pT1 colorectal cancer: A treatment dilemma

The implementation of population screening programs for colorectal cancer (CRC) has led to a considerable increase in the prevalence pT1-CRC originating on polyps amenable by local treatments. However, a high proportion of patients are referred for unnecessary oncological surgeries without a clear benefit in terms of survival. Selecting the appropriate endoscopic resection technique in the moment of diagnosis becomes crucial to provide the best treatment alternative to each individual polyp and patient. For this, it is imperative to increase the optical diagnostic skill for differentiating pT1-CRCs and decide the appropriate initial therapy. En bloc resection is crucial to obtain an adequate histological specimen that might allow organ preserving therapeutic management. In this review, we address key challenges in T1 CRC management, explore the efficacy and safety of the available diagnostic and therapeutic approaches, and shed light on upcoming advances in the field.

An atypical gastric duplication cyst as a rare cause of gastric dilatation: the key role of the endoscopy ultrasound

We have written a "letter to Editor" about a case of gastric dilatation caused by a symptomatic gastric duplication cyst with ectopic pancreas ingrowth, in a 13 years old boy. The Endoscopy Ultra Sound characterized the lesion and permitted the aspiration of the internal liquid. The patient underwent to laparoscopic excision of the mass and the histology revealed a gastric duplication cyst with ectopic pancreas ingrowth.

Study of energetic properties of different tree organs in six Olea europaea L. cultivars

Pruning is an important horticultural practice for the management of olive orchards (Olea europaea L.) that generates a considerable amount of residues every year. Olive orchards are increasingly expanding beyond the Mediterranean Basin to new growing Countries (Australia, California, Argentina, Chile and Uruguay) and this will certainly lead to larger availability of pruning material. Currently, the interest in use of olive tree pruning residues for energy purposes is increasing but unfortunately, the information on the differences among organs of the tree, in terms of calorific value and ash content, is scarce. Another unknown aspect is the effect of cultivar vigour on dry matter partition among different tree organs, these are important traits to establish the energetic quality of pruning residues. The aim of this research was to study energetic aspects of six olive cultivars, largely grown in the Sicilian olive industry and characterized by different vigour. The trees taken into consideration in the study were selected in an experimental orchard to avoid any effect due to differences in environmental conditions and management. The energetic characteristics, calorific value and ash content, were evaluated for the various tree organs particularly shoots, leaves and branches; also root system was evaluated, although the roots can only be used once the trees are uprooted. Significant differences were observed in the calorific values among the different tree organs and the cultivars. Regarding the ash, shoots and leaves showed the highest content with respect to the other organs, thus causing a possible tendency in slagging with fouling and corrosion of boiler components.

Clinical and radiological outcome after minimally invasive surgical approach for type II unstable odontoid fractures

INTRODUCTION

Anterior odontoid screw fixation is a valid surgical option for unstable odontoid fractures, as type II Anderson D'Alonzo fractures. Grauer further divided type II fractures in subtypes according to the fracture line, providing recommendations for implementation of screw fixation techniques.

OBJECTIVE

Primary endpoint of our study is to evaluate the postoperative results of minimally invasive odontoid screw insertion in terms of outcome, fusion rate and stability of cranio-cervical junction. Secondary endpoint was to investigate the influence of age or fractures' features on outcome and fusion rate.

MATERIALS AND METHODS

We report the clinical and radiological features of 32 patients harbouring unstable type II fractures operated by a minimally invasive odontoid screw insertion technique. All patients underwent a high resolution multiplanar CT in order to assess fracture features according to Grauer's classification; the integrity of ligaments was investigated by MRI. In addition, a preoperative neurological performance (modified Rankin Scale, mRS) was evaluated for patients either directly or interviewing their families. Follow-up at one, three and six months and 1 year have been performed (averaging 13.5 months) by cervical CT (fusion rate and stability) and mRS update. In order to investigate the influence of age on postoperative neurological performance, two groups (≤50 yrs, 9 pts/>50 yrs, 23 pts) were separately considered and analysed. Overall, we observed no surgery related complications. We also analysed the fusion rate and its correlation with patient age and Grauer's subtype of fracture.

RESULTS

At last available clinical follow-up, the preoperative performance was preserved (mRS 0/1: 24, 75%; mRS 2-4: 9, 15%) although with slight reduction of intact patients (mRS 0: 22 vs. 19; 71.8 vs. 59.3%). Younger patients (≤50 yrs) fared significantly better than older ones, achieving a good clinical outcome (mRS 0/1) in 100% vs. 69.5% (9/9 vs. 16/23 pts). Statistical analysis showed a fair correlation between age and outcome. Other factors such as sex and Grauer's type did not influence significantly the clinical outcome. Nine patients did not complete a full radiological follow-up and were therefore excluded from analysis of radiological outcome. Among the remaining 23 patients, only 25% of those who were followed three months or less showed fusion; conversely, all patients who have been examined from 6 to 48 months fused. Among the non-union patients, two underwent a second surgery by posterior approach.

CONCLUSIONS

In our recent experience, the minimally invasive AOSF proved safe and effective in treating odontoid peg fractures. Selection based on Grauer's type is mandatory to achieve best results. While in the elderly, an anterior approach is well accepted as the first choice treatment, we recommend that this option should be offered as a suitable alternative to Halo or orthosis also in younger patients since it provides prompt, excellent clinical outcome and high fusion rate especially in this age group.

