Correlation Between Cervical Spine Sagittal Alignment and Clinical Outcome After Standalone Intersomatic Titanium Cage CeSPACE for Cervical Anterior Discectomy and Fusion in Cervical Degenerative Disk Diseases.

The aim of this study was to determine the relationship between cervical spine sagittal alignment and clinical outcomes after using a standalone intersomatic titanium cage CeSPACE for anterior cervical discectomy and arthrodesis. We present our clinical experience in a group of 180 patients with a mean follow-up for at least 2 years. Patients were evaluated by clinical and radiological assessment preoperatively, immediately after surgery and at regular follow-up. There were 97 male and 83 female patients (average age: 56.6 years) who were preoperatively affected by cervical radiculomyelopathy that was due to spondylosis or cervical disk herniation and who underwent surgical treatment. All patients underwent an anterior discectomy and interbody fusion through the positioning of one or more levels of the CeSPACE device. Compared with the preoperative scores, improvement was seen in postoperative visual analog scale (VAS) scores and Neck Disability Index (NDI) values. The standalone intersomatic titanium cage CeSPACE for anterior cervical discectomy and arthrodesis improved radiculomyelopathy and increased the probability of cervical kyphotic alignment. However, cervical sagittal alignment after surgery was not significantly associated with clinical outcomes in terms of postoperative improvement in VAS scores and NDI values. Similarly, the change in cervical sagittal alignment was not related to visual analog scale scores or Neck Disability Index values.

Osteoblastic meningiomas: clinico-pathological and immunohistochemical features of an uncommon variant.

Osteoblastic meningioma is a rare variant of meningioma characterized by the presence of a variable number of bone spicules within the tumor parenchyma. Its histogenesis has not been yet fully clarified. Herein we report clinical and histological findings and expression of bone matrix proteins (osteocalcin and ostepontin) observed in seven osteoblastic meningiomas. None of the cases displayed recurrences or significant re-growth after partial resection. In 5/7 cases the osseous component occurred in association with psammoma bodies and dystrophic calcification. Interestingly, foci composed of immature bone trabeculae, mineralized chondroid matrix, and osteoclasts were found in one of the two cases with no psammoma bodies or calcification, suggesting enchondral ossification. Positive staining for osteocalcin, which is a marker of terminal osteoblastic differentiation, was observed within the bone spicules in all meningiomas, but not in the chondroid mineralized matrix. On the other hand, immuno-expression of osteopontin, an early osteogenic marker, was observed in the osteoclasts and in mature and immature bone spiculae, calcification, and psammoma bodies. Even more, osteopontin was extensively expressed by the neoplastic cells of cases without calcification or psammoma bodies, suggesting acquisition of osteoblastic phenotype in these meningiomas. In conclusion, osteoblastic meningioma seems to be an indolent variant of meningiomas characterized by a slow growth and good prognosis. Our histological and immunohistochemical findings suggest that bone formation may occur through two different pathways, i.e., as the final step of calcification or through a metaplastic mechanism in cases with absent calcification or psammoma bodies.

Anterior thoracic intradural arachnoid cysts. Case report and review of the literature.

Anterior thoracic intradural arachnoid cysts (ATIACs) are a rare cause of spinal cord and nerve root compression, for which different treatment strategies have been proposed. Although ATIAC represents a well-known clinical entity, the choice of surgical method has not been uniform, and no study has been specifically designed to compare the results of the different treatment options adopted. The authors report the case of a 40-year old man with a 1-year history of dorsal pain, weakness in the lower extremities, gait disturbance, and mild sexual and urinary dysfunction. On neurological examination spastic paraparesis, lower-extremity hypertonia, and hypesthesia below T-2 were demonstrated. Magnetic resonance imaging revealed the presence of an ATIAC at the T-2 level. The patient underwent complete microsurgical removal of the cyst. The authors conducted a Medline search of the relevant literature from 1966 to 1998 and also obtained data on other cases in which patients underwent surgical treatment of ATIAC. The literature search yielded five such cases. Treatment strategies were complete excision and fenestration followed by placement of a shunt. In addition, one case was characterized by intraoperative cyst rupture during retraction of the spinal cord. Correct preoperative workup coupled with microneurosurgical technique allow for successful removal of the lesion and excellent outcome. Based on the literature review and the results in our case, the complete excision of ATIAC is associated with an excellent outcome, which is different from results achieved using other surgical strategies.

