Radiation injury involving the internal carotid artery. Report of two cases.

Radiation therapy is an uncommon cause of stenosis and occlusions of the cervical internal carotid artery (ICA). We describe two cases of cerebral ischemia due to ICA stenosis in patients irradiated for malignant tumors (lymphoma and breast cancer). The first patient, a 32-year-old man, presented with an episode of cerebral ischemia. Six years previously he had received irradiation therapy for a left laterocervical mass histologically diagnosed at biopsy as a Hodgkin's lymphoma. Cerebral angiography on entry revealed bilateral occlusion of the cervical ICA, with a 2-cm stump at the origin of the left ICA. Despite anti-platelet aggregation therapy the ischemic attacks persisted, necessitating a stumpectomy. After vascular-repair surgery the patient had no further ischemic symptoms. The second patient, a 42-year-old woman, began to experience the sudden onset of pain in the right arm and left hemiparesis five years after surgery plus irradiation (4500 rad) for breast cancer, and three years after excision of a single cerebral metastasis. Cerebral angiography obtained on admission showed occlusion of the right ICA and right subclavian arteries, both lesions necessitating thrombectomy. After surgery the right radial pulse immediately re-appeared and the hemiparesis regressed. In both patients, 2-year follow-up assessment by Doppler ultrasonography and magnetic resonance angiography (MRA) confirmed that the operated arteries remained patent. These two unusual cases underline the potential risk of irradiation-induced ischemic cerebrovascular symptoms, suggesting that patients who have received radiation therapy to the neck and mediastinum who survive for more than 5 years should undergo regular non-invasive imaging of neck vessels (Doppler ultrasonography and MRA).

Congenital torticollis in association with craniosynostosis.

The incidence of congenital torticollis in association with plagiocephaly is 1 in 300 newborns, with the torticollis resulting from pathologically sustained contraction of the sternocleidomastoid. Such conditions as facial asymmetries, craniovertebral anomalies, cervical hemivertebra, and mono- or polydysostoses may also be associated with torticollis diagnosed during the neonatal period. With particular reference to synostotic (coronal and/or lambdoidal) plagiocephaly, a clear distinction is made in this paper between posterior neurocranial flattening secondary to the sustained rotation of the skull resulting from torticollis and that seen in synostotic plagiocephaly. The rarity of torticollis with sustained contraction of the sternocleidomastoid muscle relative to the frequency of occipital-parietal flattening in newborn kept in the supine position has not been discussed in the literature and is therefore of clinical importance. In light of the fact that the prognosis and, consequently, the treatment plan vary directly with the presence or absence of synostoses, clinical evaluation also includes cephalometrics, plain skull X-rays, and CT imaging. If the torticollis is associated with neurocranial deformity but synostosis is absent, cervical traction and physiotherapy resolve the symptoms. When, however, the clinical picture is complicated by synostotic plagiocephaly, corrective surgery is necessary, though cervical traction and physiotherapy are essential to provide early and complete cure of the torticollis.

Meningiomas of the tuberculum sellae. Our experience in 69 cases surgically treated between 1973 and 1993.

BACKGROUND: Meningiomas of the tuberculum sellae are lesions with well-defined characteristics in terms of both site of origin and clinical evolution which require differential diagnosis with lesions of the supra- and para-sellar region. The aim of this study is to point out the importance of the size of the lesion and early identification of symptoms for prompt diagnosis, crucially important for evaluating the reversibility of functional damage, especially of the optic nerves. METHODS: Between 1953 and 1993, 110 cases of tuberculum sellae meningioma were operated at the Neurosurgical Institute, Department of Neurosciences, of Rome "La Sapienza" University; only 69 cases of these cases were operated on after 1973, the year in which microsurgical techniques were introduced into routine surgical practice. Tumor diameter ranged from 3 to 9 cm. Most of the patients presented severe visual loss. RESULTS: Removal was total in 63 cases (91.3%), sub-total in 6 (8.7%). Besides the surgeons firsthand impression, the grade of removal was evaluated by early CT and/or MRI (24-36 hours after surgery). A minimum follow-up of 3 years was taken into consideration for assessment of late functional results. Five patients died in the postoperative period (7.2%). CONCLUSIONS: This study clearly demonstrated that a tumor diameter greater than 4 cm is a critical factor for visual function. The size of the lesion was also found to be extremely important, in that it influences the amount of tumor resection possible. Therefore, in our opinion, alternative types of treatment such as radiosurgery should be confined to the tumor residue.

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.

Multiple meningiomas in different neuraxial compartments. Report of two cases.

Multiple meningiomas in different neuraxial compartments are quite rare. The authors report two new cases of association between cranial and spinal meningiomas, one of them in a patient operated upon for multiple intracranial meningiomas. The first case was a 60-year-old woman with progressive paraparesis who had been operated on 13 years earlier for multiple intracranial meningiomas. A myelo-CT scan showed a block of contrast medium at T1-T2; the lesion was removed via a standard laminectomy. The second patient was a 76-year-old woman with a 6-month history of spastic paraparesis. MRI detected an extramedullary intradural lesion at T6-T7. A cerebral MRI, performed because of the onset of seizures, showed a right parietal lesion. Removal of the thoracic lesion was followed, 6 months later, by removal of the cerebral one. Both patients presented a progressive improvement of the paraparesis and returned to normal daily activities.

