P526Are 40 joules enough for successfully defibrillate with subcutaneous implantable cardioverter-defirbrillator?

Funding Acknowledgements

NO FUNDING

OnBehalf

Rhythm Detect Registry

Background

The subcutaneous ICD (S-ICD) is an effective alternative to the traditional transvenous option. Due to its extracardiac design the S-ICD requires a higher shock output than the traditional ICD. Nonetheless, preliminary data suggest that acute defibrillation test may be successful even at energies lower than the usually tested value of 65J, and that optimization of implantation technique may increase the defibrillation safety margin among S-ICD recipients.

Purpose

To evaluate the efficacy of conversion test performed at 40J, and to investigate the association between shock efficacy, clinical characteristics and device position.

Methods

VF was induced and subsequently, conversion test was performed by delivering a 40J shock. Success was defined as termination of VF by the first shock. S-ICD system positioning was evaluated with the PRAETORIAN score using bidirectional chest X-rays. Cranial-caudal S-ICD placement was defined as superior if the entire generator was contained in the cardiac silhouette, inferior if partially or completely outside.

Results

233 consecutive patients (83% male, 49 ± 14 years, BMI 26 ± 4kg/m2, ejection fraction 46 ± 17%, 112 (48%) ischemic/non-ischemic dilated cardiomyopathy) were enrolled and underwent S-ICD implantation with conversion test at 40J. The generator was positioned in an intermuscular pocket in 228 patients (98%). The PRAETORIAN score was <90 (low risk of conversion failure) in 218 (94%) patients. Cranial-caudal generator placement was superior in 188 (81%) patients. Overall, VF termination occurred in 191 (82%) patients with 40J. The BMI was similar in patients with successful and unsuccessful termination (26 ± 4kg/m2 versus 27 ± 6kg/m2, p = 0.195). The efficacy was comparable in patients with dilated cardiomyopathy (86%) versus other conditions (79%, p = 0.153). PRAETORIAN score was not associated with shock efficacy at 40J (82% with score <90 versus 87% with score ≥90, p = 1.000), while a trend toward higher efficacy was seen with superior generator placement (84% versus 73%, p = 0.093).

Conclusions

We observed high S-ICD defibrillation success rate at 40J, suggesting that the safety margin is frequently higher than the usually accepted 15J. We found no difference in efficacy according to the cardiac disease and no association between test failure and body habitus. The intermuscular positioning of the generator resulted in low values of the PRAETORIAN score that however did not appear associated with test efficacy.

Tumor-Like Multiple Sclerosis: Report of Four Cases and Literature Review

Aims and background

Classical multiple sclerosis plaques usually have typical features on gadolinium-enhanced MRI scan. This non-neoplastic demyelinating process of the central nervous system generally does not produce focal space-occupying lesions associated with ring enhancement. However, atypical appearance of demyelinating lesions simulating a brain tumor is a possible well-known phenomenon.

Methods

We present our experience with 4 cases of multiple sclerosis indistinguishable clinically and neuroradiologically from a cerebral tumor. All patients underwent surgery.

Results

Histological examinations of all cases were positive for multiple sclerosis plaques.

Conclusions

The presented cases demonstrate the importance of considering a demyelinating disease in the differential diagnosis of a tumor-like brain lesion.

Extremely Delayed Cerebral Metastasis from Renal Carcinoma Report of Four Cases and Critical Analysis of the Literature

Brain metastases from renal carcinoma may appear even a long time after surgical treatment of the primary tumor. The authors present 2 series of patients, one of which has already been published and the other new, for a total of 4 cases of brain metastasis from renal carcinoma with late onset, which occurred 13, 17, 26 and 12 years after primary surgical treatment. The other cases described in the literature were also critically reviewed.

Post-Traumatic Glioma. Report of Four Cases and Review of the Literature

Aims and background

To add a further contribution to the literature supporting the relationship between previous head trauma and development of glioma.

Methods

We report on four patients who developed brain gliomas in the scar of an old brain injury.

Results

All cases fulfilled the widely established criteria for brain tumors of traumatic origin. In all of our cases there was radiological evidence of absence of tumor at the time of the injury.

Conclusions

We believe that in specific cases it is reasonable to acknowledge an etiological association between a severe head trauma and the development of a glioma. This assumption is further sustained if there is radiological and surgical documentation of the absence of neoplasia at the moment of the trauma.

High-Dose Radiation-Induced Meningiomas. Report of Five Cases and Critical Review of the Literature

Radiotherapy is an important modality for the treatment of tumors and arteriovenous malformations affecting the central nervous system, even though several significant side effects have been described (radionecrosis, tumors, etc.). Meningiomas induced by high-dose radiation therapy are uncommon. In this study we describe five cases treated at our institute and review all previously published reports of meningioma occurring after high-dose radiotherapy. These tumors develop mainly in patients irradiated in childhood; their incidence peaks in the second decade of life, there is a predominance in females and a high frequency of malignant forms. Although rare, meningiomas may represent a late complication of radiation treatment. The behavior of the radiation-induced variety of meningioma seems to differ from that of its “spontaneous” counterpart. The use of radiotherapy should be carefully evaluated for relatively benign or congenital lesions which generally affect young patients with a long life expectancy.

Primary Cerebral Lymphoma: A Retrospective Study in 22 Immunocompetent Patients

Aims and background

Primary CNS lymphomas are uncommon tumors in immunocompetent patients. We describe the radiological features that should orient towards performing a biopsy and analyze the results in our series of patients.

