DHEA pre-treated patients, poor responders to a first IVF (ICSI) cycle: clinical results.

PURPOSE: To evaluate the effect of the premedication with dehydroepiandrosterone (DHEA) on the results of the in vitro fertilization (IVF) treatments in a group of women with evidence of diminished ovarian reserve. MATERIALS AND METHODS: This experimental, prospective, pre-post study enrolled 29 patients with evidence of diminished ovarian reserve and poor-responders to a previous treatment. They received 75 mg/die of DHEA for a minimum of eight weeks; from the 18th day of the cycle before the stimulation with follicle stimulating hormone (FSH), they took trans-dermal estradiol (E2) (50 mcg every other day). The protocol of the stimulation consisted of a short cycle with follicle stimulating hormone receptor-human menopausal gonadrotropin (FSHr-HMG) and low doses ofgonadotropin releasing hormone agonist (GnRH-a) (0.05 mg/die). The study was carried out comparing the results obtained respectively with the pre-DHEA and the post-DHEA treatments. RESULTS: The comparative analysis of the results showed a significant increase in the number of the retrieved oocytes (p < 0.01), of the oocyte quality (p = 0.02) and a reduction of cancelled cycles (p = 0.03). Moreover, after the treatment with DHEA, there was an increase, though non-significant, in the number of embryos, in the fertilization rate, and in the number of pregnancies. CONCLUSIONS: This study confirms the beneficial effects of DHEA in patients who resulted poor responders to IVF treatments. Therefore, DHEA appears to be an effective treatment for age related sub-fertility.

Intracranial extension of salivary gland tumors.

OBJECTIVE: The aim of this report is to describe 3 cases of salivary gland tumors with intracranial extension associated to an extracerebral mass lesion, and to discuss the frequence, pathology and treatment of these very rare localizations. CLINICAL MATERIAL: The 3 patients were 1 woman and 2 men, aged 44, 53 and 74 years, respectively. The primary tumors were an adenocarcinoma and a malignant oncocytoma of the parotid gland and an adenoid cystic carcinoma of the submandibular gland. The location of the intradural extra-axial tumor was the middle fossa and temporal region in 2 cases and the cerebellopontine angle in 1. Surgical treatment consisted in the seemingly complete removal of 2 tumors with middle fossa localization and partial removal of the cerebellopontine angle lesion. Radiotherapy was administered in all 3 cases and chemotherapy in 2. RESULTS: 1 patient is alive and free of recurrence 32 months after removal of the intracranial tumor; 2 other patients died 28 months and 12 months postoperatively. CONCLUSIONS: The intracranial extension of salivary gland tumors is a very rare event. An aggressive surgical resection followed by radiotherapy is justified in cases with significant intracranial mass lesions and scarce bone and dural involvement.

Intracranial plasma cell granuloma.

An exceptional case of intracranial plasma cell granuloma, located in the right frontoparietal convexity in a 16-year-old boy is reported. Reports of these rare inflammatory lesions locate them primarily in the lungs and in other regions of the body, and only exceptionally in the nervous system; indeed, only three intracranial cases and one other arising from the spinal meninges have been reported. The computed tomographic and surgical aspects suggested a falx meningioma in our case. The pathological diagnosis differentiating these from other intracranial lesions with a plasma cell component, including meningioma with plasma cell infiltration and plasmacytoma, is discussed.

Cerebral cavernous angiomas in the first year of life.

Two rare cases of cerebral cavernous angiomas in two infants, 9 and 6 months old, respectively, are reported and the other 11 cases in the literature concerning patients in the first year of life are reviewed. Cavernous angiomas of the brain occur rarely in the first year of life and present with seizures and head enlargement. On computed tomographic scan they typically appear as large, hyperdense, unenhanced masses, with large cysts and must be differentiated from tumors more common in infants, such as teratomas, ependymomas, and mixed tumors. Total removal is often possible, even with large lesions, because of the small amount of bleeding and the well-defined limits of the mass.

Familial cerebral cavernous angiomas.

Three families with two or more members affected by cavernous angiomas of the brain are described and the other 17 reported in the literature are reviewed. The familial occurrence of cerebral cavernous angiomas has been considered a rare event; nevertheless, the experience of the authors (positive familiarity in three patients where two or more relatives have been explored radiologically) suggests that cavernous angiomas of the brain might be, at least in most cases, a familial disease. Therefore, when a patient with cerebral cavernous angioma is observed, a careful familial history and the exploration of the familial members by computerized tomography or better still by magnetic resonance must be performed. The high frequency of multiple lesions in familial cases, the surgical indications and the role of the ultrasonic prenatal diagnosis are also discussed.

