Sphenoidal pneumosinus dilatans due to anterior skull base meningiomas - CT and MRI aspects: Report of two new cases and literature review.

We report on two patients disclosing a pneumosinus dilatans (PSD) and an anterior skull base meningioma. Our findings, together with those from the pertinent literature, support the thought that this infrequent anomaly of paranasal sinuses is a useful clue to suspect a concomitant meningioma. Moreover, hypotheses concerning the pathophysiology of PSD are discussed.

Extracranial internal carotid artery: anatomical variations in asymptomatic patients.

The anatomical variations of internal carotid artery (ICA) are mostly asymptomatic, thus being disregarded and only incidentally diagnosed, with very few symptomatic patients. The awareness of these anomalies is crucial to solve the differential with other neck lesions, preventing accidental injuries during neck surgery. Therefore, the aim of our study is to estimate the prevalence of ICA anomalies, using magnetic resonance angiography (MRA) and computed tomography angiography (CTA). 253 patients underwent head and neck MRA and CTA examinations, with multiplanar and volumetric reformations. For each set of images, the following items were investigated: origin, development, course, persistence of embryonic vessels and anomalous origin of collateral branches. In our series, ICA arose from the bifurcation of the common carotid artery at the level of: C4 in 303 hemi-necks (59.9 %); C3 in 98 hemi-necks (19.3 %); C5 in 57 hemi-necks (11.3 %); C2 in 48 hemi-necks (9.5 %). ICA kinking and/or coiling was found in 105 hemi-necks, and location variation of ICA (reversed-type) in two hemi-necks. In just one case the origin of the ascending pharyngeal artery was from ICA (0.2 %), while an anomalous persistence of the proatlantal artery was noticed in three cases (0.6 %). CTA and MRA showed similar accuracy in detecting ICA anomalies.

Long-term effects of intrathecal baclofen in multiple sclerosis.

OBJECTIVES: Spasticity is associated with various neurological conditions. In this study the authors analyzed the long term effects of intrathecal baclofen therapy in multiple sclerosis and evalued the benefits of the treatment on spasticity, disability, pain, spasm frequency and rated the incidence of side effects. PATIENTS AND METHODS: A records of 123 patients, with a severe, progressive and refractory to medical therapy spasticity from different causes, underwent baclofen pump placement, after a bolus test, from 2000 to 2012,under Department of Neurosurgery at the Second University of Naples/Italy. We present our experience in treating 28 subjects that was affected by multiple sclerosis. For all patients we reviewed long-term response to therapy, surgical technique, surgery- and pump-related complications. Every patients were evaluated by means of the Modified Ashworth Scale (MAS), Penn Spasm Frequency Scale (SFS), Visual analogue Scale For Pain (VAS), Barthel index (BI) and Self Rating Depression Scale (SDS) RESULTS: During follow up the mean MAS score for upper and lower extremities decrease significantly. Also SFS's decrease was statistically significant. This resulted in a dramatic improvement of BI. Furthermore, we observed a marked improvement in VAS and SDS. CONCLUSIONS: Intrathecal baclofen provides effective long-term treatment of spasticity multiple sclerosis related. ITB therapy increases the quality of lifestyle and functional independence in appropriately selected cases.

Cavernous malformations isolated from cranial nerves: Unexpected diagnosis?