Methods

We reviewed 22 immunocompetent patients with primary central nervous system lymphoma admitted in our Institute between 1977 and 1997. The follow-up period ranged from 2 months (patient deceased) to 69 months. Fourteen patients underwent surgical removal of the tumor and the remainder a biopsy. All patients received radiotherapy and 8 patients radiotherapy plus chemotherapy.

Results

Two of the 14 patients treated by surgical removal of the tumor died. There was no mortality related to biopsy procedures. Patients treated with radiotherapy had 1-year, 2-year and 5-year survival rates of 66%, 41.6% and 16.6%, compared to 87.5%, 62.5% and 50%, respectively, for patients who received radiotherapy and chemotherapy.

Conclusions

At present, there is no definite treatment for these highly malignant brain tumors. The most favorable results seem related to biopsy followed by radiotherapy plus chemotherapy versus surgical removal, which is related to a high risk of severe postoperative deficit for both the deep location and infiltrating nature of these lesions.

Post-Traumatic Intracranial Meningiomas

The authors present 20 cases of likely post-traumatic intracranial meningiomas selected according to the conditions specified in the relevant literature. The relationship between head injury and subsequent development of meningioma remains a controversial and fascinating subject. The etiopathogenetic mechanisms and clinical features of our patients and those of the literature are discussed.

Predictive role of dynamic contrast enhanced T1-weighted MR sequences in pre-surgical evaluation of macroadenomas consistency

PURPOSE

Our hypothesis was that pituitary macroadenomas show different areas of consistency detectable by enhanced magnetic resonance imaging (MRI) with Dynamic study during gadolinium administration.

MATERIALS AND METHODS

We analysed 21 patients with pituitary macroadenomas between June 2013 and June 2015. All patients underwent trans-sphenoidal surgery and neurosurgeon described macroadenomas consistency. Similarly, two neuroradiologists manually drew regions of interest (ROIs) inside the solid-appearing portions of macroadenoma and in the normal white matter both on dynamic and post-contrast acquisitions. The ratio between these ROIs, defined as Signal Intensity Ratio (SIR), allowed obtaining signal intensity curves over time on dynamic acquisition and a single value on post-contrast MRI. SIR values best differentiating solid from soft macroadenoma components were calculated and correlated with pathologic patterns. A two-sample T test and empiric receiver operating characteristic (ROC) curve of SIR was performed.

RESULTS

According to ROC analysis, the SIR value of 1.92, obtained by dynamic acquisition, best distinguished soft and hard components. All the specimens from soft components were characterized by high cellularity, high representation of vascularization and micro-haemorrhage and low percentage of collagen content. The reverse was evident in hard components.

CONCLUSIONS

We demonstrated that dynamic MRI acquisition could distinguish with good accuracy macroadenomas consistency.

Platinum-iridium subdermal magnetic resonance imaging-compatible needle electrodes are suitable for intraoperative neurophysiological monitoring during image-guided surgery with high-field intraoperative magnetic resonance imaging: an experimental study

BACKGROUND

Neurosurgery aims to achieve maximal tumor resection while preserving neurological function. Tools such as neuronavigation, high-field intraoperative magnetic resonance imaging (iMRI), and intraoperative neurophysiological monitoring (IOM) have consistently helped to achieve this goal, but integration has often been difficult. Surgery of eloquent areas requires IOM, which in an operating theater equipped with high-field (1.5-T) iMRI could present several issues.

OBJECTIVE

To identify the electrodes types more suitable for IOM in a high-field iMRI operating theater by performing an experimental study on phantoms, to report our experience with platinum-iridium (Pt/Ir) electrodes during surgery, and to prove that integration between IOM with Pt/Ir electrodes and high-field iMRI is safe and reliable.

METHODS

Electrodes of different materials (gold, Pt/Ir, and stainless steel) were tested on jelly phantom and apples to evaluate their safety and compatibility. Subsequently, electrodes were tested on 5 healthy volunteers before being used on patients.

RESULTS

None of the different electrodes presented thermal instability, and no damage to the volunteers' skin occurred. Stainless steel electrodes caused severe imaging distortion. Gold electrodes had no distortion, but their high cost makes their use in routine surgery unaffordable. Pt/Ir electrodes are significantly less expensive than gold electrodes and were completely safe, compatible, and suitable for use in an operating theater with high-field iMRI, providing excellent IOM and mild interference that did not affect the quality of intraoperative imaging.

CONCLUSION

We suggest the use of Pt/Ir electrodes for IOM in 1.5-T iMRI suites.

ABBREVIATIONS

DTI, diffusion tensor imagingiMRI, intraoperative magnetic resonance imagingIOM, intraoperative neurophysiological monitoring.

Neural stem cells and glioblastoma

Glioblastoma multiforme represents one of the most common brain cancers with a rather heterogeneous cellular composition, as indicated by the term "multiforme". Recent reports have described the isolation and identification of cancer neural stem cells from human adult glioblastoma multiforme, which possess the capacity to establish, sustain, and expand these tumours, even under the challenging settings posed by serial transplantation experiments. Our study focused on the distribution of neural cancer stem cells inside the tumour. The study is divided into three phases: removal of tumoral specimens in different areas of the tumour (centre, periphery, marginal zone) in an operative room equipped with a 1.5 T scanner; isolation and characterization of neural cancer stem cells from human adult glioblastoma multiforme; identification of neural cancer stem cell distribution inside the tumour.

