Predictive role of dynamic contrast enhanced T1-weighted MR sequences in pre-surgical evaluation of macroadenomas consistency.

PURPOSE: Our hypothesis was that pituitary macroadenomas show different areas of consistency detectable by enhanced magnetic resonance imaging (MRI) with Dynamic study during gadolinium administration. MATERIALS AND METHODS: We analysed 21 patients with pituitary macroadenomas between June 2013 and June 2015. All patients underwent trans-sphenoidal surgery and neurosurgeon described macroadenomas consistency. Similarly, two neuroradiologists manually drew regions of interest (ROIs) inside the solid-appearing portions of macroadenoma and in the normal white matter both on dynamic and post-contrast acquisitions. The ratio between these ROIs, defined as Signal Intensity Ratio (SIR), allowed obtaining signal intensity curves over time on dynamic acquisition and a single value on post-contrast MRI. SIR values best differentiating solid from soft macroadenoma components were calculated and correlated with pathologic patterns. A two-sample T test and empiric receiver operating characteristic (ROC) curve of SIR was performed. RESULTS: According to ROC analysis, the SIR value of 1.92, obtained by dynamic acquisition, best distinguished soft and hard components. All the specimens from soft components were characterized by high cellularity, high representation of vascularization and micro-haemorrhage and low percentage of collagen content. The reverse was evident in hard components. CONCLUSIONS: We demonstrated that dynamic MRI acquisition could distinguish with good accuracy macroadenomas consistency.

Cerebral ependymoma in a patient with multiple sclerosis case report and critical review of the literature.

BACKGROUND: The concurrence of multiple sclerosis (MS) and brain tumors is a rare but well-recognized condition. The radiologic evidence of the progressive evolution of a mega-plaque in a tumor has never been described. We report the first case of such an occurrence. METHODS: A 27-year-old woman with a diagnosis of MS was referred to us for an intense frontal headache. Magnetic resonance imaging showed a mass lesion in correspondence of a black hole lesion previously diagnosed. The patient was operated on, with complete removal of the tumor documented by an intraoperative MRI. The histologic examination evidenced an ependymoma. Postoperative radiotherapy was performed. RESULTS: The patient is well and recurrence-free at 2 years follow-up. CONCLUSIONS: The present case, documenting the transformation of a mega-plaque into a tumor, suggests a cause-effect relationship between MS and brain tumors.

Membranectomy in organized chronic subdural hematomas: indications and technical notes.

BACKGROUND: The aim of the present study is to present our operative method of removing organized CSDHs and to structure the criteria for choosing this approach as first treatment. METHODS: Between 1991 and 1999 at our Institution, 14 consecutive patients with organized CSDHs required 16 craniotomies with membranectomy. They represent 5.8% of all patients (243) treated for CSDHs in the same period. All the patients had preoperative contrast-enhanced CT, and 9 patients also had contrast MRI. RESULTS: Initially, 9 patients underwent one burr hole or twist-drill hole. Of these 9 patients, 3 were treated at the same surgery with craniotomy and membranectomy as second treatment, 3 underwent a second burr hole and then membranectomy at the same surgery, and 3 patients underwent a second burr hole 3, 4, and 21 days after the first one and then membranectomy. Five patients underwent immediate craniotomy and membranectomy. There were no morbidity or mortality associated with this procedure. All patients had a full recovery without recurrence. CONCLUSIONS: Contrast-enhanced MRI has greatly improved opportunities for discovering neomembrane before surgical intervention. We believe that MRI detection of thick and extensive membranes or solid clot with mass effect makes an immediate craniotomy to remove CSDH necessary.

Intracranial meningiomas in children: report of 27 new cases and critical analysis of 440 cases reported in the literature.

We accumulated 440 cases of intracranial meningiomas in patients under 16 years of age, and another 27 personal. This review confirms the existence of specific clinical features of spontaneous and radiation-induced meningioma in children. In addition, we discuss various points that suggest a more aggressive behavior of meningiomas in children than in adults. (J Child Neurol 2006;21:31-36).

