[Selective mutism].

Selective mutism is an uncommon disorder in young children, in which they selectively don't speak in certain social situations, while being capable of speaking easily in other social situations. Many etiologies were proposed for selective mutism including psychodynamic, behavioral and familial etc. A developmental etiology that includes insights from all the above is gaining support. Accordingly, mild language impairment in a child with an anxiety trait may be at the root of developing selective mutism. The behavior will be reinforced by an avoidant pattern in the family. Early treatment and followup for children with selective mutism is important. The treatment includes non-pharmacological therapy (psychodynamic, behavioral and familial) and pharmacologic therapy--mainly selective serotonin reuptake inhibitors (SSRI).

Spontaneous intracranial hemorrhage in immune thrombocytopenic purpura.

Spontaneous intracranial hemorrhage (ICH) is a rare but devastating complication in patients with chronic immune thrombocytopenic purpura (ITP). We report four patients with chronic ITP unresponsive to steroid treatment who developed ICH. One patient had systemic lupus erythematosus; in another patient, the ICH originated from an arteriovenous malformation. High dose steroids, platelet concentrates, emergency splenectomy, and subsequent evacuation of intracranial hematoma, if necessary, can lead to a reasonable outcome of ICH in patients with chronic ITP.

Recurrence of intracranial meningiomas: the role played by regional multicentricity.

Meningiomas are regarded as benign dural tumors that can be totally removed; however, after a resection that appears to the naked eye to be total, their recurrence rate is high. Malignancy in a few cases and an erroneous belief in many others that the excision was total are among the most accepted explanations. Few studies have mentioned multicentricity as a cause of "relapse." Therefore, the authors decided to examine the dura mater around globular meningiomas for evidence of regional multifocality. A radial strip of dura was removed from the line of attachment of globular meningiomas in 14 consecutive patients. Meningotheliomatous cell aggregates were demonstrated in 100% of these dural strips in the form of either intradural clusters or nodes protruding from the inner aspect of the dura. The benign appearance of the cells and the great prevalence in this study of the benign types of meningioma seem to exclude malignancy; the intradural position of the clusters and their independence from blood vessels apparently negate seeding and dural metastasis. Control strips of convexity dura mater taken from 10 neurosurgical patients without meningioma failed to show these meningotheliomatous conglomerates. These findings indicate that solitary globular meningiomas represent only the most visible growth in the midst of a neoplastic field change spreading over a wide area of dura mater. The authors believe that this can explain some unexpected "recurrences," and that a wide resection of dura around globular meningiomas, whenever possible, could reduce the incidence of clinical growth after true total excision of the most visible lesion. It remains to be determined what factors cause the acceleration of growth of these cell aggregates after removal of the dominant tumor.

Primary cutaneous extravertebral meningioma. Case report.

A case of cutaneous extravertebral meningioma is presented. It was diagnosed in infancy as a lumbar meningocele. Operation was initially refused but was subsequently demanded for cosmetic reasons. The findings were a very thick corrugated skin and a cutaneous meningioma connected by a fibrous tract to the dura mater. The presence of a fibrous stalk linking the tumor to the dura mater might have been the pathogenetic connection between the meningocele and cutaneous meningioma.

Recurrence of intracranial meningiomas: the role played by regional multicentricity. Part 2: Clinical and radiological aspects.

Globular single meningiomas are generally regarded as benign tumors that can be completely removed. Nevertheless, after a total macroscopic resection including the insertion zone (Grade 1 operation according to Simpson's classification), the incidence of recurrence ranged from 9% to 14% at the 5-year follow-up review. The authors have shown that single meningiomas represent only the visible predominant growth in the midst of a wide neoplastic field in the dura mater. Regional multiplicity in meningiomas would thus seem to be the rule. With this in mind, the authors propose to divide recurrences after Grade 1 operations into true local and false regional. A local recurrence is defined as a regrowth within the limits of the previous dural flap. Regional recurrence is when new growth develops outside the previous craniotomy site; this should not be considered as a recurrence but as a new primary site. These regional recurrences might explain some unexpected late tumor growth occurring after a Grade 1 operation. Five illustrative cases in which regional recurrence was detected by computerized tomography are presented. The authors also propose to add a supplementary grade to Simpson's surgical grading: Grade 0. This operation would entail a wide resection of the dura around the attachment zone of the meningioma. The authors hope that with a Grade 0 operation the incidence of recurrence might be reduced.