Spectroscopic Response Versus Interelectrodic Charge Formation Position in CdTe Detectors

The electron-hole pair production energy (∼ 4.43 eV) in cadmium telluride semiconductor based detector would allow, in principle, to achieve spectroscopic performance close to germanium. In fact the material impurities, crystal lattice defects and low charge mobility, mainly for holes, can severely degrade the spectroscopic properties through charge trapping/detrapping and recombination phenomena, limiting the usable distance between the electrodes. The charge collection efficiency depends, following the Hecht relation, on the distance between the charge production location and the collecting cathode; we have studied the dependence of some CdTe spectroscopic parameters (energy resolution, photo-peak gain and efficiency) from this distance. A set of experimental tests were performed using a well collimated photon beam. The beam spot, obtained from a 57Co radioactive source through a thick (20 mm) tungsten collimator having a 0.2×2 mm window, was positioned between the two electrodes of a CdTe crystal of size 3×5×2 mm3, with the electrodes deposited on the 3×5 mm2 sides.

The detector was irradiated on the face having the area of 2×3 mm2, in the arrangement with the collecting field orthogonal to the incoming radiation (PTF configuration), and the largest side of the spot parallel to the electrode plane. Using a micro-positioning system a fine scanning of the interelectrodic region was performed.

In order to evaluate the detector behavior in a wider energy range, further tests using energies between 14 keV to 662 keV have been performed.

The results of these measurements are presented and discussed in order to emphasize a method to improve CdTe detector spectroscopic capabilities and to understand the detection behavior

Cerebral ependymoma in a patient with multiple sclerosis case report and critical review of the literature

BACKGROUND

The concurrence of multiple sclerosis (MS) and brain tumors is a rare but well-recognized condition. The radiologic evidence of the progressive evolution of a mega-plaque in a tumor has never been described. We report the first case of such an occurrence.

METHODS

A 27-year-old woman with a diagnosis of MS was referred to us for an intense frontal headache. Magnetic resonance imaging showed a mass lesion in correspondence of a black hole lesion previously diagnosed. The patient was operated on, with complete removal of the tumor documented by an intraoperative MRI. The histologic examination evidenced an ependymoma. Postoperative radiotherapy was performed.

RESULTS

The patient is well and recurrence-free at 2 years follow-up.

CONCLUSIONS

The present case, documenting the transformation of a mega-plaque into a tumor, suggests a cause-effect relationship between MS and brain tumors.

Retroperitoneal mesenchymal chondrosarcoma mimicking a large retroperitoneal sacral schwannoma

We report a case of retroperitoneal chondrosarcoma in which preoperative radiological study induced to a possible diagnosis of sacral schwannoma. A 25-year-old woman was admitted to our neurosurgical institute for a progressive sciatic pain with gait difficulties with a sudden radicular deficit with right positive Lasegue's sign at 30 degrees, loss of Achilles reflex, sensory deficit on right S1 dermatome, and complete motor deficit of right plantar flexion. We performed an en bloc removal of the lesion via an anterior retroperitoneal approach. We believe that the treatment of choice is radical surgical excision of the tumor with complete en-bloc removal of the lesion; postoperative radiotherapy and chemotherapy should be valuated case by case.

Anterior cervical fusion with interbody titanium cage containing surgical bone site graft: our institution's experience in 103 consecutive cases of degenerative spondylosis

The objective of this study is to evaluate whether anterior cervical fusion performed using BAK-C cage is a safe and effective method in the treatment of degenerative cervical disorders. Between 1998 and 2001, a consecutive series of 103 patients underwent anterior cervical fusion with titanium cage for cervical radiculopathy and/or spondylotic myelopathy. All the patients underwent single-level surgery. The mean follow-up period was 4.8 years. Results were evaluated on the basis of Nurick scale, JOA classification, patient satisfaction, fusion status, and degree of cervical lordosis. Patients are seen postoperatively at 2, 12 months, and annually. At the last follow-up the patient satisfaction rate was excellent in 83% of the patients, good in 12%, fair in 3%, and poor in 1%. A solid fusion was achieved in 98.9% of the patients. Preoperative lordosis was maintained in 93.8% of the patients and increased in 6.2%. This study suggests that BAK-C system filled with autologous bone graft for anterior cervical fusion is a safe and effective method, with a good rate of fusion, very high rate of patient satisfaction, and satisfactory clinical outcome.

Intradural Eosinophilic Granuloma with Intraparenchymal Invasion: A New Growth Pattern

BACKGROUND

Eosinophilic granuloma is a form of Langerhans' cell histiocytosis, most commonly involving the skeletal system. We present the first case of an eosinophilic granuloma originating from the dura mater with secondary parenchymal and osseous invasion.

CASE REPORT

A 32-year-old man was referred to us for headache and swelling in the right parietal region and a history of minor head trauma. The radiological and surgical findings were suggestive of meningosarcoma. Intraoperatively the lesion was found to originate from the dura mater. Histological diagnosis was eosinophilic granuloma. After a 21-month follow-up period, MRI was negative.

CONCLUSION

Intradural development is a possible growth pattern of eosinophilic granuloma. An inflammatory process of the dural membrane with migration of Langerhans' cells could be the physiopathological basis for the formation of intradural eosinophilic granuloma. This is a mechanism similar to that of chronic subdural haematoma formation. Histological demonstration of eosinophilic granuloma cells around the lesion margin suggests the need to remove dura mater peripherally to the lesion.

Membranectomy in organized chronic subdural hematomas: indications and technical notes

BACKGROUND

The aim of the present study is to present our operative method of removing organized CSDHs and to structure the criteria for choosing this approach as first treatment.

