Neuroendoscopic management of intraventricular hemorrhage.

BACKGROUND AND PURPOSE: We reviewed our 7-year experience in neuroendoscopic management of severe intraventricular hemorrhage (IVH) to evaluate its safety, efficiency, and efficacy. METHODS: Thirteen patients with spontaneous primary or secondary tetraventricular IVH underwent neuroendoscopy. In all procedures, we used a flexible instrument. CT scans obtained before and after surgery were compared for Graeb score and ventriculocranial ratio. Glasgow Outcome Scale was assessed at 12 months. RESULTS: In all patients, the procedure resulted in a substantial removal of ventricular blood. Graeb score was reduced by 65%, and ventriculocranial ratio was reduced by 30% (P<0.002). The procedure was carried out safely even in the presence of a vascular malformation, and no rebleeding or delayed hydrocephalus was observed in any case. Mortality at 12 months was 30.7%. Favorable outcome (Glasgow Outcome Scale, 3 to 5) was observed in 61.5% of cases. CONCLUSIONS: Neuroendoscopic management of severe IVH in this cohort of patients was safe, efficiently reduced the amount of ventricular blood and ventricular dilatation, and effectively produced an outcome profile that compares very favorably with other more conventional treatments.

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.

Cyclic nucleotides in medulloblastomas: correlative study of tumoral and cerebrospinal fluid levels.

The tumoral and cerebrospinal fluid (CSF) levels of cyclic nucleotides and of the main adrenergic metabolites (homovanillic acid and 5-hydroxyindoleacaetic acid) were investigated in a group of children with posterior fossa medulloblastomas. A longitudinal evaluation of CSF change of cyclic adenosine monophosphate (cAMP), cyclic guanosine monophosphate (cGMP), and adrenergic metabolites before and after surgical removal of the tumor mass is presented. Some preliminary patterns concerning correlative levels in the neoplastic tissue are discussed. The relevant increase of cGMP in medulloblastoma specimens and in CSF samples operation and the rapid decrease in the CSF after surgical removal of the tumor seem to suggest a possible role of cyclic nucleotides in the neoplastic growth of these tumors. (Neurosurgery, 7: 359-362, 1980).

Intrarachidian lipomas. Observations on 4 cases and pathogenetic considerations.

The Authors report 4 cases of spinal lipomas: 2 intradural, 2 completely intrarachidian extradural. The intradural lipomas observed were 2 cases in the lumbo-sacral area, both operated on by the partial removal of the lesion with very good clinical results; histologically they were found to be 2 fibrolipomas. The 2 cases of extradural lipomas, completely intrarachidian, were situated in the thoracic and lumbar areas. Both were operated on with very good results and it was possible to remove all the lesion. They were found to be an angiolipoma and a mature lipoma. On the basis of the literature, the Authors maintain that, for these cases of intradural lipoma, the disembryogenetic hypothesis (such as embryological ectopia) should be accepted as etiopathogenesis. They point out the nature and origin of extradural lipomas, arising in a site where adipose tissue is abundant, have never aroused interest on their origin, but they too can be considered malformative lesions of the hamartomatous type and not neoplastic lesions. These data are confirmed by the remarkable frequency in these cases of the mixed variety of lipoangiomato or angiomiolipomatosis. The Authors thus underline the importance of the relationship between the presence of a subcutaneous lipoma in cases of completely intrarachidian extradural lipomas to support the hypothesis of malformative origin.

Therapeutic indications in upper cervical spine instability. Considerations on 58 cases.

