TOS pathophysiology and clinical features.

The authors present 280 patients operated on for thoracic outlet syndrome (TOS). In a first group of patients anatomical variants were the striking findings. The underlying factor for TOS development is therefore a well defined structural condition and its pathogenetic mechanism is known to be a nerve fibre compression. In a second group there was no specific salient finding but a postural deviation. The unique pathological features were adhesions of the brachial plexus to the scalenus muscle. Consequently its pathogenetic mechanism is generally recognized as nerve fibre distraction. In all patients neurological, vascular and myofascial pain symptoms were observed before the operation. Neurological and vascular pain disappeared after surgery, while the myofascial pain remained. The authors believe that especially in the second, larger group of patients enhancement of the pain-immobility-fibrosis loop is the central pathogenetic factor on which surgical therapy is successful, and that myofascial hemisyndrome--probably arising from a long-standing postural deviation--is not a TOS dependent symptom. In TOS, therefore, there is a pain loop that cannot be resolved by surgical therapy alone. The connection between myofascial pain syndrome and TOS might explain the many controversial opinions regarding frequency, results and surgical possibilities of this lesion.

Post-traumatic thoracic outlet syndrome (TOS).

TOS is a compressive non-tumorous syndrome of the brachial plexus. It is possible, however, to consider as TOS the irritative and lesional plexus syndrome following trauma as long as compression (or traction) on the nerves is triggered by long-lasting pathological changes of the area after trauma. Overload work of judges and lawyers after traffic accidents does not help to remind the real victim's problem, that is stretching of the neck soft tissues during head acceleration-extension. This movement is due to a forward acceleration. Both the car and the victim's trunk are violently pushed forward while the head does not move fast enough so that it is actually pushed backwards. The mandibula is even slower than the head and this leads to an opening of the mouth with possible temporomandibular joint (TMJ) dislocation. If there is nothing stopping the neck extension, like an appropriate headrest, the momentum is only resisted by cervical soft tissue stretching. Prolonged antalgic contracture and motor neglect may contribute to connective tissue changes and development of microadherences. Final result is fibrosis of paraneurium. The pain-immobility-fibrosis loop is of basic importance in the development of this syndrome.

Entrapment of crural branches of the common peroneal nerve.

Failed back surgery syndrome (FBSS) occurs in 30% of operated patients and represents a heavy problem both regarding disability and costs in first world countries. Among FBSS we found the possibility of a double crush syndrome: a disco-radicular conflict and a peripheral nerve entrapment. The latter, disguised by root compression symptoms, becomes evident only after spinal surgery. Clinical features are the same as for the restless leg syndrome. We found peroneal nerve crural branches entrapped where they crossed the fascia to reach the subcutaneous layer. Venous stasis during immobility caused presentation of symptoms. Neurolysis was performed, all cases were successful. Most of the patients were found to have myofascial pain syndrome (MPS). MPS patients "feel" entrapments more frequently than others not because of their specific pain tolerance but because they are more prone to develop them.

Chronic subdural collection after endoscopic third ventriculostomy.

Endoscopic third ventriculostomy (ETV) is considered a safe technique for the treatment of obstructive hydrocephalus. We describe a case of chronic subdural haematoma (CSDH) after ETV, revealed by MRI four weeks after the procedure, and requiring surgical evacuation, in a 69 y.o. asymptomatic male patient. In our opinion, overdrainage may evolve also in endoscopic treatment of obstructive hydrocephalus. This complication could be the starting point of the subdural collection. We review the literature and discuss the causes that may lead to CSDH after ETV procedure.

Neuroendoscopy: one year of experience--personal results, observations and limits.

After reading reports of successful neuroendoscopic treatment of hydrocephalus, colloid cysts and arachnoid cysts as well as tumor biopsy, we started using endoscopic procedures in our Department, one year ago. One surgeon (E.S.) skilled in the Decq Endoscope, performed a series of sixteen procedures, from January 2001 to March 2002 (in patients aged 28 to 69 years). The most common pathology was obstructive hydrocephalus (14 cases), one was colloid cyst, and the last case was tumor biopsy. The surgical treatment consisted of third ventriculostomy, cyst opening and shrinking and tumor biopsy. In fourteen patients treated for hydrocephalus with third ventriculostomy (ETV), one required a definitive shunt. Complication occurred in one case with chronic subdural collection. We further report one case of aqueductal restoration after third ventriculostomy. Our results, with no neurological deficits or deaths, confirmed our opinion that neuroendoscopy is a safe surgical technique in well-selected patients and we believe it is the ideal treatment in obstructive hydrocephalus.

Alpha B-crystallin is not a dominant peripheral T-cell autoantigen in multiple sclerosis amongst Sardinians.