Non-traumatic sphenoidal intradiploic arachnoid cyst as a cause of trigeminal neuralgia. A case report.

Non-traumatic intradiploic arachnoid cyst is a rare condition. We describe a young man with typical trigeminal neuralgia and intradiploic arachnoid cyst at the greater wing of the sphenoid. The patient was successfully treated with medical therapy. To our knowledge, this is the first case report of a possible correlation between trigeminal neuralgia and intraosseous arachnoid cyst. We describe the clinical case, the possible pathogenetic mechanism and briefly review the literature.

Growing skull fracture of the posterior cranial fossa and of the orbital roof.

BACKGROUND: Growing Skull Fractures (GSF) are rare complications of head trauma, primarily reported in infancy and early childhood. GSF are commonly located on calvaria, and rarely in other locations, including the skull base. METHOD: In this study, we report two cases of GSF occurring in unusual locations. The first, a 8-month old girl, with a GSF of the suboccipital posterior fossa region, and the second, a 4-year old boy with a GSF of the right orbital roof. Both cases underwent operative treatment of the GSF, with microsurgical dissection and excision of the protruding gliotic brain tissue, watertight duraplasty and autologous bone cranial repair. The authors conducted a Medline search of the relevant English literature from 1966 to 2002. FINDINGS: From the search, three cases of suboccipital posterior fossa region GSF and twelve series of orbital GSF, describing a total of 22 cases, have been found. INTERPRETATION: A survey of the pathogenic mechanisms underlying this entity in these locations is reported. A review of suboccipital posterior fossa and orbital roof GSF cases, of nosological, ophthalmological and neurological data, neuroradiological and operative findings, and results of different treatment strategies are described.

Transverse microincisions of the outer layer of the dura mater combined with foramen magnum decompression as treatment for syringomyelia with Chiari I malformation.

Numerous surgical procedures have been proposed for treatment of syringomyelia associated with Chiari I malformation, but the optimal treatment has not yet been uniformly standardised. The main aim of the surgical treatment of syringomyelia/Chiari I complex is directed toward restoration of physiological cerebrospinal fluid dynamic at the craniovertebral junction. We report the surgical results of eight patients, affected by syringomyelia and Chiari I malformation, age range from 18 to 62 years, treated by bony foramen magnum decompression combined with transverse microincisions of the outer layer of the dura mater. In an average postoperative follow-up period of two years neurological symptoms and signs improved in seven patients. Postoperative Magnetic Resonance showed a decrease in size of the syrinx in seven patients. These results suggest that foramen magnum decompression combined with transverse microincisions of the outer layer of the dura 1) is an effective and safe treatment option for syringomyelia and Chiari I malformation, 2) corrects the circulatory disturbances of cerebrospinal fluid dynamic, 3) leads to a decrease in size of the syrinx and to a significant improvement in neurological signs and symptoms, 4) avoids complications of intradural approaches and syringosubarachnoid shunting.

Supratentorial dorsal cistern epidermoid cyst in childhood.

Epidermoid cysts (ECs) are rare developmental lesions occurring anywhere along the central nervous system. Usually affecting adult patients, the occurrence of supratentorial dorsal cistern ECs has been reported in only 1 certain case of pediatric age. An additional pediatric case is presented. An 11-year-old boy had an 8-year history of petit mal seizures. Neurologic examination on admission was negative. T1-weighted magnetic resonance images demonstrated homogenous, hypointense, intradural, extracerebral, right frontal, precentral, parasagittal mass with relatively high signal intensity on T2-weighted images. The lesion was completely removed using a microneurosurgical technique with special care taken with regard to the adjacent nervous and vascular structures. Histologically, an EC was diagnosed. The patient had no recurrence for 2 years and seizures were significantly reduced. This case suggests the need to include ECs in the differential diagnosis of intradural supratentorial extracerebral lesions in childhood.