Tumor-like multiple sclerosis: report of four cases and literature review.

AIMS AND BACKGROUND: Classical multiple sclerosis plaques usually have typical features on gadolinium-enhanced MRI scan. This non-neoplastic demyelinating process of the central nervous system generally does not produce focal space-occupying lesions associated with ring enhancement. However, atypical appearance of demyelinating lesions simulating a brain tumor is a possible well-known phenomenon. METHODS: We present our experience with 4 cases of multiple sclerosis indistinguishable clinically and neuroradiologically from a cerebral tumor. All patients underwent surgery. RESULTS: Histological examinations of all cases were positive for multiple sclerosis plaques. CONCLUSIONS: The presented cases demonstrate the importance of considering a demyelinating disease in the differential diagnosis of a tumor-like brain lesion.

Brain metastasis from cutaneous squamous cell carcinoma of the dorsum. Case report.

The majority of cutaneous squamous cell carcinoma (SCC) are diagnosed early and cured using local treatment, although a minority of cases metastasize to regional structures. In this report the authors describe an unknown feature of skin SCC, namely, distant brain metastasis. This 54-year-old man, who had undergone surgery for moderately differentiated SCC of the dorsum (T2NOM0 stage), was admitted to our institution 11 months later with headache, vomiting, and ataxia. A magnetic resonance image documented a cerebellar lesion, which was totally removed. Results of histological studies revealed SCC. The patient received whole-brain radiotherapy (30 Gy over 2 weeks using a linear accelerator). A metastatic work-up showed enlarged inguinal and para-aortic lymph nodes that were histologically examined using excisional biopsy. Inguinal lymph nodes were tumor-positive and were dissected. The patient was subjected to two cycles of chemotherapy with cisplatin (75 mg/m2). After 3 months, a significant reduction in the size of the para-aortic lymph nodes was documented on control computerized tomography studies. Although the described case is unique, knowledge of the potential for this uncommon behavior in cutaneous SCC may be useful, especially because of its increasing incidence.

Traumatic epidural hematoma in children.

The purpose of this study was to investigate the characteristics of childhood acute epidural hematoma and to report our experience in recent years. A series of 35 patients below the age of 15 years treated for acute epidural hematoma at our institution between June 1991 and December 2000 was analyzed in detail. Pediatric epidural hematoma presents both age-related and atypical features when compared with epidural hematoma in adults. In selected cases, prompt surgical evacuation of the hematoma results in an excellent outcome. Outcomes seem to be directly related to the patient's preoperative neurologic status and the presence of associated intracranial lesions.

Severe craniofacial fractures with frontobasal involvement and cerebrospinal fluid fistula: indications for surgical repair.

BACKGROUND: The management of posttraumatic cerebrospinal fluid (CSF) fistulae is a controversial topic. Although recent literature shows that endoscopic repair of CSF fistula is efficacious and minimally invasive, in specific conditions open operative approach remains imperative. METHODS: A series of 36 patients underwent surgery for posttraumatic CSF fistula according to specific selection criteria. These criteria included: bone displacement more than 1 cm (5 cases), location of fracture in proximity to the midline (6 cases), involvement of cribriform plate (12 cases), presence of encephalocele (3 cases), and failure of the conservative treatment (10 cases). The dural defect was closed using vascularized pericranium and fibrin glue. Closure of the basal bone defect was necessary in very large fractures or in special localization of the fistula, such as near the optic nerve. Mean clinical follow-up was 5.7 years. RESULTS: Two patients presented meningitis without sequelae, and 12 with hyposmia. One patient died of the severity of the primary brain injury and associated extracranial lesions. None of the patients had recurrence. CONCLUSIONS: Our results indicate that surgical dural repair in selected cases is related to low morbidity and mortality preserving from delayed risks such as recurrence and infections.

Management of acute cerebellar infarction: one institution's experience.