METHODS

Between 1991 and 1999 at our Institution, 14 consecutive patients with organized CSDHs required 16 craniotomies with membranectomy. They represent 5.8% of all patients (243) treated for CSDHs in the same period. All the patients had preoperative contrast-enhanced CT, and 9 patients also had contrast MRI.

RESULTS

Initially, 9 patients underwent one burr hole or twist-drill hole. Of these 9 patients, 3 were treated at the same surgery with craniotomy and membranectomy as second treatment, 3 underwent a second burr hole and then membranectomy at the same surgery, and 3 patients underwent a second burr hole 3, 4, and 21 days after the first one and then membranectomy. Five patients underwent immediate craniotomy and membranectomy. There were no morbidity or mortality associated with this procedure. All patients had a full recovery without recurrence.

CONCLUSIONS

Contrast-enhanced MRI has greatly improved opportunities for discovering neomembrane before surgical intervention. We believe that MRI detection of thick and extensive membranes or solid clot with mass effect makes an immediate craniotomy to remove CSDH necessary.

A case of intraroot cauda equina cavernous angioma: clinical considerations

STUDY DESIGN

Case report and literature review.

OBJECTIVE

Intradural-extramedullary cavernoma is a rare condition with only 23 cases reported in the literature. Most cases described adhere to spinal root or spinal cord. We report an example of this rare entity located within the sheets of one cauda equina nerve root.

SETTING

Rome, Italy.

METHODS

The authors report clinical, radiological, surgical, and pathological features of intraroot cavernoma with a literature review.

RESULTS

Patient was operated. One year after surgery, he was healthy.

CONCLUSION

Lumbar intradural cavernous angioma may present with sciatalgia, low-back pain, neurological deficit, or, more rarely with subarachnoid hemorrhage or hydrocephalus. They are treated successfully with surgical resection but preoperative status is a predicting factor for outcome. Sometimes the sacrifice of the spinal root is inevitable because, as in present case, the cavernous angioma is included in the nerve root. These lesions are rare and benign lesions. It is important for neurosurgeons to be aware of the existence of this entity to avoid preoperative misdiagnosis with tumor.

Papillary Glioneuronal Tumor

OBJECTIVE AND IMPORTANCE

Papillary glioneuronal tumor is a recently described neoplasm composed of gliovascular pseudopapillae associated with intervening neuronal cells ranging from neurocytes to ganglion cells. This tumor is not currently included in the WHO classification of tumors of the central nervous system. We describe a new case of papillary glioneuronal tumor and analyze the data for a series of further 15 patients from international literature.

CLINICAL PRESENTATION

A 27-year-old man presented to us for generalized seizure. CT and MRI showed a cystic tumor with mural nodule in the left frontal lobe.

INTERVENTION

Frontal craniotomy with gross total removal of the tumor was performed. Histopathological examination was positive for papillary glioneuronal tumor.

CONCLUSION

The clinical, radiologic, and pathological features of our case are strikingly similar to those of the previous reported cases. A review of the literature disclosed only 15 other cases of these tumors. It is important that every new case of PGNT is reported to allow its recognition and classification.

Meningiomas infiltrating the superior sagittal sinus: surgical considerations of 328 cases

The aim of the study was to discuss our management strategy and results of patients affected by meningiomas infiltrating the superior sagittal sinus. We describe 328 patients with meningiomas that were infiltrating the superior sagittal sinus. All the patients were surgically treated. Patients with meningioma involving the anterior segment of the sinus underwent total sinus resection. Patients with meningioma that was infiltrating the middle and posterior third of the sinus had a complete sinus removal if the dural sinus was completely obliterated by meningioma and incomplete removal if the sinus was not occluded. The tumour removal was grade I according to Simpson's grading system in 193 cases and grade II or III in the remainder. The superior longitudinal sinus was totally resected in 215 patients and marginally resected in 113. The tumour reappeared in 38 patients. The number of re-interventions did not affect clinical outcome. The extent of removal significantly influenced the regrowth or recurrence rate. Our results suggest that the risks of aggressive surgery, with sinus reconstruction, may be avoided, and conservative surgery for meningiomas that are infiltrating but not obliterating the superior sagittal sinus may be a reasonable choice.

Intracranial meningiomas in children: report of 27 new cases and critical analysis of 440 cases reported in the literature

We accumulated 440 cases of intracranial meningiomas in patients under 16 years of age, and another 27 personal. This review confirms the existence of specific clinical features of spontaneous and radiation-induced meningioma in children. In addition, we discuss various points that suggest a more aggressive behavior of meningiomas in children than in adults. (J Child Neurol 2006;21:31-36).

Gliomatosis cerebri in children. Case report and clinical considerations

OBJECTIVE

Gliomatosis cerebri (GC) is an uncommon entity characterised by the diffuse overgrowth of large parts of the brain by glial cells. Reports in the literature often refer to adult patients, its occurrence in children being even more rare.

CASE REPORT

We report the case of an 8-year-old boy with GC and discuss the problem of intra vitam diagnosis.

CONCLUSIONS

Diagnosis of GC is very difficult; thus, cases diagnosed during life are rare.

Spinal glioblastoma with brain relapse in a child: clinical considerations

STUDY DESIGN

Case report.

OBJECTIVES

To describe a child with intramedullary glioblastoma at T9-T10-T11, and to discuss the clinical features of this rare pathology.

SETTING

Department of Neurological Sciences, Italy.

