Metastatic melanoma of the septum pellucidum mimicking a colloidal cyst of the third ventricle. A novel case.

We report the first case in the literature of a solitary metastatic melanoma of the septum pellucidum, mimicking a colloidal cyst of the third ventricle. In a 22-year-old man clinical and radiological examination revealed regional left inguinal, bilateral suprarenal and left broncho-pulmonary parailar nodular masses. Immunohistochemical staining on bronchoscopic, lymph nodes and neuroendoscopic biopsy confirmed the diagnosis of metastatic melanoma, in spite of extensive workup failed to detect a primary cutaneous or systemic tumor site. The clinical course was progressive and lethal. The neuroendoscopic approach to the septal lesion, performed before stereotactic radiosurgery, was extremely useful to obtain biopsy of the tumor and, by means of septum pellucidotomy, to treat biventricular hydrocephalus by monoventriculo-peritoneal drainage, in the same seat. Even if metastases can occur anywhere within the central nervous system, the novelty in this report is their intracranial localization, as they have been detected in the septum pellucidum, a case never reported previously.

Cooperative study by the Italian neuroendoscopy group on the treatment of 61 colloid cysts.

OBJECTS: Microsurgical resection, stereotactic aspiration and VP shunt have for years been the choice options for the treatment of colloid cysts of the third ventricle. Recently, endoscopic approaches have aroused increasing interest and gained acceptance. Although safer, this minimally invasive approach is considered less efficacious than microsurgery. Relatively long-term results are now available and some conclusions might be inferred on the usefulness of this procedure. MATERIALS AND METHODS: Between 1994 and 2005, 61 patients harbouring a colloid cyst of the third ventricle were treated with neuroendoscopic technique in 11 Italian neurosurgical centres. Cyst diameters ranged from 6 to 32 mm. A flexible endoscope was used in 34 cases, a rigid one in 21, both instruments in six. The technique consisted in cyst fenestrations, colloid aspiration, coagulation of the internal cyst wall and, occasionally, capsule excision. Mean postoperative hospital stay was 6.7 days. Early postoperative neuroimaging revealed a cyst residue in 36 cases (mean diameter 4.3 mm). There were two complications (3.2%). Follow-up varied between 1 and 132 months (mean 32 months, more than 5 years in 17 patients). There were seven asymptomatic recurrences, three of them evolving from a previous residue. CONCLUSION: The endoscopic approach to the treatment of colloid cysts is safe, effective and well accepted by patients. Although asymptomatic, recurrences (11.4%) cast a persisting shadow on the long-term results, and, therefore, the controversy with the traditional microsurgical treatment remains open.

Neuroendoscopic management of hydrocephalus secondary to midline and pineal lesions.

AIM: In patients with space-occupying lesions of the pineal region, increased intracranial pressure is due to direct compression of the sylvian aqueduct. Based on results of the recent literature, neuroendoscopic management of obstructive hydrocephalus, secondary to tumors of the pineal gland, has gained a preeminent role respect to shunting procedures. METHODS: In 14 select cases, hydrocephalus was secondary to midline and pineal lesions. The patient's age ranged from 1 to 56 years (mean 47.3+/-12.5), with a follow-up ranged from 3 months to 5 years after discharge. In 9 cases the endoscopic procedure represented the only surgical treatment. In 5 cases, microsurgical removal of the lesions and/or ventriculo-peritoneal shunts placement were performed, as additional treatment, while adjuvant radiotherapy was utilized in 4 cases; high dose chemotherapy followed by bone marrow transplantation was performed in 3 cases. RESULTS: In our series, obstructive hydrocephalus secondary to midline and pineal lesions, was successful treated by neuroendoscopic approach alone in 9 cases, with an unremarkable course and good outcome, except in 1 case. CONCLUSIONS: Neuroendoscopic approach affords a minimally invasive way to obtain 4 objectives by one-step surgical approach, such as resolution of obstructive hydrocephalus by endoscopic third ventriculostomy (ETV), cerebrospinal fluid sample to detect tumor markers and to perform cytological analysis, biopsy specimens and tissue diagnosis, associated to absence of shunt-related complications. Therefore, in experienced hands, ETV should be the treatment of first choice, in cases of hydrocephalus secondary to lesions of the pineal gland.

Microsurgical approach to lumbar synovial cysts. Technical notes.