OBJECTIVE: The management of cerebellar infarctions is controversial. The aim of this study was to determine which patients require surgical treatment and which surgical procedure should be performed when a patient with a cerebellar infarction exhibits progressive neurological deterioration. METHODS: A total of 44 patients (24 male and 20 female patients; average age, 56 yr) were treated at our institution for cerebellar infarctions in the past 8 years. Twenty-five patients received conservative treatment; two patients who were deeply comatose received no treatment. The remaining 17 patients underwent emergency surgery. Of those 17 patients, 8 underwent external ventricular drainage alone, 5 underwent external ventricular drainage as the first treatment plus secondary suboccipital craniectomy, and 4 underwent suboccipital craniectomy, with removal of necrotic tissue, as the first treatment. RESULTS: Of the 25 conservatively treated patients, 20 experienced good outcomes, 4 experienced moderate outcomes, and 1 died as a result of pulmonary embolism. Of the 17 surgically treated patients, 10 experienced good functional recoveries (7 treated with external ventricular drainage only and 3 treated with drainage followed by suboccipital craniectomy) and 3 survived with mild neurological deficits (one patient underwent ventriculostomy, one suboccipital craniectomy plus external ventricular drainage, and one suboccipital craniectomy only). The overall mortality rate was 13.6% (6 of 44 patients). CONCLUSION: For patients with worsening levels of consciousness and radiologically evident ventricular enlargement, we recommend external ventricular drainage. We reserve surgical resection of necrotic tissue for patients whose clinical status worsens despite ventriculostomy, those for whom worsening is accompanied by signs of brainstem compression, and those with tight posterior fossae.

Inflammation markers and risk factors for recurrence in 35 patients with a posttraumatic chronic subdural hematoma: a prospective study.

OBJECT: To evaluate the role of local inflammation in the pathogenesis and postoperative recurrence of chronic subdural hematoma (CSDH), the authors conducted an investigation in a selected group of patients who could clearly recall a traumatic event and who did not have other risk factors for CSDH. Inflammation was analyzed by measuring the concentration of the proinflammatory and inflammatory cytokines interleukin (IL)-6 and IL-8. The authors also investigated the possible relationship between high levels of local inflammation that were measured and recurrence of the CSDH. METHODS: A prospective study was performed between 1999 and 2001. Thirty-five patients who could clearly recall a traumatic event that had occurred at least 3 weeks previously and who did not have risk factors for CSDH were enrolled. All patients were surgically treated by burr hole irrigation plus external drainage. The concentration of inflammatory cytokines was very high in the lesion, whereas it was normal in serum. In five cases in which recurrence occurred, concentrations of both IL-6 and IL-8 were significantly increased (p < 0.01) in comparison with cases without a recurrence. In a layering hematoma, the IL-6 and IL-8 concentrations were significantly higher (p < 0.05). Layering CSDHs were also significantly correlated with recurrence. Trabecular hematoma had the lowest cytokine levels and the longest median interval between trauma and clinical onset. The interval from trauma did not significantly influence recurrence, although it did differ significantly between the trabecular and layering CSDH groups. Concentrations of IL-6 and IL-8 in the CSDHs did not differ significantly in relation to either the age of the hematoma (measured as the interval from trauma) or the age of the patient. CONCLUSIONS: Brain trauma causes the onset of an inflammatory process within the dural border cell layer; high levels of inflammatory cytokines were significantly correlated with recurrence and layering CSDH. A prolonged postoperative antiinflammatory medicine given as prophylaxis may help prevent the recurrence of a CSDH.

Duraplasty: our current experience.

BACKGROUND: A large variety of biologic and artificial materials have been suggested as dural substitutes. However, no ideal material for dural repair in neurosurgical procedures has been identified. The authors report their experience with Tutoplast processed dura and pericardium. METHODS: This study is designed to evaluate Tutoplast dura and pericardium. The study population was composed of 250 consecutive patients who underwent cerebral duraplasty with these homologous materials between 1996 and 1998. The average follow-up was 5.4 years. RESULTS: We have observed only four complications with uncertain relationship with the dural implant. These resulted in complete recovery. CONCLUSIONS: We support the efficacy and safety of this natural dural substitute treated with Tutoplast method.