One-trocar laparoscopy: a valid procedure to treat abdominal complications in children with peritoneal shunt for hydrocephalus.

BACKGROUND: The aim of this paper is to show the efficacy of laparoscopy using only one umbilical trocar to treat abdominal complications of hydrocephalic children with ventriculoperitoneal shunts (VPS). MATERIALS AND METHODS: In a 15-year period, 14 laparoscopies were performed on as many children with VPS complications: in the last 4 patients only one trocar was used to solve the complications, and this subgroup will be the object of the present study. Concerning the indication for surgery, the patients presented one catheter lost in the abdominal cavity; one cerebrospinal fluid pseudocysts; one bowel obstruction; and one malfunctioning peritoneal limbs of the catheter. We used the one-trocar laparoscopic approach in all the 4 patients, and the 10-mm trocar was always introduced through the umbilical orifice in open laparoscopy. RESULTS: The laparoscopic technique was curative in all four cases and permitted the solution of the complication. CONCLUSIONS: One-trocar laparoscopic surgery can be considered as the ideal procedure in case of abdominal complications of VPS in children with hydrocephalus.

[Prolactinoma and pregnancy]. / Prolattinoma e gravidanza.

The problem of pregnancy in women affected by prolactinosecreting adenoma has been evaluated and tackled in a variety of different ways over the course of the past twenty years. The early years were marked by an alarmist attitude which saw pregnancy as a considerable risk due to the expansion of the hypophyseal tumour, and women were advised against pregnancy or even to abort. Later, this was superceded by cautious observation and close monitoring. Recently, and above all with reference to microadenomas, there is a growing belief that pregnancy does not represent a real risk but can even lead to the definitive remission of hyperprolactinemia in a certain percentage of women.

Sturge-Weber disease without facial nevus.

A rare case of Sturge-Weber syndrome without facial nevus and epileptic seizures is reported. The other cases of incomplete form of the disease reported in the literature showed occipital calcification and epileptic seizures without facial nevus, while in the present case also the convulsions were absent. The possible pathogenic mechanism is discussed. The CT findings of these incomplete forms include unilateral or often bilateral occipital calcifications with no evidence of contrast enhancement. The Authors conclude that the radiologic finding of bilateral gyriform calcifications in the occipital region must suggest the diagnosis of Sturge-Weber disease even in the absence of facial nevus and epileptic seizures.

Transient visual symptoms and carotid artery disease. Exploration by real-time B-mode echotomography.

The real-time B-mode echotomographies of 100 patients with transient visual symptoms have been reviewed and their findings have been compared with those of other 100 patients with transient ischemic attacks, who never had visual disturbances in their clinical history. The rate of pathologic echotomographies was higher in the group of patients with transient visual symptoms (72%), who also had a higher percentage (50% of the positive cases) of small or mild plaques without significant hemodynamic effects. The amaurosis fugax, particularly when associated with hemispheric ischemic symptoms, should suggest a carotid disease. The non-invasive exploration by real-time B-mode echotomography and Doppler with spectral analysis is the method of choice for the diagnosis of patients with transient visual symptoms.

Cavernous angioma of the pineal region.

The pineal region is one of the most rare localizations of intracranial cavernous angiomas, with only 8 cases reported up today. The Authors report a case of cavernous angioma of such localization and review the pertinent literature. Magnetic resonance allows the correct diagnosis of cavernous malformations on the basis of their typical aspect, even in the absence of histological verification. We suggest that this imaging technique will allow to identify more frequently pineal cavernomas preoperatively, thus avoiding useless irradiation.

Giant spinal cord ependymoma in a child. Case report.

Ependymomas of the spinal cord extending to more than ten vertebral segments are rare. A case of a 14-month-old child is described and the other 13 reported cases are reviewed. The finding of a very extensive tumor (from T5 to L5) after only 14 months of life suggests that in our case the tumor was present since birth. Magnetic resonance well shows the real extent of the tumor in height and its different components. Complete removal is often possible even in very extensive ependymomas and results in clinical improvement. Postoperative radiotherapy is necessary only for incompletely removed or malignant ependymomas.

Hypertrophy of the ligamenta flava of the cervical spine. Clinico-radiological correlations.

