[Managing the hospitalizations for older patients in University Hospital of Pisa]. / L'andamento dei ricoveri ordinari relativi ai pazienti anziani in un' Azienda Ospedaliera di Alta Specializzazione.

We have analyzed hospitalizations of older people (> 64) from 2002 to 2005. Patients, discharges and stay in hospital have increased, the variation has been statistically significant. We have noticed the same trend about the rehospitalizations. Patients and discharges coming from ASL 5 and zone 4 have decreased in relation with all the elderly people. The reduction of stay in hospital and the decrease of rehospitalizations have been statistically significant.

Schwannomas of the brachial plexus--diagnostic and surgical problems.

OBJECTIVE: This paper reports four cases of schwannomas of the brachial plexus operated upon with good outcome and discusses the CT and MRI findings and the best surgical treatment of these lesions. DESIGN: All patients had large schwannomas (more than 4 cm in diameter) presenting as painless masses in the supraclavear region, explored by CT and MRI. A homogeneous mass, hypo-isointense in T1- and hyperintense in T2-weighted images, with well-defined margins, is in favor of a schwannoma. The nerve of origin, external to the tumor mass, may be defined on MRI. INTERVENTION: All patients have been operated upon using microsurgical technique: enucleation of the tumor content, piecemal removal of the capsule, identification and preservation of the neural elements were the main goals of the operation in all cases. OUTCOME: Postoperatively, one patient experienced transient deficit of the deltoid muscle (two weeks). Actually, all four patients are symptom-free with no tumor recurrence, 6 months to 7 years after the operation. CONCLUSIONS: A correct preoperative diagnosis of schwannoma of the brachial plexus may be obtained by MRI, which shows a rather typical aspect; on the other hand, needle aspiration histology and open biopsies should be avoided. The microsurgical treatment with preservation of the neural structures, as for schwannomas of the cranial and spinal nerves, results in good outcome without recurrences.

Microsurgical nervous reconstruction using autografts: a two-year follow-up.

BACKGROUND: To analyze factors influencing surgical results after microsurgical reconstruction of injured nerves. METHODS: We report a series of 32 cases of microsurgical nerve reconstruction after traumatizing lesions using nervous autografts. The series comprises 8 reconstructions of radial nerve, 8 of median nerve, 6 of ulnar, and 10 of sciatic nerve. Motor and sensitive deficits have been evaluated preoperatively using a standard grading. RESULTS: A useful sensory recovery has been obtained in radial nerve, as well as in median and ulnar nerve reconstruction. Good results regarding the motor recovery have been obtained in superior limb nerve reconstruction. Sciatic nerve reconstruction showed the worse results. CONCLUSIONS: There is a big discrepance between superior limb vs inferior limb results. A more than 10 cm gap has a negative influence on the progression of regenerating axons, especially in median and ulnar nerves.

Intracranial meningeal melanocytoma: case report.

A case of meningeal melanocytoma of the left sphenoid wing is reported and the other nine cases in the literature are reviewed. Meningeal melanocytoma is a benign melanotic tumor that derives from the melanocytes of the leptomeninges and may occur anywhere in the cranial and spinal meninges. Electron microscopy well demonstrates melanin and melanosomes within the tumor cells. The immunohistochemical pattern of this tumor includes strong positivity for S-100 protein, vimentin, and antimelanoma antibody and negativity for epithelial membrane antigen, neuron-specific enolase, cytokeratin, and glial fibrillary acidic protein. Complete surgical removal is the treatment of choice, whereas radiotherapy is usually unnecessary. In spite of benign biologic behavior of meningeal melanocytoma, the prognosis remains uncertain, because of the possible local recurrences.

Cerebral hemorrhagic complication in polyarteritis nodosa. Case report and review of the literature.

Polyarteritis nodosa (PN) is frequently cause of both central and peripheral neurological disorders. However, involvement of the central nervous system is rare at the beginning of the disease. In this paper we report a case of a 38-year-old woman hospitalized in our Neurosurgical Service because of left hemiparesis in presence of cutaneous arteritis (PN). At computed tomography (CT) an intracerebral hemorrhage was found. No radiographic evidences of vasculitis of the visible arterial branches, at angiography, were seen. Cerebral arteritis should be suspected as a cause for intracranial hemorrhage in patients without hypertension or other risk factors.

Long-term survival of low-grade astrocytomas of the cerebral hemispheres.