Radiation-induced gliomas: report of 10 cases and review of the literature.

BACKGROUND: Radiotherapy and more recently radiosurgery represent important therapeutic methods for the treatment of tumors and arterovenous malformations affecting the central nervous system, even though several significant side-effects have been described (radionecrosis, tumors, etc.). Gliomas induced by radiation therapy are decidedly unusual, and the first descriptions of this association only appeared in the 1960s. METHODS: The pertinent literature was reviewed to yield 116 cases in which a glioma developed after radiotherapy for cranial pathologies (included 10 personal cases treated in our Institution). One of our patients had undergone radiosurgery for a cavernous angioma. RESULTS: Patients who developed a radiation-induced glioma were younger, as a group, than those affected with so-called "spontaneous" gliomas. The tumor originated in the previously irradiated area, after average doses of 32 Gy and an average latency period of 9.6 years in accordance with the findings reported by the authors and in our experience as well. Radiotherapy had most frequently been performed for acute lymphoblastic leukemia. Our Case 10 is the fourth case of intracranial tumor arising after radiosurgery to be described in the literature. CONCLUSIONS: Though rare, gliomas may represent a late complication of radiation treatment. The behavior of the radiation-induced variety of glioma does not seem to differ significantly from that of its "spontaneous" counterpart. Late complications of the radiosurgery are probably underestimated because of the relatively recent introduction of this technique. On the contrary, these should be scrupulously evaluated when deciding whether to employ this method for therapeutic purposes for relatively benign or congenital lesions (which generally affect young patients with a long life expectancy).

Primary cerebral lymphoma: a retrospective study in 22 immunocompetent patients.

AIMS AND BACKGROUND: Primary CNS lymphomas are uncommon tumors in immunocompetent patients. We describe the radiological features that should orient towards performing a biopsy and analyze the results in our series of patients. METHODS: We reviewed 22 immunocompetent patients with primary central nervous system lymphoma admitted in our Institute between 1977 and 1997. The follow-up period ranged from 2 months (patient deceased) to 69 months. Fourteen patients underwent surgical removal of the tumor and the remainder a biopsy. All patients received radiotherapy and 8 patients radiotherapy plus chemotherapy. RESULTS: Two of the 14 patients treated by surgical removal of the tumor died. There was no mortality related to biopsy procedures. Patients treated with radiotherapy had 1-year, 2-year and 5-year survival rates of 66%, 41.6% and 16.6%, compared to 87.5%, 62.5% and 50%, respectively, for patients who received radiotherapy and chemotherapy. CONCLUSIONS: At present, there is no definite treatment for these highly malignant brain tumors. The most favorable results seem related to biopsy followed by radiotherapy plus chemotherapy versus surgical removal, which is related to a high risk of severe postoperative deficit for both the deep location and infiltrating nature of these lesions.

High-dose radiation-induced meningiomas. Report of five cases and critical review of the literature.

Radiotherapy is an important modality for the treatment of tumors and arteriovenous malformations affecting the central nervous system, even though several significant side effects have been described (radionecrosis, tumors, etc.). Meningiomas induced by high-dose radiation therapy are uncommon. In this study we describe five cases treated at our institute and review all previously published reports of meningioma occurring after high-dose radiotherapy. These tumors develop mainly in patients irradiated in childhood; their incidence peaks in the second decade of life, there is a predominance in females and a high frequency of malignant forms. Although rare, meningiomas may represent a late complication of radiation treatment. The behavior of the radiation-induced variety of meningioma seems to differ from that of its "spontaneous" counterpart. The use of radiotherapy should be carefully evaluated for relatively benign or congenital lesions which generally affect young patients with a long life expectancy.

Post-traumatic glioma. Report of four cases and review of the literature.