Recent Experience in the Management of Meningeal Hemangiopericytomas

Although the histogenesis of meningeal hemangiopericytomas (HMP) remains controversial, both biological and clinical evidence seems to identify these neoplasms as a separate entity with respect to meningiomas. In order to assess the current prognosis of HMP we reviewed our personal experience limited to the last decade (1986-1995): during this period 7 patients (4M, 3F) were treated by surgery alone or surgery combined with postoperative radiotherapy. In spite of meticulous attempts at radical resection, the tumors recurred in all but two cases with a mean interval of 85 months, and a total of 18 operations were performed (2.57/patient; range 1-4). Massive intratumoral hemorrhage determined acute deterioration and required emergency surgery in two cases while in one patient diffuse visceral metastases were discovered at autopsy. Five patients are still alive at follow-up but only 2 of them are in good neurological conditions and without evidence of disease. These results are similar to those reported in other series. In view of our results we conclude that intracranial hemangiopericytomas still have a dismal prognosis. Advances in neuroimaging, neuroanesthesia, microneurosurgery and adjuvant therapy do not seem to have significantly affected the recurrence rate, quality of life and mortality.

Rutin content of the grain of buckwheat ( Fagopyrum esculentum Moench. and Fagopyrum tataricum Gaertn.) varieties growtn in southern Italy

The rutin content of the grain of 31 buckwheat varieties (28F. esculentumand 3F. tataricum) grown on the high plain of Sila (Region of Calabria) and on the massif of Pollino (Region of Basilicata) presented a substantial degree of variation.Among theF. esculentumvarieties the lowest values were found for Botan and Spacinska, while the highest contents were observed in the varieties Emka and Lechnicka Krajova. As expected, the rutin content of the grain ofF. tataricumwas higher than that ofF. esculentum, with the variety Donan showing the highest value.In view of the role of rutin in conferring most of the functional food characteristics of buckwheat, knowledge of the grain rutin content expressed in a specific environment, together with the yield potential, is important for the identification of buckwheat varieties worth adopting in an area such as the high plain of Sila, which, thanks to its extent, has the potential to represent a novel territory for the profitable cultivation of buckwheat in Italy.

Cooperative study by the Italian neuroendoscopy group on the treatment of 61 colloid cysts

OBJECTS

Microsurgical resection, stereotactic aspiration and VP shunt have for years been the choice options for the treatment of colloid cysts of the third ventricle. Recently, endoscopic approaches have aroused increasing interest and gained acceptance. Although safer, this minimally invasive approach is considered less efficacious than microsurgery. Relatively long-term results are now available and some conclusions might be inferred on the usefulness of this procedure.

MATERIALS AND METHODS

Between 1994 and 2005, 61 patients harbouring a colloid cyst of the third ventricle were treated with neuroendoscopic technique in 11 Italian neurosurgical centres. Cyst diameters ranged from 6 to 32 mm. A flexible endoscope was used in 34 cases, a rigid one in 21, both instruments in six. The technique consisted in cyst fenestrations, colloid aspiration, coagulation of the internal cyst wall and, occasionally, capsule excision. Mean postoperative hospital stay was 6.7 days. Early postoperative neuroimaging revealed a cyst residue in 36 cases (mean diameter 4.3 mm). There were two complications (3.2%). Follow-up varied between 1 and 132 months (mean 32 months, more than 5 years in 17 patients). There were seven asymptomatic recurrences, three of them evolving from a previous residue.

CONCLUSION

The endoscopic approach to the treatment of colloid cysts is safe, effective and well accepted by patients. Although asymptomatic, recurrences (11.4%) cast a persisting shadow on the long-term results, and, therefore, the controversy with the traditional microsurgical treatment remains open.

The direct effect of insulin on barosensitive neurones in the nucleus tractus solitarii of rats

The present investigation was designed to determine the direct effect of insulin on the spontaneous discharge of barosensitive neurones in the nucleus tractus solitarii (NTS) of rats anaesthetized with urethane. Microinjection of 20 nl insulin (10 IU/ml) into NTS decreased the spontaneous discharge of 38 of the 52 units studied (73.1%), and this decrease was augmented by increasing the concentration to 40 IU/ml. Microinjections of insulin vehicle, glucose, hydralazine or phenylephrine did not elicit significant changes in the spontaneous discharge of NTS barosensitive neurones. These results demonstrate that insulin inhibits the spontaneous discharge of barosensitive NTS neurones. They suggest that insulin increases sympathetic nervous activity via a central neural mechanism and may play a role in the modulation of cardiovascular information within the NTS.

Microsurgical posterior fossa exploration for trigeminal neuralgia: a study on 48 cases

The authors present their experience in the microsurgical treatment of trigeminal neuralgia (TGN). Over the last five years 48 patients were explored and 34 (71 %) underwent microvascular decompression (MVD) for significant arterial or venous conflicts. The remaining 14 patients (29 %) underwent partial sensory rhizotomy (PSR) because of negative intraoperative findings (simple contact or no conflict). Excellent or good immediate outcomes were achieved in 87.5 and 12.5 % of patients, respectively. Of the three severe recurrences observed during the follow-up period (24.7 months; range: 7 - 65 months), two underwent percutaneous microcompression and one posterior fossa reexploration, which revealed teflon-induced recompression. None of the PSR cases experienced incapacitating face numbness. MVD, an extremely effective procedure in the immediate post-operative period, is burdened in the long term by 20 % recurrences, the majority occurring within two years from surgery. We believe that careful intraoperative evaluation of the conflict entity could be the key to achieve a significant reduction of recurrences: overestimation of simple vascular contact of doubtful etiologic relevance, may lead to ineffective decompression and unsatisfactory results. In our opinion PSR should be preferred to percutaneous treatments in cases of negative exploration (contact or no conflict). In accordance with others we observed that section of half or less of the inferolateral "portio major" allows long-lasting pain relief and good preservation of sensory function.