BACKGROUND: The particular biomechanics of the upper cervical spine require, when trauma occurs, careful evaluation of the stability of the lesions, in order to guarantee the best possible therapeutic and prognostic approach. To date, there has been no uniformity of opinion in merit, especially with reference to treatment of odontoid fractures. It is necessary for this reason as much as for the opportune standardisation of the patients' classification parameters to establish what is meant by stability and which lesions are to be held as being unstable in the upper cervical spine. METHODS: All the cases of upper cervical spine instability treated in our Unit from '94 to date have been reviewed. Four fractures to the first cervical vertebra, 29 to the odontoid process, 9 isolated fractures in the C2 body, 12 hangman fractures, 7 fractures of the articular processes, 2 to the occipital condyles and 4 C1-C2 dislocations without fractures were localised. Using precise prognostic indexes as our classification criteria, 56 of the 58 patients observed were addressed towards either conservative treatment or directly towards surgical treatment. In particular, 29 patients were conservatively treated with a collar or Halo-Vest. Twenty-seven surgical operations were carried out: 14 screw fixations, 6 anterior fixations using plates and screws, 4 rear ones using metal wire or wire with bone graft, 3 odontectomy operations associated with posterior fixation. RESULTS: In the follow-up, using a range of between three months to six years, good fusion with spine stabilisation was achieved in all the patients treated. In particular, surgery was carried out as the first therapeutic indication in 25 cases, obtaining excellent results. Surgery was necessary in only 2 cases after the failure of external stabilisation. CONCLUSIONS: The judgement passed on instability in traumatic lesions in the upper cervical spine represents the decisive factor in the choice of the therapeutic option. Instead of always opting for conservative treatment, in the case of C1-C2 fractures-luxations, and going ahead with surgery only when there is instability or non-fusion of the segments resulting after successive monitoring, we believe that the definition and standardisation of the prognostic factors is opportune, in order to provide patients with a specific solution, in such a way as to reduce the failure percentage of the first treatment and optimise the healing time.

Indications for the use of bleomycine-Co57 in brain scanning.

The Authors report on their experience with a new radio-active tracer, Bleomycine-Co57, which was studied in 40 patients who had previously undergone brain scanning with Indium113m. The results obtained with these two different tracers are compared and the following conclusions advanced: 1) Bleomycine-Co57 is the radio-active tracer of choice in identification of cerebral metastases, especially in those cases where brain scanning with Indium113m was non-diagnostic; 2) glioblastomas evidence less uptake of the tracer than do metastases; 3) the scarce affinity of this tracer for benign tumors is stressed; 4) owing to the long half-life of this tracer, it is preferable to use it only with those subjects suspected of having a malignant neoplasia.

Considerations on the results of surgical treatment of cerebral abscesses.

The results of surgery in 96 patients affected with cerebral abscess are reported. The lesion was completely removed in 65 patients, 33 underwent drainage (in many cases by Adso-Craig's technique) and only in one case was a combined operation performed. Overall mortality was 15.1%. More or less serious neurological and/or psychic deficits were present in 40% of patients, whereas epilepsy occurred in 26.6%. Furthermore, it was noted that excision of the abscess originates fewer epileptic complications type (20.9%) than drainage of the abscess cavity (37.5%). As regards the type of operation, the Authors suggest complete excision of the abscess as more advisable limiting drainage to cases of localization in "noble" areas or when complete removal can jeopardize patients in very serious conditions.

The dysraphic state of the posterior fossa. Clinical review of the Dandy-Walker syndrome and the so-called arachnoid cysts.

The Authors report their case material concerning some basic items of the dysraphic pathology of the Posterior Fossa: 22 cases of Dandy Walker syndromes (DWS) and "Arachnoid Cysts" (PFC). The mean clinical findings (predominant involvement of the vestibular structures of the brain stem in the DWS, frequent epileptic seizures and some cases of hypothalamic disturbances in the PFC) are discussed in the light of current embryological theories on Weed's "area membranacea". Finally the results of differential surgical treatments are examined: good or satisfactory results were obtained with shunts, while still debatable seems to be the direct surgical approach.

Spontaneous spinal subdural hematoma.

A case of spontaneous spinal subdural hematoma is reported. Clinical signs at onset, laboratory investigations and bloody CSF at lumbar punction were suggesting of subarachnoid hemorrhage. MRI was fully diagnostic. Surgery was ruled out and spinal compression cleared spontaneously over one week. Etiological factors, possible diagnostic pittfalls and the indication surgical decompression are discussed.

Growing patterns of cavernous angioma in the fourth ventricle. Case report.

Cavernous malformations are vascular lesions that occur in all parts of the central nervous system but most commonly in the cerebral hemispheres; unusually they may be found along the midline (basal ganglia, pineal region or brain stem), into the ventricle possibly encroaching upon the fourth and third ventricle. We report a case of midline cavernomas of the IV ventricle, that grew to large size in-time, demonstrating the capacity for rapid expansion.