Frontal extradural hematomas.

In a series of 1841 severe head injuries, 97 cases of epidural hematomas were observed. Among these there were 13 in the frontal area, i.e. 13.4%. The nine cases of frontal extradural hematomas not previously reported are described. Five of them had "pure" extradural frontal clots. In four cases the epidural hematoma was associated with intradural lesions. The "pure" frontal epidural cases presented a subacute to chronic course of a benign character. All of these patients survived and made a complete recovery after operation. A malignant, stormy and fatal course was observed in the "mixed" cases.

Spinal cord compression in Paget's disease of bone with reference to sarcomatous degeneration and calcitonin treatment.

Four cases of spinal cord compression stemming from Paget's disease of bone tissue are reported. Sarcomatous degeneration was proved in one case and in another one malignancy was deduced by computed tomography (CT) scanning. Clinical and radiologic manifestations as well as surgical management are discussed. The value of CT scanning of the spine as an aid in the evaluation of structural changes and the size of the soft tissue mass in sarcomatous degeneration of the lesion is stressed. After calcitonin administration, alleviation of pain and improvement in neurological status have occurred in two treated patients.

Benign osteoblastoma of vertebral column and skull.

Three cases of benign osteoblastoma in children are reported; two in the spine and one in the occipital bone. clinical, pathological and X-ray appearance are discussed. The importance of complete removal whenever possible is stressed. Radiation therapy is not considered to be beneficial.

Brain abscess and its surgical management.

A series of 56 patients with brain abscesses who were treated over a period of 23 years is reviewed. Patients with posttraumatic infections were not included. The operative mortality was 11%. Aspiration of purulent material, radical excision of the abscess, drainage of pus, or a combination of these procedures was used according to the patient's condition and the location of the abscess. The relatively low mortality may be related to the preoperative condition of these patients, who were operated upon in the subacute or chronic stage of their disease. Conservative surgery, especially when functionally important parts of the brain are involved, helps to keep the postoperative neurological deficit as low as possible. Computerized tomography is of primary importance in localizing, diagnosing, and following the evolution of a brain abscess.

Metastasis of invasive carcinoma of the breast to an extradural meningioma of the cranial vault.

A case of metastasizing invasive carcinoma of breast to an expanding extradural frontal meningioma is presented. The peculiar tendency of meningioma to be the host tumor for carcinoma is discussed. The literature pertaining to such rare occurrences is reviewed.

Orbital phlebography and cavernography in intra-cranial lesions.

Orbital phlebography has gained increasing importance in the evaluation of otologic and intracranial pathology. The practical use of this method in vascular and neoplastic lesions in the middle cranial fossa, as well as its probable value in cerebello-pontine angle tumours is reported.

Penetrating cranio-cerebral injuries due to unusual foreign bodies.

Seven cases of penetrating cranio-cerebral injury by peculiar foreign bodies are described. The clinical-pathological picture is reported wherever possible. Lack of adequate safety measures and untrained careless handling of instruments were at the root of these tragic accidents. Greater awareness of such dangers in industry and in school might help to promote the adoption of adequate safety measures.

Sphenoid sinusitis presenting as chronic meningitis.

Sphenoid sinusitis is a frequently misdiagnosed infection. Delay in recognition and treatment carries a very poor prognosis. An unusual case of sphenoid sinusitis mimicking a syndrome of chronic meningitis is presented. This case emphasizes the diagnostic challenge of sphenoid sinusitis which may present only through its complications.

Hyperhidrosis and its surgical treatment.

111 sections of high thoracic sympathectomies in 60 cases suffering from primary palmar hyperhidrosis are reported. Surgical results and postoperative complications are discussed in detail. Complications were few in number and were of a transitory nature. No mortality occurred in our series. Various surgical and nonsurgical procedures of treatment are reviewed. Surgical intervention remains the treatment of choice in essential idiopathic hyperhidrosis.