Angiomas of the cerebellopontine angle.

Angiomas situated within the pontocerebellar cistern lie superficially on the ventrolateral aspect of the brain stem. Occasionally, minor extensions penetrate into the adjacent nervous structures. Five patients bearing such lesions were operated upon, using a microsurgical technique. Radical excision was performed in all cases. Within 2 to 12 months the patients had returned to their previous occupations, being fully able to work or attend school. There is increasing evidence for the effectiveness of surgical treatment of angiomas of the ventrolateral aspect of the brain stem and the cerebellopontine angle. The illness usually presents with hemorrhages of varying severity, ranging from mild to devastating. Impairment of consciousness, contralateral hemiparesis and ipsilateral cranial nerve palsies are the most frequent neurological signs after bleeding. The outcome following excision is primarily related to the preoperative condition. No additional deficits or only minor further impairment can be expected from surgical interference. Exploration is advisable whenever the malformation appears to lie on the surface rather than within the brain stem.

Subsequent bleeding from ruptured intracranial aneurysms treated by wrapping or coating: a review of the long-term results in 47 cases.

Forty-seven patients, who underwent surgery over a 34-year period by the wrapping or coating of ruptured intracranial aneurysms, have been retrospectively evaluated. The following materials were used in the surgical procedures: muscle with gelatin sponge (7 cases), gauze (2 cases), oxidized cellulose with Biobond (28 cases), Histoacryl with gauze or fascia (10 cases). The patients were monitored for up to 37 years (mean, 13.7 +/- 8.2 yr). One or more subsequent bleedings occurred in eight patients (17%). Three patients had additional bleeding and died in the early postoperative phase (within 1 mo after surgery). In five patients, the subsequent bleeding occurred between 1 and 15 years postoperatively, with two fatalities. One patient experienced two recurrences. Therefore, the mortality rate for postoperative bleedings was 10.6% (five patients) in the whole series, and the incidence of early (within 1 mo after surgery) fatal bleedings was 6.4%. After the first month from the initial hemorrhage, the global risk of subsequent bleeding was 0.93%/yr. Among the nine patients whose aneurysms were wrapped with muscle, gelatin sponge, or gauze, four additional bleedings occurred, whereas four relapses were observed among the 38 cases treated by employing bioadhesive agents (P < 0.04; Fisher's exact test). The rate of further bleeding was higher (25%) in patients undergoing surgery in the premicrosurgical era compared with that (8.7%) recorded in patients treated by microsurgery (difference statistically not significant).

The subchoroidal approach to the third ventricle: surgical anatomy according to Galen.

THE SUBCHOROIDAL APPROACH has taken its place among the surgical access routes to the third ventricle. Eighteen centuries ago, in his major anatomic work, Galen detailed with astonishing accuracy the anatomy of the structures around the third ventricle and the procedure for exposing this cavity by entering the lateral ventricles and elevating its roof. Even more surprising is Galen's pioneering description of surgical maneuvers of the third ventricle in living animals in a way that anticipated the modern subchoroidal approach.

Repair of traumatic cerebrospinal fluid leaks using tissue adhesives.

14 cases of post-traumatic cerebrospinal fluid leaks, sealed with tissue adhesives and fascia, or galea, are reported. None of the patients had recurrence in a follow-up ranging from five months to three years. Tissue adhesives provided a tough adhesion of the patch and, as a consequence, an immediate and stable repair of the leak.

The subchoroid approach to the third ventricle.

Surgical exposure of the third ventricle can be obtained by elevating the choroid plexus from the floor of the lateral ventricle and displacing it, together with the tela choroidea and the fornix. The operative technique for the subchoroidal approach to the third ventricle is reported.

Surgical removal of striate arteriovenous malformations.

Some arteriovenous malformations fed by the striate arteries and lying within the claustrolenticular region can be excised by using microsurgical techniques. Three patients operated on with successful removal of the malformation are discussed here.

Long-term results of surgery for hydatid disease of the spine.

Long-term results of the surgical treatment of 18 patients with hydatid disease of the spine are reported. Recurrent signs of cord compression, requiring reoperation, occurred in half of the cases. The infestation can be controlled occasionally for over decades after the first operation, allowing the patients to have an acceptable life with their disease.

Redundant nerve roots of the cauda equina.

Four cases of redundant nerve roots of the cauda equina are reported, and the pertinent literature is reviewed. This disorder mainly affects males. The clinical history ranges from months to decades. The illness often starts with low back pain or sciatica, or both. Motor and sensory impairment of the legs dominate the further course of the disease. Serpentine filling defects in the column of contrast are a characteristic (but inconstant) feature on myelograms. Abatement of signs and symptoms occurs following adequate decompression of the redundant roots.