OBJECTIVES: Cranial nerves (CN) cavernous malformations (CMs) are lesions that are isolated from the CNs. The authors present three cases of CN CMs, for which MR was demonstrated to be critical for management, and surgical resection produced good outcomes for the patients. Surgical removal is the recommended course of action to restore or preserve neurological function and to eliminate the risk of future haemorrhage. However, the anatomical location and the complexity of nearby neural structures can make these lesions difficult to access and remove. In this study, the authors review the literature of reported cases of CN CMs to analyse the clinical and radiographic presentations, surgical approaches and neurological outcomes. PATIENTS AND METHODS: A MEDLINE/Pub Med search was performed and revealed 86 cases of CN CMs. The authors report three additional cases in this study for a total of 89 cases. CMs affecting the optic nerve (CN II), oculomotor nerve (CN III), facial/vestibule-cochlear nerves (CN VII, CN VIII) have been described. The records of three patients were reviewed with respect to the lesion locations, symptoms, surgical approaches and therapeutic considerations. Clinical and radiological follow-up results are reported. Three patients (2 females, 1 male; age range 21-37 year) presented with three CN lesions. One lesion involved CN III, one lesion involved CN VII-CN VIII, and one involved CN II. The patient with the CN III lesion had a one-month history of mild right ptosis and diplopia. The patient with the CN VII-CN VIII lesion exhibited acute hearing loss and on the left and left facial paresis. The patient with the opticchiasmatic lesion presented with acute visual deterioration on the right and a left temporal field deficit in the left eye. Pterional and orbitozygomatic craniotomies were performed for the CN III lesion and the CN II lesion, and retrosigmoid craniotomy was performed for the cerebello-pontine angle lesion. RESULTS: All patients experienced symptom improvement after surgery. On MR follow-up, recurrence was excluded in all patients. CONCLUSIONS: CN CMs present with specific symptoms and require complex surgical techniques for resection. These lesions are frequently symptomatic, because of the complexity of the origin tissue. Symptomatic CN CMs should be resected microsurgically and completely when possible to prevent further losses of nerve function, improve function, avoid recurrence, and to eliminate the risk of future haemorrhages. The authors discuss the therapeutic options and the radiological features of these infrequent localisation of CMs. Specifically, the authors focus on the role of magnetic resonance imaging in the identification of these rare lesions.

Transient ischaemic attack: an exceptional presenting syndrome of a superior sagittal sinus thrombosis.

We report a case of a transient ischaemic attack (TIA) as an exceptionally rare form of cerebral vein thrombosis. A 41-year-old man presented with a headache and five episodes of a transient left hemiparesis lasting approximately 10-15 min over the course of 2 weeks. Arterial origins of the disease were ruled out by detailed investigations. However, MR venography revealed a superior sagittal sinus thrombosis with numerous prominent collateral venous channels. No parenchymal lesion was seen. After medical therapy, no further transient neurological deficit occurred. Follow-up MR venography showed sinus recanalisation.

Solitary lumbar osteochondroma presenting with spinal cord compression.

We report a case of a middle-aged woman with a solitary osteochondroma of the L2 right lamina with intraspinal extension and spinal cord compression. The case is unusual in terms of localisation and age at clinical presentation. In fact, spinal osteochondromas as solitary lesions-especially when affecting the lumbar segment-are rare tumours of a maturing adolescent skeleton, infrequently affecting the neurological structures, because most of the lesions grow out of the spinal canal. Although unusual, they should be considered in the differential diagnosis. Prompt and accurate radiological investigations are important in planning appropriate management. Surgical total excision is the best treatment modality to remove spinal cord and/or nerve root compression, and to avoid the risk of recurrence or malignant transformation.

Giant frontal intraparenchymal schwannoma: unexpected diagnosis.

We report the case of an intraparenchymal frontal schwannoma, surgically resected in a middle-aged, otherwise healthy woman. Magnetic resonance imaging was ineffective for the definitive diagnosis and was instead afforded by histology. This case is unique because the rare lesion presented as a giant mass; to the best of our knowledge, such a finding has not been previously reported.

Isolated transient blindness and isolated oculomotor nerve palsy secondary to single mesencephalic metastases: report of 2 cases.

PURPOSE: Metastatic lesions of midbrain are quite rare, and only unusually they produce isolated cranial nerve palsy. METHODS: We report two cases of 2nd and 3rd cranial nerves impairment, produced by solitary midbrain metastases. RESULTS: In both patients Magnetic Resonance (MR) allowed a correct diagnosis, subsequently confirmed by histology. CONCLUSIONS: The metastatic involvement of midbrain would be included in the differential diagnosis of neuro-ophthalmic conditions to avoid the risk of misdiagnosis and consequently delay in management of this special population. MR is crucial for early detection of this infrequent pathology.