Intraspinal extradural synovial cysts are quite common in the lumbar spine. With respect to clinical presentation and surgical treatment, juxta-facet cysts (ganglion and synovial cysts) share identical characteristics and results. Nowadays, current treatment strategies of intraspinal juxta-facet cysts continue to inspire controversy regarding appropriate surgical approaches, and include many technical options. The purpose of this report is to illustrate the advantage of minimally invasive approaches in 3 cases of lumbar synovial cysts. We performed a small flavectomy in the 1st case, a transarticular partial facectomy, followed by etherologous bone graft fusion in the 2nd case, and a flavectomy and partial facectomy in the 3rd case. In our cases, a microsurgical approach to lumbar synovial cysts yielded to complete excision of the lesions and excellent pain relief, with early mobilization and hospital discharge of the patients. In our opinion, minimally invasive approaches and microsurgical excision of lumbar juxta-facet cysts are advantageous over conventional lumbar laminectomy because they reduce later development of segmental instability at the operative level, and therefore a less invasive strategy for intraspinal synovial cysts removal should be recommended.

Clinical evaluation of thallium-201 single photon emission computed tomography in equivocal neuroradiological supratentorial lesions.

BACKGROUND: We performed cerebral 201Tl SPECT study on 38 presurgical patients with equivocal neuroradiological supratentorial lesions to detect differences in 201Tl uptake index between tumor/non-tumor and high-grade/low-grade samples. METHODS: Authors identified 38 cases with presurgical equivocal neuroradiological supratentorial mass lesions. All cases were submitted to histological confirmation of the lesion by biopsy, sub-total or gross-total removal of the tumor. Between 23 patients suffering from gliomas, 13 were histologically classified as being of low-grade malignant tumors and 10 were classified as being of high-grade malignancy. Fifteen non-tumor histopathological specimens were also detected. The 201Tl index was defined as the ratio of average counts per pixel in the lesion to these in the opposite region. Analysis of variance (ANOVA) and unpaired Student's OtO-test statistical methods were applied. Actuarial survival time from the date of diagnosis was calculated using the Kaplan-Meier method. Follow-up evaluation and survival time were obtained through referring physicians. Cerebral CT or MR images were obtained every three months after discharged, or more often if indicated. RESULTS: Results showed that the 201Tl uptake index ranged from 1.10 to 3.00 in the tumors lesions (mean+/-SD: 1.68+/-0.51) and from 0.80 to 1.40 in the non-tumors lesions (mean+/-SD: 1.07+/-0.17), (alpha < 0.0006 percent;). The 201Tl uptake index ranged from 1.10 to 2.30 in 13 patients with low-grade tumors (mean+/-SD: 1.45+/-0.34) and from 1.30 to 3.00 in 10 patients with high-grade tumors (mean+/-SD: 1.98+/-0.55), (alpha < 0.5 percent;). CONCLUSIONS: Our results demonstrate the clinical utility of 201Tl brain SPECT to differentiate equivocal neuroradiological supratentorial lesions and to correlate relationship between preoperative diagnosis, histological tumor grade and prognosis.

Neuroendoscopic approach to complex hydrocephalus. Personal experience and preliminary report.

BACKGROUND: Neuroendoscopic premammilary third-ventriculocisternostomy in non-communicating hydrocephalus represents, to date, the less invasive and effective procedure, whereas the neuroendoscopic approach to complex-hydrocephalus is limited to several small anecdotal series. METHODS: Among 57 pediatric patients affected by obstructive hydrocephalus, ranging in age from prenatal diagnosis to 3 years (mean 1.2 year+/-11 months) and recruited over a 2-year period, we identified 11 cases with presurgical neuroradiological complex-hydrocephalus, at admission to our Department. In two cases Magnetic Resonance imaging showed bilateral atresic foramen of Monro and corpus callosum agenesya. In these cases an extracranial cerebrospinal fluid shunt device was implanted. The authors report retrospectively, the personal experience on a series of 9 pediatric patients with complex-hydrocephalus, such as multishunted (4 cases), multiloculated hydrocephalus (3 cases), and multiple ventricular cysts plus hydrocephalus (2 cases), in which a neuroendoscopic approach was performed. At admission, symptoms and signs of an increased intracranial pressure were presents in all cases. Follow-up ranged from 3 months to 2 years. In 8 cases third ventriculostomy was successfully performed whereas, in one case, the endoscopic procedure, in a patient younger than 1 month, was aborted and an extracranial cerebrospinal fluid device was implanted. RESULTS: In the postoperative period and during follow-up, a symptomatic relief and clinical improvement of preoperative signs and symptoms of increased intracranial pressure was seen in all cases. Nevertheless, in two patients psychomotor retardation worsened, respectively 6 and 7 months after the endoscopic procedure and then, an additional extracranial cerebrospinal fluid shunt device was implanted. CONCLUSIONS: In our selected cases of complex-hydrocephalus, the neuroendoscopic approach did not fail to determine clinical improvement after the first procedure, in spite of increased technical difficulties and minimum decreases of ventricular volume in postoperative images.

Unusual clincal presentation of cerebral-isolated sarcoidosis. Case report and review of the literature.