Penetrating craniocerebral missile injuries in civilians: a retrospective analysis of 314 cases.

Analysis of 314 cases of penetrating craniocerebral missile injuries in civilians revealed a high rate of early mortality, with 228 victims having died at the scene and a further 38 dead within 3 hours. Surgery was performed in 44 patients who had a preoperative Glasgow Coma Score of at least 4. Out of the 26 survivors, all operated upon, 19 had an adequate recovery (score of 0-3 on the expanded Glasgow Outcome Scale). Vigorous resuscitation and early surgery often resulted in useful survivals and occasionally in spectacular recoveries. However, the high mortality rate on the scene or soon after the injury restricted the possibility of effective management to a minority of cases.

Computed tomography and magnetic resonance imaging in spinal hydatidosis.

Computed tomography and magnetic resonance imaging in patients with spinal hydatidosis provide comprehensive evaluation of the actual extent of the disease. Paravertebral uncalcified cysts, hardly recognizable by conventional radiologic examinations, are clearly shown by both methods. Initial involvement of the spongy bone is evident in computed tomography scans, in contrast to what usually appears to be normal in plain films or tomograms. Occurrence of cysts within the spinal canal is revealed by both types of computed scans, with magnetic resonance imaging being able to provide further information on the involvement of the spinal cord.

Computed tomography and magnetic resonance imaging of cerebral coenurosis.

A case of Coenurus cerebralis involving both cerebral hemispheres and the interpeduncular cistern is presented to illustrate the computed tomography (CT) and magnetic resonance imaging (MRI) features. In CT scans viable cysts appear as lucent lesions surrounded by a contrast-enhanced peripheral rim. By using multiple echo sequences the cyst content is characterized in magnetic resonance images by a cerebrospinal fluid-like intensity pattern.

Subchoroidal approach to the third ventricle. Microsurgical anatomy.

The third ventricle can be approached by performing a few surgical maneuvers: (a) dividing the ependyma on the inferolateral aspect of the choroid plexus of the lateral ventricle; (b) separating leptomeningeal bundles within the tela chorioidea, and (c) dividing the roof of the third ventricle along the stria medullaris. Main landmarks are the thalamostriate vein and the direct lateral vein. Small subependymal veins or neural branches of the posterior medical choroidal artery, or both, occasionally cross the access route. The third ventricle is seen through both the opening in the roof and the foramen of Monro. A wider exposure can be obtained by cutting the terminal segment of the thalamostriate vein.

Cerebral blood flow in minor cerebral contusion.

Seventeen patients with minor cerebral contusion were selected from a series of patients with head injuries of various severity, who had undergone repeat evaluations of the regional cerebral blood flow. The mean global flow (expressed as mean global initial slope index) on early examination was found to be significantly lower, compared with that recorded in healthy volunteers. A tendency towards the recovery of higher flow values was apparent in repeat evaluations that were performed several weeks after the injury. Interhemispheric asymmetries of flow were a common occurrence, with lower perfusion and reduced attenuation values on computed tomography scans being, however, in good agreement only in approximately half of the cases.

Pineal veins in vertebral angiography.

Angiographic patterns of pineal veins in normal and pathological conditions are examined. The diagnostic value of these veins for midline growths is limited owing to their inconstant visualization, multifarious angiographic patterns and minute size. With this in mind, greater significance of classical displacements of the internal and basal veins is outlined.

Redundant nerve roots of the cauda equina. A case report.

One further case of redundant nerve roots of the cauda equina is described, and a review of eleven comparable cases in the literature is provided. In the authors' opinion, this disease appears to be a congenital anomaly, frequently but not necessarily associated with spinal changes.

Post-traumatic subarachnoid pneumocephalus. A case report.

We present a case of subarachnoid pneumocephalus fed through a basal bony breach and confined to the cysterns of the Willis circle in a traumatized patient. The peculiar configuration of the pneumocephalus is attributed to the partial obliteration of the subarachnoid space due to the increased intracranial pressure.

Intracerebral hematoma following removal of chronic subdural hematoma. Report of two cases.

Two cases of intracerebral hemorrhage consequent to surgery planned for homolateral chronic subdural hematoma are reported. Both patients were treated conservatively and made a satisfactory recovery. The pathological events leading to the formation of an intracerebral hematoma following the evacuation of a chronic subdural hematoma still remain undefined.

Extrusion of peritoneal catheter through a thoracic skin fistula: report of a rare complication of ventriculoperitoneal shunt.

A very rare complication of ventriculoperitoneal shunt is presented. The tip of the distal catheter extruded through a skin fistula in the right subclavian region. After the replacement of a new catheter in the peritoneal cavity, inflammation of the overlying scar occurred. Then, a ventriculoatrial shunt was carried out. The authors suggest a possible mechanism of this complication.