Olfactory delusional syndrome and intracranial meningioma.

We report the case of a 37-year-old female in which the removal of a suprasellar neoplasm was accompanied by the disappearance of a longstanding olfactory delusion syndrome. In primary care the patient condition was exclusively thought to be psychic in origin, neglecting the possible, not infrequent, organic contribution. The delayed diagnosis produced neurological impairment, only partially recovered after surgical therapy. This case might help to improve the patient management via multi-specialist cooperation and to broaden the knowledge about somatic mechanisms of psychic disturbances, are not often taken into account.

Post-traumatic peripheral facial nerve palsy: surgical and neuroradiological consideration in five cases of delayed onset.

The facial nerve is frequently injured after head trauma with or without temporal bone fractures. Computed tomography (CT) is the best procedure for detecting the fracture line at the level of the facial nerve canal and for assessing any associated lesions within the temporal bone. Magnetic resonance (MR) is required if there is a facial nerve paralysis, unexplained by CT findings. We present five cases of delayed post-traumatic facial nerve palsy without evidence of temporal bone fractures on CT, thus studied on MR. MR was essential for diagnosing the nerve impairment. Neuroradiological findings, clinical presentation, and electrodiagnostic tests influenced the management of the patients.

Solitary olfactory groove schwannoma.

Intracranial schwannomas that do not involve major cranial nerves in the posterior fossa are uncommon, especially if they are not associated with neurofibromatosis type II (NF-2). Subfrontal olfactory groove schwannomas are extremely rare. We report a cystic schwannoma arising from the olfactory groove in a 38-year-old Caucasian male who presented with headache, vomiting and visual impairment. We briefly review the pertinent literature, stress the distinctive clinical and neuroradiological findings and discuss the surgical planning and theories about the pathogenesis of schwannomas in this unusual location.

Double concentric craniotomy for a craniocerebral penetrating nail. Case report and technical note.

BACKGROUND: Craniocerebral penetrating injuries from nail-gun accidents are rare and usually are discovered immediately after the trauma. Several surgical procedures have been described to extract a foreign body that is infixed in the skull and has penetrated the surrounding structures; blind extraction, craniectomy, and craniotomy. CASE DESCRIPTION: We report the case of a 25-year-old ex-carpenter who presented with jacksonian seizure at the left limb. Plain radiography of the skull revealed the unexpected presence of a nail hammered in the right parietal bone, penetrating the underlying structures of the frontoparietal area up to a depth of 3 cm. The patient was operated on; a small craniotomy (1 x 1 cm) just around the head of the nail, and a concentric larger frontoparietal bone flap, involving the first craniotomy, were performed. The larger bone flap was elevated first, whereas the small bone flap with the nail infixed was carefully elevated along the axis of the nail, under direct vision of the nail tract. CONCLUSIONS: Double concentric craniotomy is the only technique that permits the removal of a foreign body that has penetrated both the skull and the brain, under direct vision, without transmitting any undue forces to the underlying structures. With this technique, control of bleeding can also be easily achieved.

Intramedullary neurenteric cysts of the spine. Report of three cases.

Neurenteric spinal cysts are infrequently occurring dysraphic lesions that are caused by persistent or abnormal communication among neuroectoderm, notochord, and endoderm. They are generally located at the intradural, extramedullary compartment of the low cervical or upper spinal canal. They occur primarily in infants and in young adults in combination with other congenital abnormalities. The authors report on three cases of lower-thoracic and thoracolumbar intramedullary neurenteric cysts that atypically presented in adult patients in whom there was no concomitant malformation. These lesions appear notable for location, clinical presentation, intraoperative findings, and imaging features.