The authors report the case of a 31-year-old man, who presented an hemorrhagic onset of a cerebral-isolated sarcoidosis, to date never described in the literature. Unusual clinical manifestation, neuroradiological study and direct histological confirmation are presented. Moreover, Gallium-67 Single Photon Emission Computed Tomography (Ga-67 SPECT) contribution is indicated to complete the evaluation of patients with cerebral inflammatory lesions, such as neurosarcoidosis, and in cases of equivocal neuroradiological imaging, to evaluate uptake activity of the inflammatory tissue. The patient did well and reported no further progression of his disease during 7 months of follow-up.

High-dose heparin plus warfarin administration in non-traumatic dural sinuses thrombosis. A clinical and neuroradiological study.

BACKGROUND: The management of intracranial dural sinuses thrombosis is still controversial and uncertain. The authors report the cases of 7 patients with non-traumatic thrombosis of the dural sinuses and describe the most important radiographic findings, the indication, effectiveness of antithrombotic therapy, and outcome. METHODS: A retrospective review was conducted of 7 cases of dural sinus thrombosis admitted, between 1994 and 1996, to our division. All patients underwent full anticoagulation therapy. Heparin was administered, using a dose of 25,000 units/day for two weeks; warfarin was given using a dose of 5 mg twice daily. Treatment course was followed by maintenance treatment with a single administration of 5 mg/day of warfarin. All patients were submitted to close titration and coagulation profile monitoring. RESULTS: In 4 cases Magnetic Resonance Imaging-Angiography (Angio-MRI) was performed for following up the recanalization of the sinuses, resulting a persistent no patency of the dural sinuses. Three patients underwent contrast-enhanced CT scan, demonstrated an "empty delta sign" in the sagittal sinus, confirming no recanalization. Nevertheless, six patients had have a good quality recovery, and one patient a moderate disability. DISCUSSION: Cerebral venous sinus thrombosis is an uncommon cause of cerebral infarction, and may be mistaken, unless specifically sought. The natural history of the disease is highly variable, with a mortality rates range from 10% to 20%. At present, in our opinion, the venous phase of Angio-MRI is the definitive examination, and a gold standard for diagnosis of dural sinus thrombosis. In our cases, antithrombotic therapy has been found to be a safe and effective treatment, despite contrast-CT scans and Angio-MRI showed no recanalization of the sinuses, in all patients.

Combined systemic beta-interferon and thymostimulin administration for metastatic brain tumors. A brief report.

Interferon-beta (IFN-B) plus thymostimulin (Th) were administered for eight weeks, intravenously and by intramuscular route to eight patients with metastatic brain tumors. No patient had a complete response. One had a stable disease and seven a progressive disease during that time. The mechanisms of the action of IFN-B and Th, and the possible therapeutic value are discussed.

Cerebellopontine angle lipoma. Case report.

A cerebellopontine angle (CPA) lipoma in a 17 year-old woman is reported. The patient was admitted for evaluation of episodic vertigo, preauricolar pain and progressive hearing loss on the right ear. Auditory brain stem evoked potentials revealed an interwave latency increase on the right ear. Computerized Tomography and Magnetic Resonance Imaging showed a low density lesion and high intensity signal, respectively, in the right CPA. Reports of surgically treated lipomas of the CPA are extremely rare. Our patient underwent a right lateral suboccipital craniotomy and a subtotal resection of the lesion. Histological examination revealed a richely vascularized lipomatous tissue traversed by nerve fibers. The surgical indication for such rare lesion is discussed.

A simple procedure for management of spontaneous cerebrospinal fluid rhinorrhea by injection of fibrin sealant. Technical note.

A simple and safe procedure is proposed to manage cases of "empty sella" complicated by rhinorrhea. It is performed under fluoroscopic control only by introducing a needle in the sphenoid sinus via a transnasal route and by injecting fibrin glue into the sinusal cavity. This procedure requires a short hospitalization and it allows to avoid the compliances of other techniques.

Late onset of a large cavernous aneurysm after spontaneous disappearance of cerebral arteriovenous malformation. Case report.

A large intracavernous aneurysm (Icav. An) revealed eighteen years after the spontaneous disappearance of a cerebral arteriovenous malformation (AVM) is reported. The main hypotheses to explain the pathogenesis of the association of such malformations and the potential for spontaneous regression of AVMs are reviewed on the light of relevant literature. The multiple congenital vascular anomalies hypothesis is stressed to explain the late onset of Icav. An in this patient.

Failure of praziquantel treatment in cerebral cysticercosis. A case report.

A case of cerebral cysticercosis unsuccessfully treated by Praziquantel is reported. Some diagnostic aspects stressing the role of epidemiologic criteria and neuroradiological evaluation as well as the limits of treatment are discussed.