Disendocrine manifestations during non tumoral aqueductal stenosis.

Disendocrine manifestations during aqueductal stenosis are more and more frequently reported in literature. In the present study, 20 cases of benign aqueductal stenosis associated with disendocrine features as amenorrhea, obesity, polydipsia and polyuria, dwarfism, acromegalic features, hypogonadism, precocious puberty, gigantism are stressed. Authors discuss clinical findings and pathogenetic hypothesis on the base of endocrine, neurological and peculiar radiological features with the support of a wide literature review.

The CSF myelin basic protein: a reliable marker of actual cerebral damage in hydrocephalus.

Raised ventricular CSF myelin basic protein (MBP) concentration has been evidenced in 17 shunted hydrocephalic patients. Contemporary evaluation both from ventricular and lumbar CSF samples showed a concentration ratio of 20:1. In all cases the raised values of ventricular CSF concentration of MBP demonstrated a significant decrease after shunt operation. This preliminary report suggests that this marker is an important index of actual brain damage in hydrocephalus and could be taken in account for the indication of shunt operation.

Stereotactic support in the excision of brain tumors. Technical note.

The surgical resection of deep-seated brain tumors may be facilitated by CT guided stereotactic methods. The Authors present a procedure of preoperative localisation and delimitation of the border of a neoplastic mass facing important functional areas. Ideally tumor excision should not be extended beyond that boundary which for this reason is targeted and is stereotactically labeled using non diffusible dyes.

Immunobiology of primary neoplasms of the C.N.S. Preliminary results.

A preliminary report on the immunological monitoring of primary intracranial neoplasms is presented. The most important findings concerning B-cells and T-cells mediated immunity and delayed hypersensitivity reactions in this kind of patients, are discussed. Among the fairly significant immunobiological pictures, the Authors stress the "normal behaviour" of the B-cells dependent pool, the undebatable depression of the delayed hypersensitivity reactions, and the noticeable failure of the T-cell dependent pool, particularly marked in malignant gliomas, which are also characterized by the presence of cells with natural cytotoxic activity.

CSF levels of cyclic nucleotides and adrenergic metabolites in malignant gliomas.

Recent advances indicate that cyclic nucleotides and perhaps certain adrenergic metabolites might be directly involved in contact-inhibition mechanisms and tumoral cell growth. CSF levels of 3'-5' cAMP, 3'-5' cGMP, HVA, and 5-HIAA were investigated in patients with supratentorial malignant gliomas, brain stem gliomas and posterior fossa medulloblastoma. cAMP levels were slightly decreased only in medulloblastomas, whereas no significant difference was detectable in patients with supratentorial gliomas. cGMP values turned out to be significantly higher, with a very peculiar increase in the most anaplastic neoplasms. Postoperative follow-up showed a gradual decrease of cGMP values, with progressive restoring of a normal cAMP/cGMP ratio. The possible correlation of these findings with CSF levels of HVA and 5-HIAA is discussed.

Juvenile pilocytic astrocytoma of the optic nerve diagnosed by fine needle aspiration biopsy.

Fine needle aspiration biopsy of an orbital mass was performed under CT guidance in a nine-year-old boy presenting with rapidly increasing proptosis of the right eye with lateral displacement and no light perception. The cytologic findings consisted of bipolar astrocytes with cytoplasmic fibrillated processes intermingled with Rosenthal fibers. A cytologic diagnosis of juvenile pilocytic astrocytoma was advanced; this was confirmed by subsequent histologic study of the surgical specimen. The differential diagnosis among juvenile pilocytic astrocytoma, neurilemmoma and meningioma of the optic nerve are discussed.

[A rare complication of ventriculo-peritoneal shunt: intracranial migration of the derivative system]. / Una rara complicanza dell'intervento di shunt ventricolo-peritoneale: la migrazione intracranica del sistema derivativo.

Two cases of intracranial migration of ventriculo-peritoneal shunt are described. The Authors discussed the possible pathogenesis and the surgical techniques required to prevent this rare complication.