Twenty colloid cysts--comparison of endoscopic and microsurgical management

The management of colloid cyst remains controversial, evaluation of the competing methods seems to be necessary. We report on our experience with colloid cysts in the last decade: ten were managed solely endoscopically, 10 were resected microsurgically (9 via a transcortical/transventricular, 1 via a transcallosal approach). The outcome in the endoscopic group was excellent in 9 cases and unsatisfying in 1 case (recurrence). In the microsurgical group we achieved a good outcome in 5 of 10 cases, a fair outcome in 4 cases and 1 lethal outcome (caused by pulmonary embolism). Complications in the endoscopic group: one intraoperative bleeding, 1 stitch granuloma, 1 mispuncture of the ventricle, and 1 meningitis. Complications in the microsurgical group: 1 subdural effusion, 1 flap infection, 1 mild hemiparesis, 1 transient impairment of consciousness and 1 pulmonary embolism. Mean operative time and length of hospitalization of the endoscopic group were clearly shorter than in the microsurgical group: 91 min versus 267 min time of surgery, 5.1 days versus 18.9 days of hospitalization. Complete resection was achieved in 8 of 10 cases of microsurgery, and in 3 of 10 cases in endoscopy. Endoscopic management results in lower costs and superior patients' comfort. The reduced number of total resections in the endoscopic group may lead to a higher recurrence rate in long-term follow-up, which might be a serious disadvantage of endoscopy. However, more experience in the endoscopic techniques may result in a higher rate of total resection of colloid cysts.

A study of blood coagulation and fibrinolytic system in spontaneous subarachnoid hemorrhage. Correlation with hunt-hess grade and outcome

BACKGROUND

Subarachnoid hemorrhage (SAH) has been studied from various standpoints with the purpose of discovering criteria that might be useful in predicting the prognosis. In the literature a high incidence of coagulative and fibrinolytic disorders has been reported in SAH patients. A prospective study was performed to evaluate hemostatic plasmatic parameters in SAH patients.

METHODS

Hemostatic plasmatic parameters were prospectively studied in 76 patients with SAH. Both the coagulative (PT, APTT, fibrinogen, thrombin/antithrombin complex: TAT, and modified antithrombin III: MAT) and fibrinolytic (D-dimer) plasmatic systems were evaluated. Von Willebrand factor was also tested.

RESULTS

PT, APTT, and fibrinogen were within normal limits. High TAT levels were associated with clinical outcome since 16 patients out of 27 (59%) with unfavorable outcomes displayed TAT levels >20 ngzaq/L, as compared with 10 patients out of 38 (26%) with favorable outcomes. Plasmatic D-dimer, an index of subarachnoid clot lysis, was invariably found to be elevated. Nevertheless, very high levels (>1000 mcg/mL) were found in 16 patients out of 22 (73%) with unfavorable outcomes but in only 9 patients out of 38 (26%) with favorable outcomes. Significant D-dimer elevation showed a strong association with severe delayed ischemic deficit (DID). Patients were also tested for von Willebrand factor, displaying a specific increase in all cases.

CONCLUSION

The study provides evidence for an early activation of the coagulation and fibrinolytic system following SAH. Increase of plasmatic TAT parallels clinical outcome. A generalized increase of D-dimer was observed as well and D-dimer levels in the high range were associated with clinical outcome and poor results with DID. Our analysis shows close statistical significance between plasma levels of TAT, D-dimer, and outcome. A similar statistical significance has been found when comparing other known prognostic factors such as clinical and cerebral computerized tomography scan (CT) grade and outcome.

A case of primary meningioma of the frontal sinus

A case of right frontal sinus tumor which at histology turned out to be a psammomatous meningioma is reported. The occurrence of primary meningiomas within the paranasal sinuses is rare and probably related to the transformation of embryonic arachnoid cell remnants or ectopic meningocytes derived from pluripotential mesenchymal cells. A search of the literature disclosed 30 further cases of meningiomas primarily involving the paranasal sinuses: a short analysis of the latters is presented and some of the distinctive features of these unusual tumors, as compared to their intracranial counterpart, are emphasized.

Pediatric migration and hepatitis A risk in host population

Hepatitis A virus (HAV) circulation in a given area is closely related to socioeconomic standards. Following the improvement of living conditions, HAV seroprevalence rates in the population have decreased steadily during the last decades in many Western European countries, including Italy, thereby leading to a shift of risk of disease towards older age groups. Since the severity of the disease closely parallels age, a higher incidence of symptomatic cases in adults is now reported in Europe and the United States, being travel-related to a large extent. Intrafamilial person-to-person spread is also an important source of infection and transmission from children to parents may occur due to the lack of immunity in the general population. In the last two decades, Italy has been the destination of an increasing number of migrants from developing countries, where HAV is highly endemic. Furthermore, international adoption programmes cause pediatric populations from HAV endemic countries to increase in low endemic areas, possibly leading to secondary cases in close contacts.7 The aim of this paper is to report the epidemic HAV outbreak which occurred among the voluntary nursing staff of a pediatric Rwandan refugee community hosted in a village of the Brescia Province, in northern Italy.

