Spontaneous intraparenchymal tension pneumocephalus triggered by compulsive forceful nose blowing

The case is described of a 50-year-old man, treated for 10 years in an outpatient psychiatric clinic for an obsessive compulsive disorder, who presented with acute loss of consciousness after forceful nose blowing. A CT scan revealed an intraparenchymal air collection with tension signs in the left frontal lobe and a bone defect in the roof of the ethmoid sinus. After emergency left frontal craniotomy and dura opening, the gaseous collection was evacuated by a ventricular catheter inserted into the brain and the bone defect was repaired with pericranium flap and muscle. The postoperative course was uneventful with neurocognitive improvement and regained motility. Spontaneous tension pneumocephalus is a rare life-threatening condition which is often caused by a bone defect near the tegmen tympani. This case illustrates both an unusual cause and a unique surgical treatment for spontaneous tension intraparenchymal pneumocephalus. It can be a dangerous entity with potential for early mortality and long-term morbidity if not promptly decompressed. The pathogenesis, diagnosis and surgical strategies for spontaneous tension pneumocephalus are briefly discussed.

Giant Intracranial Chordoma: Neuroradiological and Radiotherapeutic Aspects

We describe a rare case of giant intracranial chordoma, emphasizing the patient's long survival and his excellent response to radiotherapy that led to a progressive regression of neurological symptomatology up to disappearance, in the absence of cerebral white matter damages.

Prognostic role of depression after lumbar disc surgery

A total of 73 patients underwent microdiscectomy for lumbar disc herniation between September 2001 and May 2002 at the Department of Neurosurgery of the Second University of Naples. Preoperatively and 3 and 6 months after surgery, patients were assessed on the Zung Self-rating Depression Scale (SDS) and on a visual analogue scale (VAS) for the subjective perception of pain. At 3 and 12 months, we found that patients with lower SDS scores (n=41) had a better outcome regarding pain than patients with relevant depressive symptoms (n=32). In agreement with the literature, our results confirm the negative role of depression in outcome after lumbar disc surgery. We emphasize the consideration of psychological factors in the management of lumbar disc herniation.

Management of benign craniovertebral junction tumors

BACKGROUND

We report our surgical experience in the treatment of fifteen consecutive patients with benign craniovertebral junction tumors, observed from 1993 to 2000 at our department.

METHOD

We treated 7 meningiomas, 3 epidermoids, 3 C1 neurinomas and 2 neurinomas of the lower cranial nerves. Clinical results were evaluated by Karnofsky Performance Scale and all patients underwent preoperative neuroradiological evaluation with CT, MRI and MRA; angiography was not routinely performed and was considered for each individual case.

FINDINGS

11 partial transcondilar and 4 retrocondilar approaches were performed. Total removal was achieved in 11 cases (73,3%) and subtotal removal in 4 patients (26,7%). None of the patients required occipitocervical fusion. Patients were followed for an average period of 24+/-31 months. Clinical and radiological follow-up showed no recurrence in cases with total removal. In all patients a statistically significant postoperative increase of KPS scores was recorded. The treatment of epidermoid tumors presented particular issues: debulking the lesion, we obtained a surgical window, avoiding a large removal of bone. In Nakasu grade 1 or 2 meningiomas, we carried out total removal by piecemeal resection and without complete condylectomy and bone fixation.

INTERPRETATION

The choice of these approaches and the extent of bone resection should be defined according to the tumor's location and size. Moreover we emphasize that preoperative neuroradiological evaluations on presumptive tumor type could be helpful to the surgeon in order to tailor the technique to different lesions, providing the required exposure, without unnecessary surgical steps.

Lumbosacral dural ectasia in type 1 neurofibromatosis. Report of two cases

Dural ectasia denotes circumferential expansion or dilatation of the dural sac, and has been frequently reported in association with type 1 neurofibromatosis (NF1). The pathogenesis has not been defined, but its correlation with NF1 infers a congenital malformative hypothesis. The neural elements in the dilated sleeve typically are not enlarged or abnormal, nevertheless the enlarged area contain an increased amount of cerebrospinal fluid. The dura in the area of ectasia is extremely thin and fragile, and erodes the surrounding bony structures destabilising the spine and permitting spectacular spinal deformities. We present two cases with lumbosacral dural ectasia, enlargement of the intervertebral foramina and posterior scalloping of vertebral bodies. Neurological examination showed sciatic nerve irritation. As the etiology of this malformation remains uncertain and dysplastic changes of the spine may be intrinsic or secondary controversies remain about optimum treatment. We conclude that patients affected by NF-1 require an accurate neuroradiological study of the whole spine in order to detect possible dural and spinal anomalies. Surgical treatment is indicated only in patients with progressive neurological deterioration. The thin dural sac predisposes to a high morbidity if surgery is undertaken.