Malignant cerebellar astrocytomas in childhood. Experience with four cases.

The most frequent type of cerebellar astrocytoma in children is the pilocytic variety, for which the treatment of choice and prognosis are now well established. In contrast, an anaplastic lesion in this site is extremely rare. The authors present four cases of high-grade astrocytoma in a cerebellar site. They discuss the best type of treatment for this pathology, with particular reference to postoperative radiotherapy and chemotherapy, in the light of their results.

Intracranial actinomycosis in juvenile patients. Case report and review of the literature.

A case of actinomycotic brain infection in a juvenile patient is described. Cases of actinomycosis affecting the head and neck are rare, particularly in juvenile patients. In this case complete resolution of the infection was achieved by means of surgical treatment and prolonged antibiotic therapy. The authors emphasize the importance of a combined approach for treatment of this unusual brain infection and stress the difficulties involved in the diagnosis of this pathology.

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.

Cavernoma of the cavernous sinus: case report.

BACKGROUND: The authors report a case of extra-axial cerebral cavernoma localized at the level of the cavernous sinus. This pathology is extremely rare, therefore, differential diagnosis with tumors such as meningioma is often difficult. During recent years, surgical indications for these lesions, congenital and rarely hereditary, have become more definite due to the considerable progress made in neuroradiologic and microsurgic techniques as well as better anatomic knowledge of this region. METHODS: This 49-year-old man was admitted with a 1-year history of diplopia. Cranial computed tomography (CT) scan with contrast medium, performed prior to admission, showed an expansive lesion at the level of the right cavernous sinus. Preoperative neuroradiologic diagnosis, after cerebral magnetic resonance imaging (MRI) with gadolinium enhancement and cerebral panangiography, was probable cavernoma. The lesion was totally removed via a fronto-orbito-temporo-zygomatic craniotomy. RESULTS: Postoperatively, the patient had a right oculomotor nerve palsy. This spontaneously resolved 8 months after surgery; diplopia also completely disappeared. Early postoperative control MRI scans with gadolinium on the 2nd postoperative day and 3 months after operation confirmed total removal of the lesion. CONCLUSIONS: The clinical onset and neuroradiologic aspect of these lesions and the fact that they rarely involve the cavernous sinus, may sometimes make preoperative diagnosis of cavernous sinus cavernoma difficult. Nevertheless, given the routine use of microsurgical techniques and improved anatomic knowledge of this delicate region, the treatment of choice is surgery. However, when doubts exist regarding achievement of total removal, radiosurgery is still a valid therapeutic tool.

Malignant supratentorial astrocytomas of late childhood. Our experience with 25 cases.

The authors present 25 patients ranging in age from 8 to 16 years who had malignant supratentorial astrocytomas. This type of lesion represents one of the most important and statistically significant causes of morbidity and mortality in late childhood. Compared to adult malignant supratentorial astrocytomas, these lesions seem to show a better survival rate. The reason is unknown. The authors present their experience regarding the importance of radical removal and histology for a better prognosis.

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.

Spontaneous cerebellar haemorrhages in childhood.

Spontaneous cerebellar haemorrhage is very rare in children and is often associated with blood diseases such as haemophilia A or acute lymphatic leukaemia. During 1995, two paediatric patients with spontaneous cerebellar haemorrhage underwent surgical treatment in the Neurotraumatology Division of "La Sapienza" University hospital in Rome. The authors discuss this unusual pathology with particular regard to the age of the patients described.

Surgical treatment of thoracic disc herniation: a reappraisal of Larson's lateral extracavitary approach.

Twenty patients with thoracic disc herniations underwent removal of the transverse process, articular facet, pedicle, and rib--a procedure described by Larson as the lateral extracavitary approach. Eleven patients presented with myelopathy: five mild, nine moderate, and four severe. Fifteen patients showed significant neurologic improvement after the operation and five patients none. Postoperative follow-up ranged from 1 to 8 years. The pros and cons of each of the surgical approaches to this type of lesion are considered with reference to the published data.

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.

[Intracranial actinomycosis]. / L'actinomicosi intracranica.

Actinomycosis is a bacterial infection mainly affecting the cervico-oro-facial area, abdomen and lungs, sometimes spreading to the central nervous system. Extremely rare is the primary cerebral location of the disease.

Epileptic seizures in intracerebral hemorrhage: a clinical and prognostic study of 55 cases.

Fifty-five cases of epileptic siezures associated with spontaneous intracerebral hemorrhage are reported. Seizures appeared as the first symptom in 23 patients, early (within two weeks after HI) in 18 and late (later than 2 weeks after HI) in 14. From the analysis of the observed cases we noticed that: 1) partial seizures were most frequent type (63%). These appeared mainly in cases with lobar hemorrhage above all; 2) development chronic epilepsy occurred frequently in the case of patients affected by late seizures. We compare our data with those reported in literature in order to highlight main factors which affect the onset and development of seizures associated with spontaneous intracerebral haemorrhage.

Haemangiopericytoma and meningioma presenting clinically with intracranial haemorrhage: report of three cases and review of the literature.

We report one case of haemangiopericytoma and two cases of meningioma whose presenting symptom was subarachnoid haemorrhage. We discuss the etiopathogenetic factors involved in this rare mode of onset in the light of the published work.