Solitary fibrous tumor of the meninges: two new cases and review of the literature

BACKGROUND

Solitary fibrous tumor (SFT), a mesenchymal neoplasm originally described in the pleura has been more recently reported to arise in a number of other sites, including the meninges. Nowadays immunohistochemistry facilitates the otherwise problematic differential diagnosis with regard to other benign and malignant spindle cell neoplasms of the central nervous system.

METHODS

Two recently treated cases of meningeal SFT (one craniospinal, one spinal) are presented and discussed in the light of the present knowledge and a review of the literature.

RESULTS

Total resection was followed by complete recovery and both patients are presently asymptomatic and without evidence of disease. The microscopic and immunohistochemical profiles (CD 34, vimentin positive; S-100, EMA negative) were consistent with those of previously reported cases.

CONCLUSIONS

The majority of SFTs behave in a benign fashion and do not recur unless subtotally resected. Malignant variants may account for up to 37% of SFTs in other locations but have never been reported to occur in the meninges. Meningeal SFTs are to be considered a new pathological entity. Wider use of immunohistochemical screening should enable the determination of their real incidence; larger series and longer follow-up will provide conclusions about their treatment and prognosis.

An early approach to controlled hypotension: Felice Visalli and the "pneumoanemizator."

In this historical vignette, the authors describe the conception and realization of the "pneumoanemizator," an ingenious pneumatic apparatus originally designed in the 1940s for the purpose of controlled hypotension. The authors also give a biographical sketch of its inventor, the pioneering Italian neurosurgeon Felice Visalli. The general working features of this nearly forgotten device and its performance in experimental and clinical trials are evoked in the light of a brief history of controlled hypotension.

[Colloid cysts in the 3rd ventricle: a microsurgical series and new perspectives]

Colloid cysts are rare benign CNS lesions (0.5-2% of tumors), mostly located within the third ventricle. Although sometimes asymptomatic they may cause life-threatening complications and sudden death and therefore require active treatment in the vast majority of cases. Microsurgical removal warrants excellent radicality at low morbidity/mortality rates but emerging neuroendoscopic techniques have been applied successfully worldwide although longer follow-up of these patients is needed. We present out personal microsurgical series from last decade and discuss the results in the light of current knowledge and preliminary neuroendoscopic experiences.

Successful cervical disc surgery by Professor Angelo Chiasserini Sr of Rome in 1937: a historical case report

Although resection of cervical "chondromas" had been reported since the late twenties, the true nature of this condition was not recognized at that time. This paper reports a case of "inferior cervical radiculitis by herniation of nucleus pulposus" operated by Prof. Angelo Chiasserini Sr, one of the founders of Italian neurosurgery, in January 1937. To our knowledge this represents one of the first examples of correct etiopathogenetic interpretation of cervical disc disease. Surgery was followed by excellent recovery, a quite remarkable result in those times. The case history is reported in detail, and a short historical sketch of cervical disc disease is depicted.

Dumbbell tumor of the anterior skull base. Meningioma? No, adenoid cystic carcinoma!

BACKGROUND

Adenoid cystic carcinoma (ACC) is a rare neoplasm of the exocrine glands. Because of its tendency for skull base involvement and intracranial spread, ACC should be diagnosed promptly by the neurosurgeon, although discrimination from meningioma is often difficult. Radical resection of such tumors requires familiarity with complex craniofacial approaches.

CASE DESCRIPTION

An unusual case of dumbbell-shaped ACC centered over the planum sphenoidale is presented. Regular margins and neuroimaging features suggested a preoperative diagnosis of meningioma. The lesion was gross, totally resected in a two-staged procedure through frontobasal and transfacial approaches, with good functional and aesthetic result.

CONCLUSION

The epidemiologic, histologic, and clinical features of ACC are reviewed. ACC is rarely encountered by the neurosurgeon; however it should always be considered in the differential diagnosis of skull base tumors. Interdisciplinary surgical approaches represent the major advance in the treatment of these complex neoplasms.

[Surgery of lumbar disk hernia: historical perspective]

Although the clinical picture of discogenic sciatica is well known already in the ancient world, it is not until 1933 that WJ Mixter and JS Barr provide the correct pathogenetic interpretation and suggest surgery as the treatment of choice. The work of the American Authors was however based on the knowledge acquired during the previous centuries starting with Domenico Cotugno, who first suggested the neurogenic nature of sciatica (1764) and later with the neurologists of the french school Valleix, Lasègue, Dejerine, Sicard who elucidated the semeiology and debated in detail the etiopathogenesis of the condition. The german pathologists Schmorl and Andrae (1927-29) are to be credited for their contribution to the pathology of intervertebral disc, recognizing the frequency and degenerative (not neoplastic) nature of nucleus pulposus herniation. Surgery of disc herniation starts with Oppenheim and Krause (1909). Mixter and Barr used laminectomy and a transdural route although a more limited approach to the spinal canal had already been proposed by the italian Bonomo (1902), unknown to many. Love, of the Mayo Clinic (1937-39) introduced the extradural/interlaminar approach while Caspar and Yasargil (1977) applied the concepts of microsurgery to the procedure. The latest advances are represented by percutaneous and endoscopic techniques.

