Intradural abscess: A challenging diagnosis. Case series and review of the literature.

Spinal intradural abscesses are extremely rare. To our knowledge, only a few cases have been described in the literature. We report 2 cases of spinal intradural abscesses in patients presenting to our institution with different symptomatology. Both cases involved the lumbar spine, with different etiologies: Case 1 was presumptively related to spondylitis phenomena, with surgery confirming the intradural localization of the abscess; case 2 was of probable iatrogenic nature (secondary to lumbar drain positioning). The aim of this report is to briefly discuss the clinical significance and pathogenesis of these cases.

Epidural bleeding secondary to a synovial cyst rupture: a case report and review of literature.

Hemorrhage into a juxtafacet cyst is rare and cyst rupture with hemorrhagic extension into the epidural space is even less commonly seen. We describe the case of a patient with a hemorrhagic synovial cyst with rupture associated to abundant bleeding in the epidural space. A 61-year-old man had a 5-month history of worsening low back pain radiating into the right leg with associated weakness and numbness. A magnetic resonance imaging scan showed the presence of a mild anterior spondylolisthesis of L5 on S1 with increased synovial fluid into both facet joints. A suspected synovial cyst of the right facet joint at level L5-S1, with signal characteristics consistent with hemorrhage was seen. Caudally, epidural blood was evident from S1 to S2 that involved spinal canal and right S1 and S2 foramens. These findings were confirmed at surgery.

Referencing for anterior atlantoaxial trans-articular osteosynthesis: a radiological study and proposal of a decisional algorithm.

PURPOSE: Anterior trans-articular C1-C2 screw placement can be considered as a surgical alternative in different conditions affecting the atlantoaxial region. While its rigidity is similar to posterior Magerl and Harms techniques, it also provides some surgical advantages. However, the literature lacks papers exhaustively describing indication criteria, surgical steps, and pitfalls. METHODS: This is a radiological study on 100 healthy subjects. Thin-layer CT scans of the craniovertebral junction were retrieved from the institutional database. The coronal inclination of the C1-C2 joint rim and the depth of the entry point of the screw with respect to the anterior profile of C2 were measured. The antero-posterior and the medio-lateral surgical corridors for the screw placement, and the wideness of the target area on the upper surface of C1 were also measured. RESULTS: The multivariate analysis showed that the coronal inclination of the C1-C2 articular joint rim strongly influences the surface extension of the C1 target area; the depth of the entry point and the C1-C2 articular rim inclination seem to be independent factors in influencing both the medio-lateral and the antero-posterior surgical corridors wideness. A decisional algorithm on whether to perform an anterior or posterior approach to the atlantoaxial region was also proposed. CONCLUSIONS: We can conclude that, as much as the C1-C2 articular rim is tending to the horizontal line, and as deeper is the entry point of the screw on the anterior profile of C2, as easier the anterior C1-C2 trans-articular screw placement will result.

5-Aminolevulinic Acid False-Positive Rates in Newly Diagnosed and Recurrent Glioblastoma: Do Pseudoprogression and Radionecrosis Play a Role? A Meta-Analysis.

BACKGROUND: Several studies have confirmed the impact of 5-aminolevulinic acid (5-ALA) on the extent of resection in newly diagnosed glioblastoma (GBM). However, there are controversies on the 5-ALA fluorescence status in recurrent GBM surgery, with specific reference to pseudoprogression or radionecrosis; therefore, the safety and accuracy of surgical planning in 5-ALA-assisted procedures in the recurrent context are still unclear. MATERIALS AND METHODS: This is a systematic review and meta-analysis of comparative studies on the use of 5-ALA in newly diagnosed and recurrent GBM, consistently conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Data on fluorescence status and correlation between fluorescence and histological findings were collected. We performed a meta-analysis of proportions to estimate the pooled rates of each outcome. RESULTS: Three online medical databases (PubMed, Scopus, Cochrane Library) were screened, 448 articles were evaluated, and 3 papers were finally included for data analysis. Fluorescence rate was not different between newly diagnosed and recurrent GBM [p = 0.45; odds ratio (OR): 1.23; 95% CI: 0.72-2.09; I2 = 0%], while the rate of 5-ALA fluorescence-positive areas not associated with histological findings of GBM cells was higher in recurrent GBM (p = 0.04; OR: 0.24; 95% CI: 0.06-0.91; I2 = 19%). Furthermore, there were no cases of radionecrosis in false-positive samples, while inflammation and signs of pseudoprogression were found in 81.4% of the cases. DISCUSSION AND CONCLUSIONS: Therefore, a robust awareness of 5-ALA potentialities and pitfalls in recurrent GBM surgery should be considered for a cognizant surgical strategy. Further clinical trials could confirm the results of the present meta-analysis.

