Next generation of ventricular catheters for hydrocephalus based on parametric designs.

BACKGROUND: The flow pattern of the cerebrospinal fluid is probably the most important factor related to obstruction of ventricular catheters during the normal treatment of hydrocephalus. To better comprehend the flow pattern, we have carried out a parametric study via numerical models of ventricular catheters. In previous studies, the flow was studied under steady and, recently, in pulsatile boundary conditions by means of computational fluid dynamics (CFD) in three-dimensional catheter models. OBJECTIVE: This study aimed to bring in prototype models of catheter CFD flow solutions as well to introduce the theory behind parametric development of ventricular catheters. METHODS: A preceding study allowed deriving basic principles which lead to designs with improved flow patterns of ventricular catheters. The parameters chosen were the number of drainage segments, the distances between them, the number and diameter of the holes on each segment, as well as their relative angular position. RESULTS: CFD results of previously unreleased models of ventricular catheter flow solutions are presented in this study. Parametric development guided new designs with better flow distribution while lowering the shear stress of the catheters holes. High-resolution 3D printed catheter solutions of three models and basic benchmark testing are introduced as well. CONCLUSIONS: The next generation of catheter with homogeneous flow patterns based on parametric designs may represent a step forward for the treatment of hydrocephalus, by possibly broadening their lifespan.

The current management of lumbar spondylolisthesis.

Lumbar spondylolisthesis can lead to disabling low back pain and neurological deficits. This review details the clinical history, neurological examination, clinical presentation, imaging modalities, and current management standards for lumbar spondylolisthesis. Based on the available clinical trials, there is evidence that, compared with nonsurgical care, the surgical treatment of symptomatic spondylolisthesis offers a significant clinical benefit in the presence of progressive neurological deficits; cauda equina syndrome; failure of an adequate response to conservative therapy: radiographic instability with neurological symptoms; radiographic progression of subluxation to greater than grade II; symptomatic grades III, II, or spondyloptosis; and unremitting pain that affects the quality of life. Optimizing the diagnostic paths and surgical indications and standardizing both the surgical procedures as well as the outcome measurements with validated instruments should assist the spine care community in acquiring data that are essential for providing the best evidence-based treatment while reducing or eliminating procedures that lack evidence of either efficacy or value.

Simple, effective, supine positioning for the retrosigmoid approach.

BACKGROUND: The retrosigmoid approach is often used for posterior fossa pathology. Many variations of positioning exist. Here, we report a simple, safe, and quick positioning technique which maximizes patient safety, surgeon comfort, and intraoperative view. METHODS: We reviewed the senior author's prospective surgical database for retrosigmoid approaches to the posterior fossa and noted any complications or difficult exposures. RESULTS: Over 970 retrosigmoid operations were performed over the course of 19 years. There were no positioning-related complications and no aborted surgeries due to inadequate exposure. No normal cerebellum was ever resected to increase exposure and no retractor was ever used in the posterior fossa. CONCLUSIONS: Supine positioning for the retrosigmoid approach is an excellent and safe positioning alternative.

Association between cavernous angioma and cerebral glioma. Report of two cases and literature review of so-called angiogliomas.

The association between vascular malformations and cerebral gliomas is unusual. While the association between cavernous angioma with gliomatous lesions is even more rare, it is considered by certain authors to be a particular pathological entity termed angioglioma. The authors report on two cases of association of a cavernous angioma with a ganglioglioma and an oligodendroglioma respectively. Subsequent review of the literature on the so-called angiogliomas was conducted. In the author's opinion, the entity of angiogliomas represents a general spectrum of angiomatous neoplasms that include gliomatous tumors, in the majority low-grade gliomas, associated with a major vascular component.

Neuroma of the spinal accessory nerve disclosed by a subarachnoid hemorrhage: case report.

OBJECTIVE AND IMPORTANCE: Neuroma of the 11th nerve disclosed by subarachnoid bleeding is a very rare condition. Clinical diagnosis is almost impossible, but previous episodes of muscle spasm and mild signs of subarachnoid hemorrhage with a hematoma in the cisterna magna should suggest magnetic resonance imaging as well as angiography. CLINICAL PRESENTATION: We present a case of an 11th nerve neuroma disclosed by subarachnoid bleeding. Previous episodes of muscle spasm and neck pain treated with nonsteroid anti-inflammatory drugs had been overlooked, preventing the neuroma from being diagnosed at that time. The computed tomographic scan showed an intracisternal hematoma spreading into the subarachnoid space. The hematoma appeared heterogeneous on the magnetic resonance image, and a tumor mass growing into the cisterna magna against the brain stem was also revealed. INTERVENTION: The tumor was totally removed by a suboccipital craniectomy and C1 laminectomy. It originated from the spinal root of the 11th nerve, from which it was able to be dissected without damage to the nerve. CONCLUSION: To our knowledge, this is the first reported case of an 11th nerve neuroma disclosed by a subarachnoid hemorrhage. Furthermore, this is the seventh documented case of an 11th nerve neuroma developing in the cisterna magna. We emphasize the importance of a high index of suspicion for the rare instances of hematic density limited to the cisterna magna, especially if associated with recurring episodes of localized neck pain and muscle spasm treated with nonsteroid anti-inflammatory drugs.