[Neurosurgery in Rome: 1880-1970]

Among many factors contributing to the birth of Neurosurgery, the "awareness of feasibility" of neurosurgical procedures is especially significant. June 1st, 1885 is the arbitrary birthdate of Neurosurgery in Rome: Francesco Durante, Professor of Surgery at the Royal University, successfully resects an olfactory groove meningioma, arising admiration worldwide. Roberto Alessandri succeeds Durante in 1919. In roman hospitals outstanding surgeons perform from time to time neurosurgical procedures, sometimes with satisfactory results: Paolo Postempski, Cesare Antonucci, Guido Egidi and Raffaele Bastianelli, first director of the "Regina Elena" Cancer Institute (IRE) (April 1933) and friend of Harvey Cushing. Angelo Chiasserini sr. is however the first roman surgeon constantly committed to Neurosurgery and founder of the first neurosurgical unit in Italy, in 1937; also, from 1941 to 1944 he directs a neurosurgical service at the "Celio" military hospital of Rome, to which patients from the various battle theatres are referred. While Mario Margottini and Piero Frugoni follow Bastianelli's steps at the IRE, the roman neurosurgeons Felice Visalli and Libero Ugelli serve in the Army, during the greek-albanian conflict and in Russia, respectively. In May 1955 Beniamino Guidetti, an Olivecrona pupil, is called at "La Sapienza" University of Rome and elevates the neurosurgical clinic at the highest standards. The other main neurosurgical pole is founded in 1958 at the San Camillo Hospital: within both institutions modern neurosurgical teams are formed along with neuroradiological and neuroanesthesiological staffs.

Minimally invasive treatment of giant CSF pseudocyst complicating ventriculoperitoneal shunt

A two-liter cerebrospinal fluid pseudocyst complicating a ventriculoperitoneal shunt was drained and a distal catheter retrieved from the peritoneal cavity by laparoscopy. Adoption of such a minimally invasive approach allowed the prompt resolution of the complication and an early recovery for out patient.

Management of intracranial aneurysms: "state of the art"

The authors provide an overview of the past, present and future of intracranial aneurysms management. Excellent results achieved today by neurovascular surgeons are to be ascribed not only to refinements in microsurgical technique but also to an always more aggressive and effective treatment of vasospasm, the most feared complication of aneurysmal SAH. "Triple H" therapy, calcium channel blockers, rTPA and balloon angioplasty represent the corner-stones of arterial spasm treatment. Hopefully new agents such as lazaroids, endothelins inhibitors and nitric oxyde modulators will become available for clinical use in the next future. Although clipping of aneurysmal neck is still considered the "gold standard", obliteration of the aneurysmal sac can now be safely achieved by coil embolization: the exact role and respective indications of each technique are yet to be defined. Further prognostic improvement will be possible through an early diagnosis, i.e. before the occurrence of SAH, as shown by negligible morbidity and mortality associated with the treatment of "incidental" and "unruptured" aneurysms.

Detection of cystathionine ketimine and lanthionine ketimine in human brain

The sulfur containing imino acids cystathionine ketimine (CK) and lanthionine ketimine (LK) have been detected in the human brain by an HPLC procedure. The HPLC procedure takes advantage of the selective absorbance at 380 nm of the phenylisothiocyanate-ketimine adduct. Quantitation of cystathionine ketimine and lanthionine ketimine indicates a mean concentration (mean +/- SD, n = 4) of 2.3 +/- 0.8 nmol/g for CK and of 1.1 +/- 0.3 nmol/g for LK in four human cerebral cortex samples of neurosurgical source. The identification of these cyclic ketimine derivatives of L-cystathionine and L-lanthionine as normal human metabolites in human nervous tissue may have interesting metabolic and physiological implications.

Non-acoustic neuroma tumor (NANT) of the cerebello-pontine angle: a 15-year experience

Between 1980 and 1994, 145 patients affected by tumors of the CP angle underwent surgery at the Division of Neurosurgery of the San Camillo Hospital in Rome. The 56 (39%) "non-acoustic tumors" have been analyzed with regard to epidemiologic factors, clinical picture, neuroimaging findings in order to determine their distinctive diagnostic features. Moreover, the surgical outcome and follow-up results are presented and compared with those of the literature.

Transosseous reconstruction of temporalis muscle for pterional craniotomy: technical note

Temporalis muscle asymmetry is a bothersome complication of pterional craniotomy, resulting from atrophy, malposition, and unreliable fixation. The authors describe a simple, quick, and inexpensive technique to achieve firm, anatomic reapproximation of the temporalis muscle to its bone attachment.

Successful excision of hemorrhagic cavernous angioma in a patient with severe factor VII deficiency: perioperative treatment with factor VII concentrate

A case of an uncomplicated neurosurgical procedure in a patient affected by a rare bleeding disorder is described. The interest is twofold: first because of the possible influence of underlying coagulopathy in disclosing the vascular anomaly. And second although surgery in factor VII deficiency has been reported before, with and without replacement therapy, to our knowledge, this is the first neurosurgical case in which factor VII concentrate was used. This treatment allowed safe surgery and protected the patient from complications associated with plasma and protrombin complex use.

Cystic extra-axial cavernoma of the cerebellopontine angle

Besides acoustic neuromas, the cerebellopontine angle harbors a wide variety of masses, named "nonacoustic neuroma tumors," as a whole. Although magnetic resonance imaging has much improved our ability to differentiate among posterior fossa lesions, misdiagnoses may still occur when facing rare, controversial cases.

Spontaneous spinal epidural hematomas: is the role of dural arteriovenous malformations underestimated?