Relapsing Long-Lasting Garcin Syndrome Revealing Skull Base Diffuse B Cell Lymphoma: The Diagnosis through the "Hartel's Route".

The Garcin syndrome is a rare condition characterized by multiple unilateral cranial nerve palsy, without neither long-tract involvement nor intracranial hypertension. Non-Hodgkin lymphoma is a systemic malignant disease that localizes in a minority of cases in the central nervous system. We report a case of Garcin syndrome that revealed a diffuse large B cell lymphoma (DLBCL) located in the skull base and in the right kidney. We reached the diagnosis by mean of a nonstandard, mini-invasive, transforamen ovale biopsy of the intracranial lesion (Hartel's route). The nature of the renal mass was determined ex juvantibus. The patient responded to the polichemotherapy with a complete regression of the intracranial lesion and of the renal mass evaluated by computed tomography and total body positron emission tomography scans. We, therefore, confirmed the DLBCL location in the right kidney. Over 4 years of follow-up, the patient has showed a complete remission of the disease. In this report, we emphasize the importance of biopsy in case of Garcin syndrome.

Risk of Postoperative Performance Status Worsening after Resection of Lesions Involving the Motor Pathway: A Multinomial Logistic Regression Model.

BACKGROUND AND STUDY OBJECTIVE: In surgery for gliomas and brain metastases, preservation of neurologic functions is essential to ensure a good quality of life and the eligibility for adjuvant therapies. This article assesses which factors could influence the functional outcome in patients with lesions located in the motor pathways. MATERIALS AND METHODS: A total of 92 patients with gliomas and metastases involving the motor pathways were studied for concerns regarding quality of life (Karnofsky performance status [KPS] and modified Rankin scale [mRS]) before and after surgical treatment supported by intraoperative neuromonitoring. Patient-related, surgery-related, and lesion-related data were recorded to identify the relationships with postoperative performance status. The relationship between lesions and the corticospinal tract were investigated with preoperative magnetic resonance imaging sequences and tractographic reconstructions. RESULTS: Means of preoperative mRS and KPS were 1.91 ± 1.34 and 80.8 ± 20, and at 30 days postoperatively they were 1.93 ± 1.63 and 79.8 ± 24.4, respectively. The better preoperative performance status was a predictor of better outcome in terms of quality of life. Gender showed a statistical association with ∆KPS (p = 0.033) and ∆mRS (p = 0.031). A recurrent lesion was a predictor of poor functional outcome (p= 0.045 for KPS at 30 days).A left-sided lesion showed a statistical association with a lesser improvement with respect to right sided. Complications were associated with a lesser functional improvement (∆mRS, ∆KPS, and clinical improvement: p = 0.001, p = 0.006, and p = 0.003, respectively). Hemorrhagic complications were associated with the worst functional prognosis. CONCLUSIONS: In our experience, factors associated with worse functional prognosis and quality of life were a poor preoperative performance status, female gender, operating on a recurrent lesion, involvement of the left corticospinal tract, and surgical or medical postoperative complications.

Motor Outcomes After Surgical Resection of Lesions Involving the Motor Pathway: A Prognostic Evaluation Scale.

BACKGROUND: Preservation of function is essential in surgical resection of lesions involving the motor pathways. The aim of this work is to evaluate the effect of anatomic features of lesions located in the motor pathway on neurologic and functional outcome. We propose an evaluation score to assess the risk of postoperative worsening. METHODS: A total of 92 patients suffering from lesions involving the motor pathways have been studied for what concerns motor functions (muscular strength scale [MRC]) after surgical treatment. Patient-related, surgery-related, and lesion-related data were recorded to identify relations with motor outcomes. Cortical surfacing of the lesion and amount of millimeters of interface between the lesion and corticospinal tract have been investigated with preoperative magnetic resonance imaging sequences and tractographic reconstructions. RESULTS: Means of the MRC Scale preoperative and 7 days postoperative were 3.6 ± 2.23 and 3.8 ± 2.28 for the upper limbs, and 4.1 ± 2.31 and 4.4 ± 2.33 for the lower limbs, respectively. Patients that were stable or improved at 7 days from surgery were 82.6%. The anatomic features investigated have been summed up in a single score (envelopment/surfacing [ES]). In cases of ES classes V and VI, a total cumulative predicted worsening rate was 24.2% and 14.8%, respectively. The risk of worsening was 1.682 times greater for the higher ES classes (IV-VI). CONCLUSIONS: The anatomic features of lesions are crucial in the prediction of motor outcome. The new proposed score (ES score) is useful to stratify motor function prognosis.

Primary Lymphomas of the Skull Base from a Neurosurgical Perspective: Review of the Literature and Personal Experience.

