Use of spiral computerized tomography angiography in patients with cerebral aneurysm. Our experience.

BACKGROUND: The purpose is to highlight the usefulness of CT angiography (CTA) in the diagnosis and surgical treatment of cerebral aneurysms. METHODS: Thirty-one patients with subarachnoid haemorrhages were subjected to CT angiography and in those cases where this test did not reveal the aneurysm or did not supply sufficient information relating to it, subsequently a digital subtraction angiography was also performed. Each aneurysm-positive CTA was re-processed using the 3-D techniques, with the neuro-radiologist and the neuro-surgeon working in close co-operation. RESULTS: In 27 cases the CTA diagnosed an aneurysm, and in the 4 cases where no vascular malformations were revealed, also the traditional angiography did not show any pathology. In 17 out of 18 cases operated on in order to clip the aneurysm, the CTA supplied all the information needed for the surgery and it was possibile to reconstruct images similar to those of the surgical field. This led to improvement in the programming of the surgical intervention; in 1 case only was it also necessary to perform the DSA before the operation. CONCLUSIONS: CT angiography, because it is non-invasive, easy to perform, diagnostically reliable, and because the 3-D re-constructions offer the chance to create images of the possible operating field, is the first-choice test to be adopted in the treatment of subarachnoid haemorrhages, even though in some cases the use of the traditional angiography is still necessary and should be carried out whenever the CTA does not reveal vascular malformations.

Ureteral stent forgotten in renal transplanted patient. Its removal.

The emblematic case of a forgotten ureteral stent in a renal transplanted patient is reported. The removal was performed with no more difficulties than in a not transplanted patient, but we would emphasize the importance of removing the stent when its function of protecting the anastomosis finished, but before its permanence could compromise the graft.

Metastatic spinal cord compression. Clinical remarks.

BACKGROUND: Metastatic compression of the spinal cord is a frequent occurrence throughout the evolution of neoplastic disease. Possible clinical-diagnostic strategies and therapeutic management of this pathology are discussed in terms of survival and quality of life. METHODS: The study includes 59 patients (40 males and 19 females, with an average age of 48.4 years) with metastatic spinal compression treated surgically in our centre (in some cases with stabilization of the spinal segment involved). RESULTS: In 40 cases the localization of the primary tumor was known when the patient was admitted. The segment involved was the dorsal one in 41 cases. The most frequent type of tumor was pulmonary carcinoma in males and breast carcinoma in females. Average survival was 5.3 months. Treatment integrated by stabilization improved the quality of life in comparison to laminectomy alone. Survival was also influenced by the histological type and site of the primary tumor. CONCLUSIONS: Surgical treatment not only prolongs survival but, above-all, guarantees a satisfactory quality of life.

[Therapeutic considerations in solitary cerebral metastases from uterine carcinoma]. / Considerazioni terapeutiche sulle metastasi cerebrali solitarie da carcinoma uterino.

Brain metastases from endometrial carcinoma rarely involve the nervous system and are solitary in exceptional cases (< 1% of cases). Two cases of solitary cerebral metastasis from endometrial carcinoma are described. Two patients, submitted to the therapeutic protocol established for endometrial carcinoma, underwent surgery, radiotherapy and chemotherapy for solitary cerebral metastasis after at average interval of 18 months. Average survival was 46 months and death was due to progression of the systemic disease. An examination of our cases and those described in the literature has shown that, although these metastasis do not respond well to therapeutic treatment, a better outcome may be achieved by combined treatment consisting of surgery, radiotherapy and chemotherapy.

[Epidermoid cyst of the cranial vault. Neuroradiological and therapeutic considerations]. / Cisti epidermoide della volta cranica. Considerazioni neuroradiologiche e terapeutiche.

AIM: Intradiploic epidermoid cyst is a slow-growing tumor affecting only rarely the cranial bones. PATIENT: The authors describe a case of intradiploic epidermoid cyst of the cranial vault in which there was a predominantly intracranial extension. Roentgenographic and CT findings do not permit a differential diagnosis. Complete removal of the cyst and its capsule was accomplished, with complete recovery. CONCLUSION: Total removal oft the tumor and its capsule is associated with a very good long-term prognosis without recurrences.

Epithelioid schwannoma of the ulnar nerve. Some clinical observations.

The authors describe one case of purely epithelioid schwannoma of the ulnar nerve and discuss the therapeutic management. A 44 year-old man was referred to us for a fusiform, movable mass in the left ulnar nerve and was removed by a wide en bloc excision. Intraoperative nerve action potentials were performed both prior to and following excision of the lesion. Histologically, the tumor was composed of round or polygonal cells arranged in necrotic clusters and anastomosing cords. There were areas of spindle cells. The epithelioid cells were round with abundant cytoplasm. Mitoses were frequent. S100 protein immunoreactivity was present diffusely in tumor cells (both nuclear and cytoplasmic), whereas cytokeratin, NSE, and anti-melanoma reactions gave negative results. After a 13 months, the patient's neurological conditions are excellent and there are no signs of either recurrence or metastasis.

Radiological assessment of necrosis in glioblastoma: variability and prognostic value.