Diaphragma sellae meningiomas. Report of two cases and a review of the literature.

Diaphragma sellae meningiomas are very rare and often manifest themselves with aspecific symptoms. Before the advent of MR, the diagnosis was very difficult or even impossible. For this reason they were often included in the broader category of suprasellar meningiomas. We describe two cases of diaphragma sellae meningiomas anterior to the pituitary stalk, manifesting with visual disturbances. We present the clinic and diagnostic data and we compare our experience with that reported in the literature. The tumor were removed by pterional (case 1) and subfrontal approach (case 2) with a recover of vision. Our experience support a clear demarcation of the diaphragma sellae meningioma among the wither group of suprasellar meningiomas. It is mandatory to define its position relative to the pituitary stalk and to the diaphragma sellae to chose the best surgical approach.

Cranio-orbital missile wound and bullet migration. Case report.

An unusual case of craniocerebral missile injury, with orbital roof perforation and spontaneous bullet migration into the maxillary sinus, is reported. Emergency treatment consisted in wide craniectomy around the bullet entry point, blood and foreign bodies debridement. Subsequent procedures were necessary for abscess evacuation, transmaxillary bullet removal and later cranial vault reconstruction. Challenging aspects were the treatment of the infectious complications, following cerebrospinal fluid fistula through the wound, and the onset of post-traumatic epilepsy, scarcely responsive to common antiepileptic drugs. The treatment of the abscess by combined systemic and intracavitary antibiotic therapy and of the chronic seizures by progressive adjustment with new protocols of antiepileptic drugs under EEG and brain mapping revealed successful.

Acute subdural hematoma and pachymeningitis carcinomatosa: case report.

Subdural hematomas may affect 0.4-5 p. 100 of patients with cancer, because of predisposing risk factors or because of the cancer itself. The most likely association is with hematological cancer with coagulative disorders. An association with pachymeningitis carcinomatosa is less likely. In this instance the subdural hematoma is due to a neoplastic obstruction of dural vein with subdural engorgement and hemorrhage or subdural effusion. We report a case in which an acute neurological deterioration due to a subdural hematoma disclosed a dural metastasis from a breast cancer operated four years earlier and present a literature review.

Lumbar spinal osteoblastoma mimicking a dumbbell radicular schwannoma.

Spinal dumbbell tumors originate from nerve roots, usually growing within the spinal canal, the neural foramen and the extraforaminal compartment in the paraspinal region. We report a case of a 20-year-old man who presented with back pain radiating to his left lower limb mostly when in a supine position. Magnetic resonance imaging of the lumbar spine showed a dumbbell lesion at the L5-S1 neural foramen, with enlargement of the foramen and extension into the left paraspinal compartment. Although MR imaging studies were strongly suggestive of a dumbbell radicular schwannoma, the histological diagnosis was an osteoblastoma of the lumbar spine originating from the left L5 pedicle with intracanalicular, intraforaminal and extracanalicular extension. The presentation, imaging studies, intervention, pathology and differential diagnosis are described.

Endovascular treatment of primitive persistent trigeminal artery aneurysm associated with middle cerebral artery aneurysm.

We report the case of a primitive trigeminal artery aneurysm associated with an ipsilateral middle cerebral artery aneurysm. A 64-year-old Caucasian woman suffered from a severe acute headache. A head CT scan displayed subarachnoid hemorrhage and subsequent cerebral angiography showed right, wide-necked persistent trigeminal artery and ipsilateral middle cerebral artery aneurysms. The patient underwent embolization of both aneurysms with Guglielmi detachable coils. The association of a PPTA aneurysm and an ipsilateral MCA aneurysm has not been reported in the English literature.

Balloon-assisted endoscopic retroperitoneal gasless approach (BERG) for lumbar interbody fusion: is it a valid alternative to the laparoscopic approach?