Primary lymphomas of the skull base are exceedingly rare and thus not commonly dealt with in everyday clinical practice. Primary diffuse large B cell lymphoma is the most commonly found (30-40% of primary non-Hodgkin lymphomas of the bone). This article reports a case of primary lymphoma of the skull base and reviews all the relevant literature in the PubMed, National Institutes of Health Library, and Google Scholar databases to outline the clinical, diagnostic, and surgical traits of this yet widely unexplored pathology. The incidence of cases peaks between 60 and 70 years of age; those affected tend to be mostly male. The clinical presentation of this pathology is usually abrupt with headache and acute deficit of cranial nerves that improves dramatically with intravenous corticosteroid therapy. The abducens nerve is most commonly involved. Imaging can be unclear because corticosteroid medications can significantly alter magnetic resonance imaging findings, at least in the early stages of the disease, similarly to what happens for primary brain lymphomas ("the ghost tumor"). Cavernous sinus, parasellar region, upper clivus, and Meckel cave are usually found to be already affected by the time a diagnosis can be made. The intracavernous internal carotid artery is usually encased by the lesion rather than displaced. Because of the anatomical pattern of primary lymphomas of the skull base and their well-known chemosensitivity, surgery is usually only used for diagnosis. Surgical approaches for primary lymphoma of the skull base include transcranial and transnasal-transsphenoidal endoscopy and microsurgery as well as other minimally invasive techniques. Due to the rarity of this neoplasm, there are no definitive data regarding the overall survival rate among patients.

Brain abscess after percutaneous therapy for trigeminal neuralgia.

We report a case of brain abscess following the percutaneous treatment for trigeminal neuralgia. This procedure envisages the access with a needle into the middle cranial fossa through the oral cavity. Thus, in this case, the bacterial infection can be more likely ascribed to the possible contamination of the needle inside the oral cavity rather than to other frequent and more controllable causes of infection like an imperfect sterilization of surgical instruments or an inadequate antiseptic preparation of both operator's hands and patient's skin. The subsequent brain abscess was treated with antibiotic therapy (Vancomycin 2 gr a day and Meropenem 8 g a day for 22 days before the surgical procedure and 30 days after, until complete normalization of laboratory parameters, clinical parameters, and neurological symptoms) and surgical drainage, although the culture of the abscess capsule and the purulent material resulted sterile. In conclusion, the percutaneous therapy for trigeminal neuralgia can be objectively related to risks, even if performed by expert hands. Therefore, it is important that the patient should be advised regarding risks/benefits and/or septic complications of such procedures, even if they occur very seldom. An association of surgery and antibiotic therapy results as effective treatment for this pathologic condition.

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.

Spinal en plaque meningiomas: a contemporary experience.

OBJECTIVE: Spinal en plaque meningiomas are rare and challenging lesions because of their tendency to induce spinal arachnoiditis. The surgical treatment of this type of meningioma is more complex than that of classic meningioma. METHODS: We report seven cases of spinal en plaque meningiomas and review all the cases reported in the literature accessible to us by a MEDLINE search. RESULTS: All patients underwent microsurgery. Complete tumor removal was achieved in three patients. Subtotal removal was performed in four patients. A permanent neurological worsening was observed in one patient. CONCLUSION: Spinal meningiomas en plaque bear a prognosis poorer than that of classic meningiomas with regard to the possibility of a definitive surgical cure because recurrence or postoperative arachnoiditis occurs frequently. Total surgical removal should be attempted only when a clear plane of cleavage between tumor and arachnoid exists.

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.

Cyst of the medullary conus: malformative persistence of terminal ventricle or compressive dilatation?

The ventriculus terminalis is a cavity situated at the level of the conus medullaris, enclosed by ependymal tissue and normally present as a virtual cavity or as a mere ependymal residue. In rare cases, and almost exclusively in pediatric age, the ventriculus terminalis may be visualized by radiological investigations, either by sonography or MRI, and represents a transient finding in children under 5 years of age. In pathological conditions, a cyst of the conus medullaris is probably the result of a persistent ventriculus terminalis and is usually described in children in association with a tethered cord; in a very limited number of cases, it has been described in adults whose clinical symptoms consist of neurological and/or sphincter disturbances not associated with other pathologies. The authors describe the case of a 42-year-old female with a cyst of the conus whose only symptom was imperious minction; she had been suffering from these urinary disorders for many years. The patient was not operated on because the clinical situation remained stable, without modifications of the MRI in follow-up over a 6-year period. The authors therefore suggest that in adult patients, a cyst of the conus medullaris is probably an expression of malformative persistence of the fifth ventricle and does not necessarily have a progressive evolution.