Traumatic subependymal hematoma during endoscopic third ventriculostomy in a patient with a third ventricle tumor: case report

Endoscopic third ventriculostomy has become a routine intervention for the treatment of non-communicating hydrocephalus. This technique is largely considered safe and a very low incidence of complications is reported. However, hemorrhage in the course of neuroendoscopy is still a problem difficult to manage. The authors present a case in which endoscopic third ventriculostomy and tumor biopsy were performed in a young patient with a huge tumor growing in the posterior part of the third ventricle. The surgical approach to realize the stoma was difficult because the tumor size reduced the third ventricle diameter. Surgical manipulation produced a traumatic subependymal hematoma. This hematoma drained spontaneously after few minutes into the ventricle and the blood was washed away. The postoperative neurological course was uneventful and the ventriculostomy showed to work well by reducing the size of the lateral ventricles and the intracranial pressure in three days. This complication during endoscopic third ventriculostomy has never been reported before. We emphasize the difficulty of endoscopic procedures in patients with huge tumors in the third ventricle. Where reduction in size of the third ventricle and of the foramen of Monro ist present we suggest a careful approach to the third ventricle.

Spontaneous resolution of chronic subdural hematoma

BACKGROUND

Spontaneous resolution of chronic subdural hematoma has rarely been reported in the literature, and its mechanism has not been fully investigated. Response to surgery has been very satisfactory; in fact, this is generally considered the treatment of choice.

METHODS

From a series of 24 cases of chronic subdural hematomas, we observed five patients between 1996 to 1998. These patients showed headache and decrease of cognitive level, 4-5 weeks after minor head injury. Neurologic evaluation revealed only worsening of mental function according to Mini Mental State Examination (MMSE). Computed tomography (CT) scans showed brain atrophy and chronic subdural hematoma without increased intracranial pressure. These patients were treated by clinical observation and serial cerebral CT scans.

RESULTS

After 7 to 10 days, all patients showed improvement of clinical signs. After 30 to 45 days, radiological disappearance or marked reduction in size of the hematoma and complete clinical recovery were obtained. No neurological deficits and no recurrences have been observed during follow-up (3 months to 2 years).

CONCLUSIONS

We believe that age greater than 70 years, decreased cognitive level (MMSE = 21), brain atrophy, and absence of increase of intracranial pressure are clinical and radiological signs that allow one to choose conservative treatment.

[Total intravenous anesthesia in neurosurgical patients]

The authors present an anesthesiologic technique, consisting of the use of propofol + fentanyl + O2. The main advantages, described in 82 neurosurgically treated patients, are the following: moderate decrease both of ICP and MAP, absence of frequency, modifications rapid recovery both of consciousness and of motility, which allows a preliminary valuation of neurological status.

[Urapidil: hypotension induced in neuroanesthesia]

The authors report their experience on the use of urapidil in 31 patients, submitted to neurosurgical procedures. Urapidil, administered both in the inductive (0.7-1 mg/kg) and in preoperative phases (0.6-0.8 mg/kg/h), produced a MAP decrease of about 25% without significant variations in cardiac frequency or of other monitored parameters.

Trigeminal neuralgia treated by percutaneous thermocoagulation. Comparative analysis of percutaneous thermocoagulation and other surgical procedures

The authors analyze the results they obtained by percutaneous radiofrequency technique for trigeminal neuralgia. The clinical material consists of 605 cases observed from 1977 to 1986 at their Institute. There was a female preponderance (62%) and an average age of 65 years. Idiopathic, atypical and symptomatic trigeminal neuralgia has been diagnosed respectively in 568, 21 and 16 cases. From 1977 to 1980 the working temperature was above 65 C, thereafter a lower temperature has been employed to coagulate the Gasserian ganglion. The rate of pain relief was 97% for idiopathic trigeminal neuralgia, 75% for symptomatic and 21% for atypical. The loss of facial sensation accounts for 80% of side effects of this procedure in their series. The recurrence of pain was observed in 16% of cases with a follow-up ranging from 2 to 10 years. It is noteworthy that there is a correlation between the coagulation temperature and the rate of recurrence, the higher the former, the lower the latter. The authors compare their results (rate of pain relief, morbidity, mortality, rate of recurrence) with those of major reports in the literature concerning either percutaneous or other surgical procedures (mircosurgical decompression of the trigeminal nerve, glycerol injection into the trigeminal cistern and percutaneous microcompression).