The heat shock protein alpha B-crystallin appears to be the dominantly recognized autoantigen in the early demyelinative process of multiple sclerosis (MS) in brain of patients. In Sardinia, MS is linked to human leucocyte antigen (HLA)-DR alleles that might influence the production of cytokines from peripheral lymphocytes. We tested the nature of peripheral anti-alpha B-crystallin-specific T-cell response in the context of predisposing HLA haplotypes both in MS patients and healthy controls. The alpha B-crystallin specific T-cell lines were generated by using the 'split-well' technique. The results indicate that the presence of short-term T-cell lines towards alpha B-crystallin is numerically comparable between the two groups and not restricted to MS-predisposing HLA-DR alleles. As for the T-cell characterization, CD4+ anti-alpha B-crystallin T cells secreting high levels of interferon-gamma are similarly identified in MS and healthy donors. In conclusion, the peripheral response towards the myelin antigen alpha B-crystallin is neither quantitatively nor qualitatively peculiar to MS, in contrast to the theoretical paradigm suggesting peripheral activation of myelin-reactive T cells to be the prerequisite for MS induction.

Overdrainage after endoscopic third ventriculostomy: an unusual case of chronic subdural hematoma--case report and review of the literature.

Endoscopic third ventriculostomy is considered a safe technique for the treatment of obstructive hydrocephalus. However, the literature contains several reports of complications related to this procedure. We describe a case of chronic subdural hematoma (CSDH) after ETV, which required surgical evacuation, in a 69-year-old male patient completely asymptomatic up to the control MRI four weeks after the operation. We believe this unusual complication could result from the ICP changes caused by ETV. In our opinion, successful ETV gives a boost to CSF absorption, and overdrainage may evolve also in endoscopic treatment of obstructive hydrocephalus. This situation could be the starting point of the subdural collection. We review the literature and discuss the causes that may lead to CSDH after ETV procedure.

"Matrioska head". Case report of calcified chronic subdural hematoma.

We report an asymptomatic case of a large calcified chronic subdural hematoma (CCSH). Skull X-ray examination, computer tomography (CT) and magnetic resonance imaging (MRI), showed an adhering calcification extending to the whole cerebral cortex, as if the skull had another concentric skull inside it. These radiological findings recall the famous Russian doll named "Matrioska"; for this reason we defined this case "Matrioska head". The patient was absolutely asymptomatic and we discuss the causes that may give the calcification of chronic subdural hematoma (CSH).

Chlamydia pneumoniae in the cerebrospinal fluid of patients with multiple sclerosis and neurological controls.

Chlamydia pneumoniae infection is a common event in neurological patients and recovery of C. pneumoniae DNA in the cerebrospinal fluids (CSF) of multiple sclerosis (MS) patients could represent an epiphenomenon. We assessed the relevance of C. pneumoniae infection in 62 CSF samples from 32 MS patients and 30 neurological controls by means of PCR, immunofluorescence microscopy, enzyme-linked fluorescence and antibody detection. Multiple sclerosis (9.3%) and neurological controls (13.3) had similar percentage of anti-C. pneumoniae antibodies. However, C. pneumoniae DNA was only detectable in MS patients' CSF (9.3%). Our data support the hypothesis that C. pneumoniae persistence in some MS patients may be the result of an impaired clearance within the central nervous system.

Regression of syringomyelia after removal of a posterior fossa epidermoid tumour.

The case is reported of a 49-year-old man with a giant infratentorial extradural epidermoid tumour, with cervical syringomyelia and hydrocephalus, and partial protrusion of the cerebellar tonsils through the foramen magnum. The patient complained of symptoms of raised intracranial pressure and was admitted to our Department, where ventriculoperitoneal shunting and total removal of the epidermoid tumour were performed. One year later, MR imaging demonstrated collapse of the cervical syringomyelia.

The surgical treatment of intracranial abscesses today.

The indications and the results of different surgical procedures for the management of intracranial abscesses are dealt in a cooperative study. Two series, amounting 68 patients altogether, collected in epidemiologically homogeneous areas with high percentage of rural population without adequate medical control, are appraised. Due to the high rate of chronic lesions, particularly in the pre-CT scan era (1968-1975), radical excision was required in 70.6% of cases. Overall postoperative mortality was 14.7%: 7.3% during the hospital stay, mostly due to pyrogenic ventriculitis in patients with large deep located abscesses, and 7.4% for different complications, both intra- and extracerebral, at home or other institutions several months after surgery. 29% of patients recovered completely and 45.6% have only minor disability, only 10.3% remained severely crippled and dependent. The results of the surgery, both in terms of operative mortality and functional recovery seem to depend on the neuropathological background rather than on the kind of therapeutic procedure implemented. Even though it must be acknowledged that at present conservative and minor surgical procedures are more often successfully used, radical excision still appears to keep far from negligible indications.