CASE REPORT

Spinal cord glioblastoma in children has only rarely been reported. It most frequently involves the thoracic region with a predilection for the second and third decades of life. This report describes one case of thoracic glioblastoma multiforme in a 6-year-old child and reviews other cases reported in the literature.

RESULTS

Laminectomy and excision of the tumour were performed. Postoperative radiotherapy and chemotherapy were given, but 4 months later the patient presented with a brain relapse of the tumour. At 9 months after diagnosis the patient died from cerebral tumour regrowth.

CONCLUSIONS

Full neuraxis MRI is always recommended in order to detect possible metastases. The prognosis after multimodality therapy (surgery, radiotherapy, chemotherapy) remains poor. From the literature, only four cases of paediatric patients with long-term survival have been reported.

Gliosarcomas: analysis of 11 cases do two subtypes exist?

There are conflicting reports regarding gliosarcomas. The goal of this study is to examine clinical, radiological, surgical and therapeutic aspects of 11 patients with gliosarcoma. Between 1993 and 2001, 11 patients with cerebral gliosarcoma were treated at our Institute. Ten patients underwent surgery and one patient had stereotactic biopsy. Four patients received whole brain radiotherapy with (60)Co, five underwent radiotherapy with LINAC extended 2 cm beyond the edema margins. One patient refused any additional treatment after surgery and one patient was not treated postoperatively for poor clinical conditions (KPS 40). Chemotherapy (temozolomide) was administered to four patients. Four patients had a prevalence of sarcomatous component that corresponded to surgical and radiological aspects similar to meningioma while six patients showed a prevalence of gliomatous component and radiological and surgical aspects similar to those of glioblastomas. Surgical resection was total in six and subtotal in four patients. Patients with prevalent sarcomatous component showed median survival time more prolonged than patients with prevalent gliomatous component (71 +/- 6 weeks vs. 63 +/- 6; P=0.0417). Moreover, the survival rate differed in relation to the therapy: patients treated with multimodality therapy (surgery, radiotherapy and chemotherapy) had a longer survival time than patients treated in single or bimodality. Despite prognosis of gliosarcomas remains poor, a multidisciplinary approach (surgery, radiotherapy and chemotherapy) seems to be associated with slight more prolonged survival times.

Multilevel oblique corpectomy without fusion: our experience in 48 patients

STUDY DESIGN

The authors provide their results in performing multilevel oblique corpectomy for degenerative spondylotic myelopathy in 48 patients.

OBJECTIVE

To demonstrate the efficacy and safety of the multilevel oblique corpectomy when applied in selected cases.

SUMMARY OF BACKGROUND DATA

The technique of multilevel oblique corporectomies for treatment of cervical spondylogenetic myeloradiculopathies allows anterolateral access to the cervical spine so that the spinal canal and conjugate foramen can be widened at more than one level, without the need for vertebral stabilization.

METHODS

During a 7-year period, multilevel oblique corpectomy was performed in 48 consecutive patients for degenerative spondylotic myelopathy. The outcomes were analyzed according to the Japanese Orthopaedic Association classification modified to Western customs, and according to Nurick's scale 1 month, 1 year, and 2 years after surgery. Spinal stability was evaluated in all patients by plain radiograph films of the cervical spine, lateral views in flexion and extension, on discharge, 1 month and 1 year after operation.

RESULTS

Significant clinical improvement occurred in 29 patients with a complete functional recovery in 22; moderate improvement was achieved in 12 patients; neurological status remained stable in 5, and it worsened in 2. All patients showed spinal stability.

CONCLUSIONS

Multilevel oblique corpectomy was found to be a safe technique that guarantees good results in terms of both regression of clinical symptoms and long-term spinal stability.

Intrameningioma metastasis as first clinical manifestation of occult primary breast carcinoma

Metastasis from extracranial tumor into an intracranial primary tumor is an uncommon event. A predominant tendency of meningioma to be the host tumor for breast carcinoma has been found. In the current report, three cases of breast carcinoma metastatic to intracranial meningiomas are described. In our cases, metastasis in meningioma was the first clinical manifestation of the occult primitive breast carcinoma. We review widely the literature concerning such rare occurrences and discuss all the postulated pathogenetic mechanisms. There are few cases reported in the literature on resonance magnetic imaging of metastatic carcinoma in meningioma. Two of our patients have been studied by MRI, but we do not find predictive radiological finding of this particular association.

Traumatic epidural hematoma in children

The purpose of this study was to investigate the characteristics of childhood acute epidural hematoma and to report our experience in recent years. A series of 35 patients below the age of 15 years treated for acute epidural hematoma at our institution between June 1991 and December 2000 was analyzed in detail. Pediatric epidural hematoma presents both age-related and atypical features when compared with epidural hematoma in adults. In selected cases, prompt surgical evacuation of the hematoma results in an excellent outcome. Outcomes seem to be directly related to the patient's preoperative neurologic status and the presence of associated intracranial lesions.

Brain metastasis from cutaneous squamous cell carcinoma of the dorsum

✓ The majority of cutaneous squamous cell carcinoma (SCC) are diagnosed early and cured using local treatment, although a minority of cases metastasize to regional structures. In this report the authors describe an unknown feature of skin SCC, namely, distant brain metastasis. This 54-year-old man, who had undergone surgery for moderately differentiated SCC of the dorsum (T2N0M0 stage), was admitted to our institution 11 months later with headache, vomiting, and ataxia. A magnetic resonance image documented a cerebellar lesion, which was totally removed. Results of histological studies revealed SCC. The patient received whole-brain radiotherapy (30 Gy over 2 weeks using a linear accelerator). A metastatic work-up showed enlarged inguinal and para-aortic lymph nodes that were histologically examined using excisional biopsy. Inguinal lymph nodes were tumor-positive and were dissected. The patient was subjected to two cycles of chemotherapy with cisplatin (75 mg/m2). After 3 months, a significant reduction in the size of the para-aortic lymph nodes was documented on control computerized tomography studies. Although the described case is unique, knowledge of the potential for this uncommon behavior in cutaneous SCC may be useful, especially because of its increasing incidence.