AIMS AND BACKGROUND: To add a further contribution to the literature supporting the relationship between previous head trauma and development of glioma. METHODS: We report on four patients who developed brain gliomas in the scar of an old brain injury. RESULTS: All cases fulfilled the widely established criteria for brain tumors of traumatic origin. In all of our cases there was radiological evidence of absence of tumor at the time of the injury. CONCLUSIONS: We believe that in specific cases it is reasonable to acknowledge an etiological association between a severe head trauma and the development of a glioma. This assumption is further sustained if there is radiological and surgical documentation of the absence of neoplasia at the moment of the trauma.

Extremely delayed cerebral metastasis from renal carcinoma: report of four cases and critical analysis of the literature.

Brain metastases from renal carcinoma may appear even a long time after surgical treatment of the primary tumor. The authors present 2 series of patients, one of which has already been published and the other new, for a total of 4 cases of brain metastasis from renal carcinoma with late onset, which occurred 13, 17, 26 and 12 years after primary surgical treatment. The other cases described in the literature were also critically reviewed.

Post-traumatic intracranial meningiomas.

The authors present 20 cases of likely post-traumatic intracranial meningiomas selected according to the conditions specified in the relevant literature. The relationship between head injury and subsequent development of meningioma remains a controversial and fascinating subject. The etiopathogenetic mechanisms and clinical features of our patients and those of the literature are discussed.

Neural stem cells and glioblastoma.

Glioblastoma multiforme represents one of the most common brain cancers with a rather heterogeneous cellular composition, as indicated by the term "multiforme". Recent reports have described the isolation and identification of cancer neural stem cells from human adult glioblastoma multiforme, which possess the capacity to establish, sustain, and expand these tumours, even under the challenging settings posed by serial transplantation experiments. Our study focused on the distribution of neural cancer stem cells inside the tumour. The study is divided into three phases: removal of tumoral specimens in different areas of the tumour (centre, periphery, marginal zone) in an operative room equipped with a 1.5 T scanner; isolation and characterization of neural cancer stem cells from human adult glioblastoma multiforme; identification of neural cancer stem cell distribution inside the tumour.

Platinum-iridium subdermal magnetic resonance imaging-compatible needle electrodes are suitable for intraoperative neurophysiological monitoring during image-guided surgery with high-field intraoperative magnetic resonance imaging: an experimental study.

BACKGROUND: Neurosurgery aims to achieve maximal tumor resection while preserving neurological function. Tools such as neuronavigation, high-field intraoperative magnetic resonance imaging (iMRI), and intraoperative neurophysiological monitoring (IOM) have consistently helped to achieve this goal, but integration has often been difficult. Surgery of eloquent areas requires IOM, which in an operating theater equipped with high-field (1.5-T) iMRI could present several issues. OBJECTIVE: To identify the electrodes types more suitable for IOM in a high-field iMRI operating theater by performing an experimental study on phantoms, to report our experience with platinum-iridium (Pt/Ir) electrodes during surgery, and to prove that integration between IOM with Pt/Ir electrodes and high-field iMRI is safe and reliable. METHODS: Electrodes of different materials (gold, Pt/Ir, and stainless steel) were tested on jelly phantom and apples to evaluate their safety and compatibility. Subsequently, electrodes were tested on 5 healthy volunteers before being used on patients. RESULTS: None of the different electrodes presented thermal instability, and no damage to the volunteers' skin occurred. Stainless steel electrodes caused severe imaging distortion. Gold electrodes had no distortion, but their high cost makes their use in routine surgery unaffordable. Pt/Ir electrodes are significantly less expensive than gold electrodes and were completely safe, compatible, and suitable for use in an operating theater with high-field iMRI, providing excellent IOM and mild interference that did not affect the quality of intraoperative imaging. CONCLUSION: We suggest the use of Pt/Ir electrodes for IOM in 1.5-T iMRI suites. ABBREVIATIONS: DTI, diffusion tensor imagingiMRI, intraoperative magnetic resonance imagingIOM, intraoperative neurophysiological monitoring.