In a previous study, we found that the extent of necrosis was the only radiological feature which correlated significantly with survival in patients with glioblastoma. The aim of this paper was to evaluate the variability and prognostic value of the extent of the necrotic area as seen on contrast-enhanced MRI and CT in a larger series. We studied 72 patients who underwent surgical removal of supratentorial glioblastomas and had CT and/or MRI with contrast medium before surgery; 38, all undergoing the same treatment (surgery plus radiotherapy), were followed clinically. Necrosis within the tumour varied greatly, ranging from none (only 1 case) to involvement of 76% of the tumour. Survival data in the subgroup suggested that only patients with a small area of necrosis (less than 35% of the tumour) had a significantly longer survival time. When necrosis involved more than 35% of the mass, patients had a shorter survival time, without any further correlation with the extent of necrosis.

Solitary cerebral metastasis from tumor of the testis: some observations about treatment in two cases.

The authors describe two cases of solitary cerebral metastasis from non-seminatous germ cell tumors of the testis: in the first case, the histology was teratocarcinoma; in the second, it was embryonal carcinoma. Both patients underwent surgery, whole-brain radiotherapy and chemotherapy, and are still alive and disease-free after respectively 42 and 72 months. Although systemic metastasis from tumors of the testis are relatively common, they rarely involve the nervous system. A review of our cases and those reported in the literature shows that the outcome in these patients can be improved by the combined surgical, radiological and chemotherapeutic treatment of the metastasis.

Radiation-induced sarcoma of the skull: report of two cases.

The authors describe two cases of sarcomas of the skull following cranial irradiation in patients treated for other neoplasms, acute lymphatic leukemia, and astrocytoma, respectively. The patients (one man and one woman: mean age 24.5 years) developed sarcomas within the irradiated field after a mean latency period of 11.5 years. Histologically, the tumor proved to be a fibrosarcoma. Despite aggressive surgery and other therapy, the survival of the patients was short (10 and 8 months, respectively). The pathological and clinical aspects of this unusual complication are analyzed with reference to 41 cases taken from the world literature.

Osteoblastoma of the calvaria: report of two cases diagnosed with MRI and clinical review.

The authors describe 2 cases of osteoblastoma of the calvaria and review the clinical features of the 28 cases reported in the world literature. Benign osteoblastoma is a rare tumor that effects young patients, most frequently at temporal level. On the basis of its neuroradiological appearance, it is difficult to formulate a differential diagnosis against other osteoblastic tumors or against osteoid osteoma. In only a few cases MRI findings are reported. In our cases, MRI was more effective than CT scans and radiographs for evaluating the intracranial and intraosseous extension of the tumor. The definitive diagnosis was obtained by combining the histopathological features of the tumor with the clinical and radiological data. The prognosis of this tumor is very good regardless of the type of treatment performed, although both relapse and, more rarely, malignant tumor evolution are possible.

Supratentorial diffuse astrocytic tumours: proposal of an MRI classification.

The aim of this study was to obtain an MRI severity-related classification of diffuse astrocytic tumours able to integrate the histological data in the grading of such tumours. We studied presurgical MR images of 91 patients with a histological diagnosis of astrocytoma, anaplastic astrocytoma and glioblastoma. A score ranging from 1 to 3 was assigned by two independent readers to each of the following MR features: oedema, mass effect, contrast enhancement, borders, signal homogeneity, necrosis, haemorrhage and flow void. Statistical analysis showed significant differences in the mean MRI scores between the three histological grades. Contrast enhancement was found to be the best predictor of the histological grade followed by necrosis, signal homogeneity and border scores. This classification represents a simple and reproducible means of carefully evaluating some macroscopic characteristics of these tumours. It could be used to integrate histological data especially in cases in which tissue sampling defects may affect the validity of this examination.

[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.

Osteosarcoma of the skull in a child: case report and review of the literature.

Osteosarcoma does not often affect the bones of the skull, occurring preferentially in the appendicular skeleton. The patient's age at onset seems to be later when the tumor is in the skull than in other sites. CT and MRI are at present the best means of establishing the extent of the tumor. Surgical removal of the lesion combined with polychemotherapy is the basis of treatment. We report a case of osteosarcoma of the skull in a child and review relevant publications.

Post-Paget osteosarcomas of the skull. Remarks on five cases.

We report our experience with 5 cases of post-Paget osteosarcoma of the skull, a rare lesion of the neurocranium. Four patients were treated by surgery and radiotherapy and one by surgery alone. Two patients received chemotherapy. Histologically, the tumor was found to be an osteosarcoma, fibroblastic in 2 cases, mixed in 2, and osteoblastic in 1. Combined treatment (surgery, radiotherapy and chemotherapy) positively influenced survival (median survival, 6 months). The prognosis for post-Paget osteosarcomas of the skull seems to be worse than for primary sarcomas, probably due to their intense vascularization. This facilitates the spread of tumor cells to other organs (as observed in our cases) and reduces the reduced effectiveness of chemotherapy. Although the latter lengthens survival and reduces the incidence of metastases, it is not as efficacious as in primary sarcomas.