The authors have reviewed 6 patients operated on, with histologically proven diagnosis of grade-II astrocytomas who have survived more than 10 years even with many reoperations. Young age, pre- and postoperative neurological status, aspect of the tumor mass on CT and MRI, site of the tumor in non-high functional areas and extent of surgical removal are the most important variables in predicting length of survival. In young patients without severe neurological deficits and with astrocytic tumors located in non high-functional areas, very long survivals may be obtained even with many operations, when the interval between the recurrences is at least three years.

Hydatid cyst of the lumbosacral spine with large pelvic mass.

A rare case of hydatid cyst of the lumbosacral spine, causing extensive destruction of the sacrum and a large pelvis mass, is reported; a cutaneous fistula from the pelvic cavity to the posterior lumbar region was also present. The patient was studied by computerized tomography and operated on by combined anterior and posterior approach. The sacral localization of the spinal hydatidosis and its extension into the pelvic cavity are unusual. CT and MR allow a good definition of the bone destruction and the abdominal and pelvic extensions. Radical removal of spinal hydatid cysts may be rarely accomplished, because of the extensive bone invasion, and multiple recurrences, requiring repeating operations, occur in most cases.

Cerebral gliosarcomas: correlation of computed tomographic findings, surgical aspect, pathological features, and prognosis.

The cases of 5 patients with cerebral gliosarcomas examined by computed tomography are reported and the correlations among the computed tomographic (CT) findings, the surgical and histological aspects, and the prognosis are discussed. In some patients, these tumors appear on CT scan as intracerebral lesions, with large necrotic areas and peripheral contrast enhancement; this CT aspect, similar to that of glioblastomas, corresponds to a diffusely infiltrating growth of the tumor and the prevalence of a gliomatous component. In other patients, the tumor appears on the CT scan as a hyperdense mass with well-defined margins and homogenous contrast enhancement; this CT finding, which may mimic that of a meningioma, corresponds to a rather well-demarcated surgical aspect and the prevalence of sarcomatous component. In our series, we have also noticed a more prolonged survival in a patient with a CT aspect that suggested a meningioma and prevalence of the sarcomatous component.

Symptomatic tension pneumocephalus after evacuation of chronic subdural haematoma: report of seven cases.

We present seven cases of tension pneumocephalus developing after burr hole evacuation of chronic subdural haematoma. After a careful review of the literature we discuss the physiopathology, the diagnosis and the treatment of this complication of chronic subdural haematoma surgery.

Serum and cerebrospinal fluid enzymes in subarachnoid haemorrhage.

Serum levels of creatine kinase (CK) and its isoenzyme CK-MB, lactate dehydrogenase (LDH), hydroxybutyric dehydrogenase (HBDH), glutamic oxalacetic transaminase (GOT) and glutamic pyruvic transaminase (GPT) were studied in 50 patients with subarachnoid haemorrhage. In 18 cases the cerebrospinal fluid (CSF) was also examined for total concentration of CK and CK-MB. The results were correlated with the degree of neurological deterioration, the angiographic spasm and prognosis. Concurrent increase of CK-MB, LDH and HBDH serum levels indicates a poor prognosis, whereas increase of GOT and GPT does not have clinical significance. High CK-MB levels in CSF were associated with the worst clinical evolution. However, increase of serum enzymes coincided in most cases with the appearance of the spasm. Monitoring of CK-MB, LDH and HBDH serum levels can be useful for following the evolution of the spasm and in predicting the outcome for patients with subarachnoid haemorrhage.

Tumors of the neuron series presenting as cysts with mural nodules.

Two cases of tumors of the neuron series presenting as cysts with mural tumor nodules are described. This radiographic and surgical aspect may be observed in astrocytomas, meningiomas or ependymomas, whereas it is more rare for neuroblastomas and ganglioneuromas. There are not CT features which allow to differentiate cystic tumors of the neuron series from the other cystic tumors. The finding of cyst with enhancing mural tumor nodule and unenhanced wall is more favorable from a surgical point of view; the complete removal of the nodule with preservation of the reactive cyst wall results in the cure of patients with ganglioneuroma and ganglioglioma and in good long-term survival in those with cerebral neuroblastomas.

Cerebrospinal rhinorrhea in a patient with a posterior cranial fossa tumor.

A rare case of a meningioma of the posterior margin of the petrous temporal bone associated with cerebrospinal fluid rhinorrhea is presented. After a careful review of the literature, the possible pathogenesis of the fistulous tract is discussed.