Microsurgical management of suprasellar and intraventricular meningiomas

A series of 78 intracranial meningiomas (68 suprasellar, 10 intraventricular) were operated on in our Institute after the advent of the operating microscope. In our review, we discuss the microsurgical technical problems related to the preservation of vascular and brain structures in the removal of intraventricular and parasellar meningiomas. Basic diagnostic criteria to plan correctly the surgical approach will be emphasized. Mortality and morbidity in parasellar meningiomas is, in our opinion, related to the experience of the surgeon in using the operating microscope rather then in using the laser and CUSA. We will also discuss the utility of preoperative embolization of the lesion as well as the indications for intraoperative EC/IC bypass. Finally, morbidity and mortality related to different approaches for intraventricular meningiomas will be discussed.

Simultaneous multiple brain tumors of different histological nature. Report of two cases

Two cases of patients harbouring simultaneously multiple brain tumors of different histological nature are here reported. Clinical presentation, site of growth and neuroradiological findings are illustrated and discussed in light of the data previously reported by the literature.

Association of bilateral extracranial internal carotid artery occlusion and midline brain tumour

A 42-year-old patient with a bilateral extracranial internal carotid occlusion which was associated with a midline intracerebral tumour of the genu of the corpus callosum, is reported. This rare association is discussed in the light of the pathogenetic theories referred to in the literature in similar cases. It is felt that, such cases, although rarely encountered, should stimulate the adoption of more accurate neuroradiological investigations, in patients harbouring brain tumours, in order carefully to plan the anaesthetic and surgical procedures.

Nontumoral aqueductal stenosis in children affected by von Recklinghausen's disease

The authors report three cases of primary nontumoral aqueductal stenosis associated with von Recklinghausen's disease in children. Moreover, 16 similar cases collected from the literature are presented. The clinical features are evaluated in light of data from the literature. Among all 19 cases, the median age was 19 years (range 6-46 years), and nine patients were under the age of 13 years. Our own patients underwent ventriculoatrial shunt procedures, followed by clinical recovery (follow-up 2-5 years). In one patient, computed tomography scanning performed 20 months after the operation showed a chronic calcified subdural hematoma in the right frontoparietal area. In conclusion, it is felt that, among all the pathological events usually described in patients affected by neurofibromatosis, primary aqueductal stenosis seems to be part of the natural history of this neurological syndrome.

Aqueductal stenosis as isolated localization involving the central nervous system in children affected by von Recklinghausen disease

The Authors report three cases of non tumoral aqueductal stenosis associated with von Recklinghausen disease in children. Moreover, 16 similar cases collected from the literature are illustrated. The clinical features are evaluated in light of literature's data. Among all 19 cases, the median age was 19 years (range 6-46 years) and 9 patients were under the age of 13 years. In this latter group, the most represented clinical symptoms were headache and gait disturbances. As regards the neuroradiological procedures, CT scan represented the best tool in the evaluation of the ventricular size. Our own three cases underwent to ventriculo-atrial shunt procedures, followed by clinical recovery (follow-up: 3 months-5 years). In conclusion it is felt that, among all the pathological events usually described in patients affected by neurofibromatosis, aqueductal stenosis seems to belong to the natural history of this disease.

[Angioma of the Gasserian ganglion. Morphological and histogenetic considerations on a case]

A cavernous haemangioma of the Gasserian ganglion in a 37-year-old man is presented. It is the third reported case of cavernoma in this region, where infrequently tumors develop. Carotid angiogram shows a network of neoformed vessels in the middle cranial fossa. The hypotheses about the malformative origin of this tumor and the differential diagnosis toward other highly vascularized meningeal tumors are discussed.

Considerations on the operative results in a group of elderly neurosurgical patients

536 patients from 60 to 84 years old, operated on for neurosurgical lesions, are evaluated with reference to post-operative mortality rate related to the type of pathology. 83 deaths (15.6%) occurred in this series. Mortality rate increases progressively with advancing age. It is outlined that the aged patients have lesser chances of surgical success, but the present data induce to consider with greater favour the outcome of these patients.

[Anatomo-clinical considerations on cerebral sarcomas]

The Authors present six cases of sarcoma of the brain. After doing a short review of the cases described in literature, they discuss the clinical anathomo-pathological and terapeutic aspects of these peculiar tumours.