Brain metastasis from prostate cancer. Report of 13 cases and critical analysis of the literature

Brain metastasis from prostate carcinoma occurs very rarely. We describe 13 patients with single brain metastasis from prostatic cancer. Total removal of the lesions was performed in ten patients. Three patients underwent stereotactic biopsy. All patients were treated with postoperative whole brain radiotherapy (WBRT). Eight patients died for systemic disease after a mean time of 9.2 months with a diagnosis of metastasis. Five patients are still alive at 20, 14, 11, 7 and 6 months, respectively. Even if brain metastasis from prostate cancer is often a terminal event with death occurring within few months from diagnosis, we suggest the same protocol (surgery and/or radiosurgery plus postoperative WBRT) usually adopted to treat brain metastasis from other primitive tumours. A non specific neurological symptomatology and a possible normal dosage of serum specific antigen may contribute to a delay in diagnosis. However, considering the rarity of brain metastasis from prostate carcinoma, standard brain MRI follow-up in men with prostatic cancer does not seem to be necessary yet.

Central nervous system mesenchymal chondrosarcoma

Central nervous system mesenchymal chondrosarcomas are rare malignant tumors that constitute a separate entity from the classical chondrosarcoma and myxoid variant. Clinical behaviour of central nervous system chondrosarcomas is still unknown. We describe two rare examples of intracranial mesenchymal chondrosarcoma with a review of the literature, in an attempt to clarify the clinical characteristics, prognosis and treatment of choice of these unusual tumors. Among the 55 reported cases, 23 had postoperative radiotherapy. Although there is no statistical significance according to the Log-Rank test (p=0.7), the patients treated with radiation therapy seem to have a better chance of survival. Patients who had adjuvant chemotherapy (only 5) showed survival times similar to those patients who had none. Although clinical behaviour of central nervous system chondrosarcomas remains to be defined, data from our series as well as literature show that radical removal is the best therapeutic choice. In addition, patients treated with postoperative radiotherapy seem to show a trend toward increased survival.

Severe craniofacial fractures with frontobasal involvement and cerebrospinal fluid fistula: indications for surgical repair

BACKGROUND

The management of posttraumatic cerebrospinal fluid (CSF) fistulae is a controversial topic. Although recent literature shows that endoscopic repair of CSF fistula is efficacious and minimally invasive, in specific conditions open operative approach remains imperative.

METHODS

A series of 36 patients underwent surgery for posttraumatic CSF fistula according to specific selection criteria. These criteria included: bone displacement more than 1 cm (5 cases), location of fracture in proximity to the midline (6 cases), involvement of cribriform plate (12 cases), presence of encephalocele (3 cases), and failure of the conservative treatment (10 cases). The dural defect was closed using vascularized pericranium and fibrin glue. Closure of the basal bone defect was necessary in very large fractures or in special localization of the fistula, such as near the optic nerve. Mean clinical follow-up was 5.7 years.

RESULTS

Two patients presented meningitis without sequelae, and 12 with hyposmia. One patient died of the severity of the primary brain injury and associated extracranial lesions. None of the patients had recurrence.

CONCLUSIONS

Our results indicate that surgical dural repair in selected cases is related to low morbidity and mortality preserving from delayed risks such as recurrence and infections.

Thirty-seven cases of intracranial meningiomas in the ninth decade of life: our experience and review of the literature

OBJECTIVE

We report a series of 37 elderly patients who were surgically treated for intracranial meningioma in the ninth decade of life at our neurosurgical division between 1985 and 2002.

METHODS

Our study included 37 patients ranging in age from 80 to 86 years (29 women, 8 men). The preoperative neurological status was evaluated according to Karnofsky Performance Scale (KPS) status. The patients' general health condition was evaluated according to the American Society of Anesthesiology (ASA) classification.

RESULTS

Five patients (13.5%) experienced perioperative mortality. The risk of postoperative mortality was higher in patients graded as ASA Class III who had low preoperative KPS ratings (< 70), whereas it was lower in patients graded as ASA Classes I and II (P > 0.001). The postoperative mortality rate was significantly higher in patients graded as having a KPS score of less than 70 (P > 0.01). The risk of postoperative morbidity seems higher with larger maximum tumor diameters (P < 0.05). Surgical excision and the presence of a severe peritumoral edema seem to be associated with a higher risk of postoperative morbidity (P < 0.05).

CONCLUSION

Surgical removal of a meningioma in the elderly is a safe procedure if the preoperative ASA classification is I or II and if the KPS rating is at least 70. Age seems not to be an insuperable obstacle when adequate management of all risk factors has been obtained.