A preliminary study of angiogenesis in paediatric glioblastoma multiforme and its correlation with survival.

OBJECTS: There is a distinct challenge in bringing modern insights into glial tumour genesis to bear on improved outcomes for patients. Insights provided by neuroncological, neuroradiological, neuropathological, and neurosurgical investigations may offer significant advantages in the management of paediatric GBM. The goal of this study was to evaluate angiogenesis as a potential indicator of survival in paediatric glioblastoma multiforme (GBM). METHODS: Angiogenesis was evaluated in six cases of paediatric GBM with multiple criteria, including contrast enhancement on preoperative CT scan, histological vascular hyperplasia (VH) and endothelial proliferation (EP) and immunohistochemical tenascin-C (TN-C) expression. We employed a semiquantitative scale, ranging from not detected (zero) to marked (+3), for each investigational parameter. We evaluated the influence of angiogenesis on survival in each case. CONCLUSIONS: In this preliminary study, angiogenesis provided information that correlated with survival, albeit in a limited number of patients. As we gain better understanding of the molecular biology of brain tumours, with the multitude of genetic alterations and growth factors new therapeutic approaches may emerge, which may hold the promise for cure.

Reversible cerebral perfusion alterations in children with transient mutism after posterior fossa surgery.

Mutism is an infrequent and transitory complication observed following posterior fossa surgery. Patients become mute in the immediate postoperative period, with restoration of speech within a few weeks in the absence of additional neurological alterations. The anatomical structures thought to be involved are the connections between the cerebellar dentate nucleus, the ventrolateral nucleus of the contralateral thalamus and the supplementary motor area. In an attempt to understand the pathophysiology of this syndrome, and to depict the perfusion of different brain areas semiquantitatively, in two children who had become mute after posterior fossa surgery we performed a Tc99M-HM-PAO SPECT study during the period of mutism and again when normal speech had returned. In one patient, who had a left cerebellar astrocytoma, the SPECT study showed a marked reduction of cerebral perfusion in the right fronto-parietal region, and in the other, who had a medulloblastoma, a left fronto-temporo-parietal perfusion alteration was observed. When the patients regained normal speech, the follow-up SPECT studies revealed normalization of the cerebral perfusion. This study demonstrates the occurrence of a focal dysfunction of cerebral perfusion in children with cerebellar mutism after posterior fossa surgery. These observations are useful in extending our understanding of the pathophysiology of this postoperative clinical syndrome.

Temporal osteoclastoma: an exceptional lesion in infancy.

Osteoclastoma is a rare skeletal lesion, characterized by large multinucleated giant osteoclastic cells; this lesion usually affects young adults with a prevalence of 1 case/1 million population. We report the case of a 9-year-old girl with a right temporal tumescence: X-ray, CT and MRI revealed the presence of a right temporal hyperostotic ring-like area over the lambdoid suture, with irregular margins and calcareous deposits. The tumour was expanding mainly toward the endocranium involving both cranial tables and diploë, without infiltrating the brain parenchyma. The child underwent complete microsurgical removal of the lesion. Histopathological findings revealed the giant cell tumour osteoclastoma. Correct modern preoperative neuroimaging workup, coupled with microneurosurgical technique, allowed successful lesion removal with good outcome. A review of the more recent literature and of mechanisms of pathology together with neuroradiological protocol and results of treatment are discussed.

Xanthomatous posterior pyramid meningioma in a 2-year-old girl.