Two recent observations of spinal epidural hematomas (SEH) are presented: one of them was associated with iatrogenic coagulopathy, the other, apparently "spontaneous", required reoperation for early recurrence and was finally attributed to ruptured epidural arteriovenous malformation missed during the first procedure. Both patients underwent complete recovery. Although modern neuroimaging provides quick, noninvasive, and sensitive assessment of spinal epidural bleeding, we believe that preoperative spinal angiography is indicated in "spontaneous" SEH with subacute clinical course. Demonstration of underlying vascular anomaly would allow better surgical planning, complete obliteration of abnormal vessels, and prevention of recurrences. Essential epidemiological, pathogenetical, and clinical aspects of SEH are reviewed.

Aneurysms of the sphenoid segment of the middle cerebral artery

Aneurysms of the M1 segment of the middle cerebral artery are rare. Anatomically they are classified into a "temporal" variety, projecting supero-laterally and a "striate" variety projecting infero-laterally. Between 1960 and 1992, 13 such aneurysms were treated at our Institution. Among them, 11 underwent surgery: 8 (73%) had an excellent or good outcome, 1 (9%) a poor outcome and 2 (18%) died. Two patients treated conservatively carried thrombosed aneurysms: one was a giant unruptured aneurysm with complete occlusion of the parent vessel; the other one was found at autopsy following transsphenoidal surgery and unexplained SAH. All these cases were carefully reviewed with special reference to their clinical and anatomo-surgical features. Exact knowledge of the anatomy of lenticulostriate and temporal branches and awareness of all possible anatomical variants are crucial for correct opening of the Sylvian fissure and successful surgical approach to M1 segment aneurysms.

Surgical treatment of spasmodic torticollis: is there a role for microvascular decompression? With an illustrative case report

Spasmodic torticollis (ST) is a puzzling movement disorder, characterized by involuntary tonic or clonic contractions of various neck muscles. From time to time, psychogenic, extrapyramidal and neuroperipheral origins have been postulated and reflecting the variety of theories proposed, as many different treatments have been attempted, none of which has shown absolute effectiveness. Surgery of ST classically includes destructive procedures such as myotomies, stereotactically placed lesions, rhizotomies and neurectomies. The recent application of the concept of "neurovascular conflict" to ST induced several authors to perform microvascular decompression (MVD) in these patients, with encouraging and in some cases long-lasting results. Our case report joins this group. From the analysis of pertinent literature we conclude that: a. Spasmodic torticollis is probably a collection of separate clinical entities; b. Even in the so-called "ST of neuroperipheral origin" some coexising central factor must be admitted; c. Neurovascular compression underlies at least some cases of ST. Historical, anatomical, physiopathological and clinical aspects of ST are extensively discussed.

Life threatening intracranial complications of frontal sinus osteomas: report of two cases

Paranasal sinuses osteomas are known as biological benign tumours. However, due to the peculiar anatomical relationships, patients harbouring an osteoma within the frontal sinus are exposed to serious orbital and intracranial complications. We report two unusual cases of intracranial mucocoeles associated with frontal osteomas. In one of them, a superposed tension aerocoele required emergency surgery. Although aggressive treatment of asymptomatic osteomas is not warranted, these lesions must be carefully observed and resected as soon as they show clinical and/or radiological signs of progression. The physiopathological and clinical aspects are discussed.

Acromegaly and pituitary tumors: early anatomoclinical observations

The elucidation of pituitary physiopathology has been a major challenge for physicians since early ages. Due to the unawareness of the endocrine system, acromegaly, the most striking pituitary disorder, was commonly regarded as an intrinsic bone disease. Andrea Verga and Vincenzo Brigidi, Italian authors of the 19th century, reported the first macroscopic and microscopic descriptions of pituitary adenomas in acromegalic patients. Although far from providing a correct pathogenetic interpretation of the disease, they opened the way to forthcoming observations and discoveries. A short history of acromegaly and pituitary physiopathology is drawn.

Celebrating the centennial (1894-1994): Leonardo Gigli and his wire saw

In spite of the recent introduction of craniotomes in neurosurgical practice, the simple but brilliant wire saw invented by Leonardo Gigli still holds an important place in neurosurgical instrumentation. Born in Florence in 1863, Gigli was forced by circumstances to leave Italy soon after getting his medical degree. He first spent 2 years attending the most celebrated obstetrical clinics in Paris and London and then, in 1892, moved to Breslau where he worked with Fritsch and Mikulicz. During this successful and rewarding period, Gigli proposed the lateralized pubiotomy (Gigli's operation) for safe delivery in cases of maternal pelvic deformities and, inspired by the sight of a jagged knife during a country banquet, conceived his wire saw to simplify the procedure. In 1894, at Professor Obalinski's suggestion, he successfully tested a modified saw type with a whalebone guide for the preparation of osteoplastic cranial flaps. In spite of his great popularity and the high esteem in which he was held abroad, Gigli's aims were systematically belittled in Italy, where he never qualified for a university teaching position. He died in 1908, at age 44. Although the once celebrated Gigli's operation has merely historical interest today, the favorable features of his wire saw make it a safe and efficient tool in the hands of twentieth-century neurosurgeons worldwide.

Pseudohypoaldosteronism: report of a case presenting as failure to thrive

We report a 2 month-old infant referred for failure to thrive. At birth, weight was 3820 g and length 52 cm. After physiologic weight loss, the patient showed no further weight gain for the next two months. On admittance (age 2 mo), weight was 3340 g and length 53 cm; the infant had severe dystrophy, generalized hypotonia and dehydration; blood chemistry showed hyponatremia, hyperkalemia and hypochloremia. A salt losing syndrome of adrenal origin was hypothesized. However, rehydration and hydrocortisone administration failed to correct hyponatremia and hyperkalemia. Endocrine assessment showed high levels of aldosterone and plasma renin activity, suggesting pseudohypoaldosteronism. Oral sodium chloride supplementation normalized electrolyte balance and the patient showed progressive weight gain and catch-up growth, confirming the diagnosis.