Occipital condyle fractures: report of five cases and literature review

Occipital condyle fractures (OCFs) are uncommon and potentially fatal lesions. After the advent of CT, prompt diagnosis can be readily made and consequently better prognosis of these patients is expected. Early recognition of some types of OCF is imperative to avoid fatal results. We analyzed 121 cases of OCF (116 from the literature and five of our own). Rarely patients with a deficit of the lower cranial nerves make a complete recovery. However, quoad vitam prognosis of patients with "pure OCFs" remains good. Immobilization provides good recovery of most OCFs, but delay of treatment can lead to serious morbidity. We want to emphasize that not only an OCF with instability of O-C1-C2 can be a fatal injury unless prompt surgical intervention, but a displacement and migration of the fractured condylar fragment can also result in a fatal outcome. A high level of suspicion is fundamental for the early diagnosis of these fractures, so that when a posterior basal cranial or occipital squama fracture occurs, a CT study of the occipital condyles becomes imperative.

High-Dose Radiation-Induced Meningioma in Children

OBJECT

High-dose radiation-induced meningiomas in children are a rare occurrence. We discuss the clinical data and the differences of these rare tumors from those of spontaneous counterpart and radiation-induced meningiomas of the adult population.

CASE REPORT

We report a case of meningothelial meningioma, which occurred in a 9-year-old boy who underwent radiotherapy for a parieto-occipital cutaneous angioma. In addition, we collected 18 cases of high-dose radiation-induced meningiomas in children from a literature review with Medline.

RESULTS

Radiation-induced meningiomas in children show a female predominance, a short latency period that seems to be related to the age at irradiation, and an aggressive behaviour.

CONCLUSION

Exposure to the potentially carcinogenic effects of radiotherapy should be reserved only for tumors that demonstrate subsequent progression. A meticulous follow-up of patients treated with radiation therapy is mandatory.

“Supine-Prone” Dynamic X-Ray Examination

Lumbar instability often causes clinical symptoms, and spondylolisthesis is a main factor of the low back pain. Segmental lumbar instability generally is due to a degenerative or listhesic process of the lumbar spine and radiological imaging is essential to diagnose it. Lumbar spine segmental mobility has commonly been studied by dyanamic radiographic methods. Dynamic X-rays, with maximal extension and flexion of the lumbar tract, represents the most widely used technique and a valid method to estimate sagittal segmental lumbar motion. Between 1998 and 2002 we treated 75 patients for low-grade spondylolisthesis. All patients underwent a preoperative dynamic X-rays examinination, to evaluate the degree of the lumbar mobility. We report a supine-prone position as new method to clearly estimate the slipping of lumbar vertebrae. The patients had a standard lateral X-rays film in the supine position, and then in the "prone" position. We compared the two methods and we found a higher degree of listhesis in 19 cases (14 I grade, 5 I-II grade), while there was no difference in 56 cases. The higher degree of listhesis was in the prone position. We believe that the supine-prone position is an economic method and should be mandatory performing a dynamic X-rays examination.

Spinal en Plaque Meningiomas: A Contemporary Experience

OBJECTIVE:

Spinal en plaque meningiomas are rare and challenging lesions because of their tendency to induce spinal arachnoiditis. The surgical treatment of this type of meningioma is more complex than that of classic meningioma.

METHODS:

We report seven cases of spinal en plaque meningiomas and review all the cases reported in the literature accessible to us by a MEDLINE search.

RESULTS:

All patients underwent microsurgery. Complete tumor removal was achieved in three patients. Subtotal removal was performed in four patients. A permanent neurological worsening was observed in one patient.

CONCLUSION:

Spinal meningiomas en plaque bear a prognosis poorer than that of classic meningiomas with regard to the possibility of a definitive surgical cure because recurrence or postoperative arachnoiditis occurs frequently. Total surgical removal should be attempted only when a clear plane of cleavage between tumor and arachnoid exists.

Solitary cerebral metastases from ovarian epithelial carcinoma: 11 cases

Ovarian cancer is quite common in women, but brain metastases from ovarian cancer are considered rare. Eleven patients with solitary cerebral metastasis from ovarian epithelial carcinoma were treated at the Neurosurgical Department of University of Rome La Sapienza, between 1980 and 2000. We treated all of the 11 patients by surgical en bloc removal and by postoperative radiotherapy and chemotherapy. Mean survival was 28 months, and the cause of death was recurrence of the systemic disease in all cases. Multimodal treatment by surgery, radiation and chemotherapy is the best choice of treatment and leads to a median survival of about 20 months.

Spontaneous, Multiple Meningiomas

OBJECT

The aim of this study is to discuss the management strategy of patients with multiple meningiomas.

METHODS

We describe 35 patients with multiple meningiomas. No patients carried stigmata of neurofibromatosis. All patients were studied using MR or CT after surgical treatment.

RESULTS

All 35 patients received surgical treatment. A total of 40 operations was performed. The resection of 4 meningiomas was subtotal and all other tumors were radically resected. We had excellent results with reversible operative complications in only three patients. There were no recurrences.

CONCLUSIONS

We suggest that surgery is suitable for the treatment of multiple meningiomas with the following characteristics: symptomatic meningioma, asymptomatic meningioma greater than 3 cm in size and surgically accessible, and asymptomatic expanding tumor. In patients with multiple tumors, each tumor must be treated as an individual entity. The mere presence of multiple tumors does not justify their removal.