OBJECTIVE: In the last years the use of interbody fusion devices with an anterior spinal lumbar approach has become a common procedure for the treatment of degenerative disc disease and spinal instability. We analysed our series of a simplified endoscopic approach to the anterior spine and made a review of the retroperitoneal endoscopically assisted approach to the anterior lumbar spine in the international literature. METHODS AND RESULTS: From 1999 through 2002, twenty consecutive "balloon-assisted endoscopic retroperitoneal gasless (BERG)" lumbar fusions were performed at San Filippo Neri Hospital in Rome, Italy. The surgical indications included patients with grade I or II spondylolisthesis and symptomatic degenerative disc disease with foraminal stenosis. Fourteen patients underwent a single level fusion (4 cases at L4-L5; 10 cases at L5-S1) and six patients underwent a double level fusion (L4-L5 and L5-S1). Mean operating time was 135 minutes (single level fusion), 175 minutes (double level fusion) and the mean intraoperative blood loss was 177 mL. No perioperative complications were observed and no procedure was converted to open surgical fusion. Patients were allowed to ambulate on the second postoperative day. Fusion was achieved in nineteen patients (fusion rate of 95%) 12 months after surgery. CONCLUSIONS: The BERG technique is a safe, effective, simplified, less technically demanding alternative approach when performing ALIF procedures, without the morbidity associated with laparoscopic or traditional approaches.

Continuous subgaleal suction drainage for the treatment of chronic subdural haematoma.

BACKGROUND: Chronic subdural haematoma is one of the most common entities encountered in daily practice. Many methods of treatment have been reported, each with its own advantages and disadvantages. METHOD: The authors present a novel technique for the management of chronic subdural haematoma which is a variation of a closed drainage system. After evacuation of the haematoma through a single burr hole, we inserted a Jackson Pratt drain into the subgaleal space, with suction facing the burr hole, allowing for continuous drainage of the remaining haematoma. FINDINGS: We used the method for over 4 years to treat 224 patients. Seventeen patients (7.6%) needed a second operation for a recurrence of the haematoma no patient required a third operation. Postoperative complications developed in 3 patients. Two patients died while in the hospital, a mortality rate of 0.9%. CONCLUSIONS: The use of suction assisted evacuation, is followed by results that compare satisfactorily to reports of previous methods, with a low rate of recurrence and complications. It is relatively less invasive and can be used in high risk patients.

Spinal cord gliomas and hydrocephalus: utility of neuroendoscopy.

OBJECTIVE: The aim of this study is to report on the role of neuroendoscopy during the management of hydrocephalus that led to the diagnosis of intracranial tumoral dissemination and the subsequent finding of a spinal cord glioma. METHODS AND RESULTS: We present two children each with an intramedullary astrocytoma that presented initially with hydrocephalus without spinal cord symptoms. In both cases leptomeningeal gliomatous dissemination was asserted during routine endoscopy for the management of hydrocephalus. The diagnosis of a cervical and a lower thoracic intramedullary tumor was made soon after on magnetic resonance imaging. CONCLUSIONS: Spinal cord MRI with contrast should be considered initially in selected cases of hydrocephalus without evident diagnosis. The intraoperative diagnosis of gliomatous dissemination and secondary hydrocephalus due to unrecognized spinal cord gliomas was possible, in our experience, with the routine use of the neuroendoscope.

Association between cavernous angioma and cerebral glioma. Report of two cases and literature review of so-called angiogliomas

La asociación entre las malformaciones vasculares y los gliomas cerebrales es inusual. Mientras que la asociación entre angioma cavernoso con lesiones gliomatosas es aún más rara, es por esto considerado por algunos autores como una entidad patológica particular llamada angioglioma.Los autores reportan dos casos de asociación de un angioma cavernoso con una ganglioglioma y un oligodendroglioma, respectivamente. Además se realizó una revisión de la literatura sobre los llamados angiogliomas.En opinión de los autores, la entidad de los angiogliomas se presenta dentro de un espectro general de neoplasias angiomatosas, que incluyen tumores cerebrales, en su mayoría gliomas de bajo grado, asociados a su vez, con un componente vascular importante (AU)

The association between vascular malformations and cerebral gliomas is unusual. While the association between cavernous angioma with gliomatous lesions is even more rare, it is considered by certain authors to be a particular pathological entity termed angioglioma. The authors report on two cases of association of a cavernous angioma with a ganglioglioma and an oligodendroglioma respectively. Subsequent review of the literature on the so-called angiogliomas was conducted. In the author's opinion, the entity of angiogliomas represents a general spectrum of angiomatous neoplasms that include gliomatous tumors, in the majority low-grade gliomas, associated with a major vascular component (AU)