[The inhalational therapy of respiratory pathology]

The inhalation of aerosolized drugs for therapeutic purpose has been used for many years in respiratory diseases as asthma, chronic bronchitis, cystic fibrosis. Therapeutic aerosols have the advantages to deliver active substances directly to the site of disease, without systemic side effects, to produce a more rapid clinical response, to avoid barriers to the absorption of drugs such as the gastrointestinal tract. We review the mechanisms and the site of lung deposition and the range of devices that can provide an effective aerosol such as metered dose-inhaler and spacers. Besides drugs as cromolyn, beta-2-agonists and topical steroids, recently new inhalation therapies were proposed using antiviral drugs (interferon), pentamidine for Pneumocystis carinii in immunocompromised host, inhalation of attenuated virus (measles) for active immunization. However there is a need for further work in this area.

Short report: imported mosquito: an uninvited guest

Recently, the trend in the number of people traveling from the tropics to malaria-free areas has tremendously increased and this is paralleled by the number of imported malaria cases. Imported infected mosquitoes transmitting the infection to persons living or working nearby international airports have been reported. The possibility that mosquitoes may also reach areas far away from the landing area in the baggage of international travelers is indicated by two cases that are reported here. Malaria should be investigated in any case of unexplained fever even if no apparent risk factor for imported malaria is present, regardless of the distance from international airports.

Intravenous immunoglobulin in two children with Guillain-Barré syndrome

Two children with Guillain-Barrè syndrome were successfully treated with high-dose intravenous immunoglobulin (IVIG) and no relapses occurred over a 1 year follow up. No side-effects were observed. These data provide further evidence that IVIG may be safely and effectively employed in children with Guillain-Barrè syndrome.

Antonio Pacchioni (1665-1726): early studies of the dura mater

The clustering of arachnoid villi along the sagittal sinus forms what is known as "Pacchioni granulations." These structures were first described in 1705 by Antonio Pacchioni, an Italian scientist. Pacchioni was born in Reggio Emilia, Italy, in 1665, and there he received his degree in medicine. Later he moved to Rome where he built a successful career dedicated to medical practice, research, and teaching. He became a friend of some of the leading scientists of his age: Lancisi, Malpighi, and Morgagni, among others. He devoted himself to elucidating the structure and function of dura mater, and in his studies often used the new technique of maceration of anatomical specimens in various fluids. Among Pacchioni's written works, the Dissertatio Epistolaris de Glandulis Conglobatis Durae Meningis Humanae (1705) deserves the greatest consideration as it contains the first description of arachnoid granulations. He compared dura to cardiac muscle and attributed to its "glandulae" (glands) the faculty of secreting lymph for lubrication of the sliding movements between meninges and brain during contractions. Three centuries after Pacchioni's death in Rome in 1726, the fine structure of arachnoid villi has not been fully elucidated; moreover, many questions related to mechanisms underlying cerebrospinal fluid absorption remain unanswered.

[Antonio Pacchioni (1665-1726): pioneer studies on the dura mater]

Clustering of arachnoid villi along the sagittal sinus gives rise to the so-called "Pacchionian Granulations". These structures were originally described in 1705 by Antonio Pacchioni, an Italian scientist. Born in Reggio Emilia in 1665, he graduated in Medicine in his hometown and later moved to Rome were he built up a successful career by dedicating to medical practice as well as to research and teaching. He became friend and often collaborated with some of the leading scientists of his age: Lancisi, Malpighi and Morgagni among the others. Moreover he carefully followed research developments in Europe as testified by frequent quoting of foreign authors in his works. He devoted himself to the elucidation of structure and function of Dura Mater, often by using new techniques of maceration of anatomic specimens in various fluids. Among Pacchioni's works, the "Dissertatio epistolaris de glandulis conglobatis Durae Meningis humanae" (1705) is particularly well known and contains the first description of arachnoidal granulations. He compared Dura to cardiac muscle and attributed to its "glandulae" (glands) the faculty of secreting lymph for lubrification of the sliding movements between meninges and brain during contractions. He died in Rome in 1726. Three centuries after Pacchioni's death fine structure of arachnoid villi hasn't been fully elucidated; moreover many questions on mechanisms underlying CSF absorption remain unanswered.

[Evaluation of a new ambulatory blood pressure measuring device, the Sandoz Pressure System]

The accuracy of "Sandoz Pressure System", in comparison with the mercury sphygmomanometer, was studied in 171 patients in 2 centers. The correlation, as estimated for 657 pairs of measurements, was excellent: systolic and diastolic coefficients were r = 0.986 and r = 0.940 respectively. The individual difference is less than or equal to 5 mm Hg for 90% of the systolic values and 82% of the diastolic values. The ambulatory reliability is demonstrated for 300 profiles, of which 279 (93%) are complete. Of 7902 determinations, 59 (0.75%) were deleted because considered to be incorrect.