Multiple sclerosis and gliomas. Clinical remarks on 10 cases and critical review of the literature

The association between multiple sclerosis and tumours of the central nervous system is unusual. The authors analyzed the clinico-pathological elements of the correlation. The pertinent literature on this subject is critically reviewed. Ten cases of patients with an history of multiple sclerosis for more than 15 years and a clinical and radiological evidence of brain tumour were submitted to surgery in order to remove the lesion and/or to chemo- and radiotherapy. The various aspects of the association were studied in detail. A patient with multiple sclerosis, particularly with atypical symptoms, should be evaluated by an annual MRI investigation with intravenous paramagnetic contrast medium. The diagnostic work-up should be: clinical and radiological assessment; MRI in the event of atypical symptoms; Sstereotactic or neuronavigation-aided biopsy in any suspected lesions. Patients with multiple sclerosis and glioma present survival times identical to those observed in patients not suffering from multiple sclerosis. The coexistence of multiple sclerosis and brain tumours does not seem to influence the clinical evolution of either of these pathologies. We believe that it is important to achieve an early diagnosis of brain tumour in such patients with a clinical and neuroradiological follow up, so that they can be treated promptly.

Lumbar spinal angiolipomas: report of two cases and review of the literature

STUDY DESIGN

Case report and review of the literature.

OBJECTIVES

To describe two patients with angiolipoma in the ventral aspect of the lumbar epidural space, to discuss the clinical, radiologic, and surgical features of these lesions, and to review previously reported cases.

SETTING

Rome, Italy.

METHODS

Two cases, a 60-year-old man and a 54-year-old woman presented with lumbar-sciatic pain but with no abnormal neurological signs. Investigation (CT and MRI) demonstrated lumbar tumours.

RESULTS

Laminectomy and excision of the tumors were performed, and symptoms improved immediately.

CONCLUSIONS

Magnetic resonance imaging with suppression fat sequences allows the recognition of these lesions. The prognosis after surgical removal of spinal angiolipoma is favorable.

Cerebral astroblastoma

BACKGROUND

Astroblastoma is a rare glial tumour about which little is known.

METHOD

We report a case of cerebral high grade astroblastoma and discuss the clinical, histopathological, surgical, radiological and prognostic features of this tumour, in the light of the pertinent literature.

RESULT

Present patient had an initial histological diagnosis of glioblastoma multiforme. Three years later an histological reevaluation was performed and revealed a high grade astroblastoma. Our patient underwent surgical removal and radiotherapy; five years after the operation he is alive and without evidence of recurrence.

INTERPRETATION

Classification and histogenesis of this tumour is still debated. The lack of a clinicopathological correlation makes the prognosis of this tumour unpredictable. The optimal management is not defined, but total resection and post-operative radiotherapy seem to be the effective means to treat the astroblastoma.

Management of the entered frontal sinus

The opening of the frontal sinus is a common occurrence in surgical practice. It may involve many surgical disciplines. The complications that may derive from incorrect treatment of an opened frontal sinus are potentially fatal. Unfortunately, the treatment of patients with injured frontal sinus is not uniform and standardized. Here, we describe our technique of treatment. We propose our treatment modality on the basis of our personal experience, which has been excellent in the past 20 years, that is from the time of the technique's introduction and routine application.

Solitary fibrous tumors of the meninges

Central nervous system solitary fibrous tumors are a new pathological entity. To our knowledge, only 60 meningeal solitary fibrous tumors both in the spinal cord and in the brain have been described in the literature. The 56 previously reported cases of meningeal solitary fibrous tumors are critically reviewed. In addition, we report four new cases of solitary fibrous tumors of the meninges. There is a slight male prepoderance. Meningeal solitary fibrous tumors show a tendency to arise in the posterior fossa (26%) and spine (25%). The treatment was mainly total surgical excision. Radiotherapy was given only to four patients with tumors involving the cerebral parenchyma. Sporadic cases of recurrence and distant metastasis have been reported. The prognosis of meningeal solitary fibrous tumors is still unknown because the follow-up of the reported cases is short. It is probable that cases of solitary fibrous tumors of the meninges have been misdiagnosed as other tumors in the past. The best management of these tumors seems to be total surgical excision whenever possible. It is important that every new case of meningeal SFT be reported to throw light on this particular tumor and to affirm its status as a clinicopathological entity.

Solitary Brain Metastases from Uterus Carcinoma: Report of Three Cases

Solitary brain metastases from uterine carcinoma are uncommon. Intracranial metastases from uterus usually occur in widely disseminated disease. We report three cases of solitary brain metastasis from uterine cancer. In one of these patients metastasis was detected prior to diagnosis of primitive cancer. In a review of the literature only seven cases of solitary brain metastasis preceding the diagnosis of uterine cancer have been documented.

Single cerebral metastasis from colorectal adenocarcinoma

Single cases are described in 50% of reported intracranial metastases. Single cerebral metastasis from colorectal adenocarcinoma is not very common, with a frequency varying between 0.5% and 1%. In our institute between 1960 and 2000, 44 patients affected by single metastasis from colorectal carcinoma were surgically treated. Surgical treatment with postoperative radiant therapy is necessary. These patients show improved quality of life, above all in relation to the maintenance of functional autonomy during the survival period.

Duraplasty: our current experience

BACKGROUND

A large variety of biologic and artificial materials have been suggested as dural substitutes. However, no ideal material for dural repair in neurosurgical procedures has been identified. The authors report their experience with Tutoplast processed dura and pericardium.

METHODS

This study is designed to evaluate Tutoplast dura and pericardium. The study population was composed of 250 consecutive patients who underwent cerebral duraplasty with these homologous materials between 1996 and 1998. The average follow-up was 5.4 years.

RESULTS

We have observed only four complications with uncertain relationship with the dural implant. These resulted in complete recovery.

CONCLUSIONS

We support the efficacy and safety of this natural dural substitute treated with Tutoplast method.