Meningiomas are common lesions in adults but unusual in infancy and meningiomas located in the posterior cranial fossa are even more rare. Metaplastic changes of meningothelial meningiomas can lead to the rarely observed xanthomatous form. We describe the case of a posterior pyramid xanthomatous meningioma in a 2-year-old girl. After detailed neuroradiological evaluation, the histological diagnosis was confirmed with the aid of immunohistochemical evaluation. A critical case evaluation in the light of the more recent literature, the surgical strategy and technique, and an immunohistological hypothesis are reported.

Does subarachnoid blood extravasation per se induce long-term neuropsychological and cognitive alterations?

Although recent advances in medical and management strategies have reduced the mortality and morbidity rates related to subarachnoid haemorrhage (SAH), patients who survive a SAH may remain nevertheless affected by persistent cognitive and neuropsychological disturbances. The presence of these deficits has been attributed to the neurotoxic effects of the widespread subarachnoid blood. To assess the long-term neuropsychological and cognitive outcome related to subarachnoid blood extravasation per se we evaluated 20 patients affected by an unknown origin subarachnoid haemorrhage, and having SAH characteristics generally considered predictive of a favourable outcome. Patients were enrolled after a one-year interval from the initial insult, and were selected accordingly to a pre-designed protocol. We employed a complete battery of tests, assessing general cognitive and language functions, memory and construction ability, attention and vigilance, anxiety and depression. The results were compared with normal reference values and with performances of a socio-demographically homogenous sample of control volunteers. This study did not evidence any significant long-term cognitive and neuropsychological alteration after subarachnoid blood extravasation. These results indicate that the presence of subarachnoid blood initiate a number of secondary mechanisms of pathology.

An immunohistochemical study of extracellular matrix proteins laminin, fibronectin and type IV collagen in paediatric glioblastoma multiforme.

AIMS: In the recent decades many studies have been addressed in the literature to assess specific factors related to glioblastoma multiforme (GBM) invasion. However, few studies have evaluated tumour cell's interaction with specific extracellular matrix (ECM) components, and, moreover, there is a lack of information regarding the occurrence of these phenomena in paediatric GBM. METHODS AND RESULTS: ECM proteins were evaluated in six cases of paediatric GBM assessing the immunohistochemical expression of laminin, fibronectin, and type IV collagen. We used a semiquantitative scale, ranging from not detected (zero) to marked (3). Laminin expression was minimal in three cases, moderate in one case, marked and generalised in one patient and marked and focal in the last case. Fibronectin expression was minimal in three patients; moderate immunoreactivity was documented in one case. Conversely, one case was classified as marked with generalised distribution and the remaining case as marked with focal immunostaining. Type IV collagen expression was minimal in three cases, moderate in one, marked with focal reaction in one and marked with generalised reaction in the remaining case. CONCLUSIONS: This study provides additional insights into tumour invasion features of paediatric GBM, as ECM plays a pivotal role in numerous cellular functions during normal and pathological processes. Although based on a limited number of patients, this investigation may serve as a challenge for the management of paediatric GBM, stimulating trials with larger patient numbers aimed at documenting specific factors influencing GBM prognosis.

Immunohistochemical tenascin-C expression in paediatric supratentorial glioblastoma multiforme.

Tenascin-C (TN-C) plays an important part in the growth of neoplastic tissue, leading to new vessel development. TN-C has been assessed in adult glioblastoma multiforme (GBM) and has been evaluated as anti-neoplastic therapy. No studies have focused on this tissue in paediatric GBM. Tissues were obtained from six paediatric supratentorial GBMs. Immunohistochemistry was performed using a mouse antibody directed against human TN-C, and expression in tumour vasculature was described on the basis of TN-C immunoreactivity. The expression was minimal in three, moderate in two, and intense in one specimen. TN-C was not correlated with clinical history, neurological findings, or with tumour site. Although based on a limited number of patients, this study provides additional insights into tumour growth modulation and cytogenetic profile of paediatric GBM. The detailed understanding of events responsible for GBM growth is a prerequisite for the development of therapeutic modalities leading to improved prognosis and cure.