeding along easily accessible routes like the cerebrospinal fluid pathways or the median commissures. We consider the pathogenetic hypotheses and problems of diagnosis, especially differential from other multifocal diseases of the central nervous system.