Glial uptake of excitatory amino acids influences neuronal survival in cultures of mouse hippocampus

Several reports have described apparently normal survival and development of hippocampal and spinal cord culture preparations grown in Ham's F-12 medium, which contains 100 microM each of L-glutamate and L-aspartate. As at this concentration these amino acids are neurotoxic, some adaptive mechanism must occur to allow neuronal survival. We have investigated the mechanism underlying such adaptation. Dissociated cultures of mouse hippocampal neurons were grown in either Eagle's minimum essential medium or Ham's F-12 medium, supplemented with 5% horse serum. Analysis of neuronal density in cultures stained for neuron-specific enolase showed that although large numbers of neurons were present in mature cultures grown in either medium, neuronal survival in cultures grown continuously in F-12 was reduced to 41% compared to controls grown in Eagle's minimum essential medium. Physiological studies showed that those neurons which survived in F-12 did not lose their sensitivity to excitatory amino acids. In addition, the acute application of fresh, serum-free F-12 to 10-14-day-old cultures grown in either minimum essential medium or F-12 was highly neurotoxic. Three lines of evidence suggest that glial uptake of amino acids, and reduction of the extracellular concentration of glutamate and aspartate below neurotoxic levels, rather than receptor desensitization underlies the adaptive mechanism allowing neuronal survival. First, application of fresh F-12 produced large depolarizations, and profound neuronal swelling in cultures grown in F-12; however, after several hours swelling reversed suggesting a slow onset of the adaptive process. Second, pressure application of conditioned F-12 obtained from sister cultures also elicited depolarizations in neurons grown in F-12, but the amplitude of the underlying inward current was 25-30% of that produced by fresh F-12, suggesting a loss of potency of F-12 exposed to prolonged contact with hippocampal cultures. Third, measurement by high performance liquid chromatography showed reduction of aspartate concentrations to around 10% of those present in fresh F-12, within 24 h after exposing glial cell cultures to fresh F-12. It is concluded that cellular uptake mechanisms for amino acids have a strong impact on excitotoxicity in vitro, and most likely play an important role in protecting neurons from the potentially damaging action of high concentrations of excitatory transmitters in vivo. In addition our experiments help to explain the mechanisms permitting neuronal survival in cultures grown in Ham's F-12 medium, which when applied acutely to mature cultures is strikingly neurotoxic.

Galactose elimination capacity and liver volume in aging man

The galactose elimination capacity, a measure of the functional liver cell mass, and liver volume were measured in 50 normal subjects of five different age groups (less than 50, 51 to 60, 61 to 70, 71 to 80 and greater than 81 years). The volume of the liver was evaluated by ultrasonography. All subjects had normal routine liver function tests and no history of liver disease. Galactose elimination progressively decreased from 3.05 +/- 0.58 (S.D.) mmoles per min in younger subjects to 1.83 +/- 0.24 mmoles per min in subjects over 81 (p less than 0.00003), without any change in the apparent volume of distribution of the sugar. Similarly, the estimated volume of the liver decreased from 110 +/- 14 units to 75 +/- 13 units with increasing age (p less than 0.0002). Both galactose elimination capacity and the estimated liver volume inversely correlated with age (r = -0.728 and r = -0.579, respectively) whereas a positive correlation was observed between galactose elimination and the estimated liver volume (r = 0.520). Part correlation analysis confirmed that age, when entered in a multiple regression already containing body weight and estimated liver volume as independent variables, had a significant effect on liver function, whereas no significant independent effect of liver volume was present. Both age and body weight had a significant independent effect on the estimated liver volume. The maximum functional capacity of the liver, measured by galactose elimination, is reduced in the elderly. Although several factors may play a role, our data suggest that aging is associated with a slight decline in the intrinsic metabolic activity of the hepatic parenchyma.

Portal venous flow in response to acute beta-blocker and vasodilatatory treatment in patients with liver cirrhosis

The drugs currently under investigation in the prevention of recurrent gastrointestinal bleeding in cirrhosis are likely to decrease the portal pressure by means of a primary reduction of portal blood flow. The hemodynamic effects of beta-blocking agents and vasodilatory drugs were noninvasively measured in eight patients with cirrhosis by means of pulsed echo-doppler equipment. Portal caliber, blood velocity and flow were recorded hourly after a single dose of propranolol (40 mg p.o.) or atenolol (100 mg p.o.), and every 5 min after treatment with isosorbide dinitrate (5 mg sublingually). The drugs were administered at random with an interval of 2 days or more. The portal caliber decreased after atenolol, but did not change after propranolol and isosorbide. The blood velocity decreased by 29 +/- 2% 3 hr after propranolol, by 26 +/- 2% 3 hr after atenolol and by 31 +/- 3% 15 min after isosorbide. The portal blood flow decreased by 0.29 +/- 0.03 liters per min after propranolol, by 0.34 +/- 0.06 after atenolol and by 0.26 +/- 0.03 after isosorbide, without any difference among the various treatments. beta-blockers and vasodilatory drugs have comparable effects on portal blood flow. beta 1-selective and nonselective beta-blockers are similarly effective in keeping with the hypothesis that changes in portal blood flow are mainly due to the block of beta 1-receptors.

Protein accumulation, RNA and soluble amino nitrogen content in developing endosperm of two varieties of Triticum aestivum with high and low protein seed

The kinetics of protein accumulation, the variation in RNA, the soluble amino nitrogen content of developing endosperm of two varieties of Triticum aestivum, with high and low protein content in the mature seed, suggest a possible relation between maintenance of the RNA content and the ability to synthesize protein. A sudden halt in protein accumulation is observed as the RNA starts to decrease. The hypothesis is also advanced that maintenance of the RNA content might, in turn, be dependent on the presence, in the endosperm of developing wheat seed, of a certain level of soluble amino nitrogen which could then play the role of limiting factor for protein synthesis.