Among 1,000 myelographies performed between 1974 and 1983, 22 patients with isolated hypertrophy of the ligamenta flava of the cervical spine have been selected and their neurological troubles correlated with the radiological findings. The degree of neurological involvement resulted in relation with the degree of hypertrophy of the ligaments, the diameter of the spinal canal and the number of spaces involved by compression. The radiological diagnosis and the indications to surgery are discussed.

Spinal cord compression by an eosinophilic granuloma. Case report and review of the literature.

A spinal cord compression syndrome due to a vertebral eosinophilic granuloma is a rare event. A case of a 15-month-old child is reported and the 16 cases of the literature are reviewed. The diagnostic difficulty and the therapeutical problems are discussed.

Intracranial lipomas. Diagnostic and therapeutic considerations.

Fourteen cases of intracranial lipomas are reported and 200 cases from the literature are reviewed. Intracranial lipomas are rare lesions of developmental origin, which mainly occur in the region of the corpus callosum, more rarely in the ambient, interpeduncular, cerebellopontine angle and sylvian cisterns. Although they are usually asymptomatic, they can sometimes show neurological symptoms, mainly epileptic seizures. Computerized tomography and magnetic resonance imaging usually lead to the diagnosis, because of the very low-density attenuation values of lipomas on CT scan and the short T1 and T2 on magnetic resonance. A direct surgical approach is only rarely indicated, whereas cases associated to hydrocephalus require a CSF shunt. The anticonvulsivant therapy usually results in remission of the seizures.

Fibromuscular dysplasia of the carotid arteries. Clinical and radiological considerations.

Seven patients with fibromuscular dysplasia of the carotid arteries are described. Three were asymptomatic and four had ischemic troubles. Angiographically, 3 had a fibromuscular dysplasia of type 1 and 4 of type 2; one patient also had an associated aneurysm of the cervical internal carotid artery. The neurological troubles and their pathogenesis, the angiographic findings and the differential diagnosis of this angiopathy are briefly discussed; the surgical procedures and their risks are also analyzed.

Symptomatic subependymomas of the lateral ventricles. Report of eight cases.

Subependymomas are rare, slow-growing, benign intraventricular tumors, which often are asymptomatic and are discovered incidentally. The review of the literature shows more than 100 symptomatic cases, less than half located in the lateral ventricles. Here we report 8 cases of symptomatic subependymomas of the lateral ventricles, studied by CT and/or MR and treated by direct surgical approach. The suspicion of a subependymoma should arise when a patient older than 10-15 years with long clinical history presents an intraventricular tumor isodense on CT and isointense in T1 and hyperintense in T2 on MR, with scarce or discrete contrast enhancement. Surgical treatment is indicated in symptomatic subependymomas of the lateral ventricles and usually allows complete tumor removal. The prognosis is usually good, also without postoperative irradiation.

Neuroendoscopy. Personal experience, indications and limits.

The authors report a series of 40 patients treated by endoscopic neurosurgery. It includes 31 cases of obstructive hydrocephalus, 4 paraventricular or intraventricular CSF cysts, 3 cases of multiloculated hydrocephalus, one suprasellar arachnoid cyst and one cystic astrocytoma with mural tumor nodule. Third ventriculostomy is the most frequent indication of the endoscopic neurosurgery, which is very useful also for performing fenestration of CSF cysts and multiloculated hydrocephalus. The surgical endoscopic techniques in the different above mentioned pathologies are exposed. The criteria for patient selection, the clinical results and the postoperative radiological findings, that confirm the patency of the fenestration, are discussed.

Arachnoid cyst of the lateral ventricle.

BACKGROUND: Arachnoid cysts rarely occur within the lateral ventricles, with only 10 reported cases in the literature. They may arise from the arachnoid layer that is present in the choroidal fissure. CASE DESCRIPTION: This 25-year-old man with headache and a left jacksonian seizure had an intraventricular arachnoid cyst of the right occipital horn and trigone found on radiologic examination by computed tomography (CT) and magnetic resonance imaging (MRI). He was successfully treated by evacuation of the cyst and removal of its wall through a right parietooccipital craniotomy. Histologic studies of the cyst wall confirmed the presence of arachnoid cells and connective tissue. CONCLUSIONS: Arachnoid cysts of the lateral ventricles occur in the occipital horns and trigone (all but 1 of 10 cases) in young patients with symptoms of intracranial hypertension. MRI well defines the relationship of the cyst with the ventricular wall. Surgical removal of the cyst wall or cystoperitoneal shunt have been successfully performed in the reported cases; however, endoscopic fenestration of the cyst must be considered today as the treatment of choice.