Neuralgic Amyotrophy and Hourglass Nerve Constriction/Nerve Torsion: Two Sides of the Same Coin? A Clinical Review

Neuralgic amyotrophy, also called Parsonage-Turner syndrome, in its classic presentation is a brachial plexopathy or a multifocal neuropathy, involving mainly motor nerves of the upper limb with a monophasic course. Recently, a new radiological entity was described, the hourglass constriction, which is characterized by a very focal constriction of a nerve, or part of it, usually associated with nerve thickening proximally and distally to the constriction. Another condition, which is similar from a radiological point of view to hourglass constriction, is nerve torsion. The pathophysiology of neuralgic amyotrophy, hourglass constriction and nerve torsion is still poorly understood, and a generic role of inflammation is proposed for all these conditions. It is now widely accepted that nerve imaging is necessary in identifying hourglass constrictions/nerve torsion pre-surgically in patients with an acute mononeuropathy/plexopathy. Ultrasound and MRI are useful tools for diagnosis, and they are consistent with intraoperative findings. The prognosis is generally favorable after surgery, with a high rate of good motor recovery.

MRI Tractography of Corticospinal Tract and Arcuate Fasciculus in High-Grade Gliomas Performed by Constrained Spherical Deconvolution: Qualitative and Quantitative Analysis

BACKGROUND AND PURPOSE

MR imaging tractography is increasingly used to perform noninvasive presurgical planning for brain gliomas. Recently, constrained spherical deconvolution tractography was shown to overcome several limitations of commonly used DTI tractography. The purpose of our study was to evaluate WM tract alterations of both the corticospinal tract and arcuate fasciculus in patients with high-grade gliomas, through qualitative and quantitative analysis of probabilistic constrained spherical deconvolution tractography, to perform reliable presurgical planning.

MATERIALS AND METHODS

Twenty patients with frontoparietal high-grade gliomas were recruited and evaluated by using a 3T MR imaging scanner with both morphologic and diffusion sequences (60 diffusion directions). We performed probabilistic constrained spherical deconvolution tractography and tract quantification following diffusion tensor parameters: fractional anisotropy; mean diffusivity; linear, planar, and spherical coefficients.

RESULTS

In all patients, we obtained tractographic reconstructions of the medial and lateral portions of the corticospinal tract and arcuate fasciculus, both on the glioma-affected and nonaffected sides of the brain. The affected lateral corticospinal tract and the arcuate fasciculus showed decreased fractional anisotropy (z = 2.51, n = 20, P = .006; z = 2.52, n = 20, P = .006) and linear coefficient (z = 2.51, n = 20, P = .006; z = 2.52, n = 20, P = .006) along with increased spherical coefficient (z = -2.51, n = 20, P = .006; z = -2.52, n = 20, P = .006). Mean diffusivity values were increased only in the lateral corticospinal tract (z = -2.53, n = 20, P = .006).

CONCLUSIONS

In this study, we demonstrated that probabilistic constrained spherical deconvolution can provide essential qualitative and quantitative information in presurgical planning, which was not otherwise achievable with DTI. These findings can have important implications for the surgical approach and postoperative outcome in patients with glioma.

GLYOXALASE I A111E, PARAOXONASE 1 Q192R AND L55M POLYMORPHISMS IN ITALIAN PATIENTS WITH SPORADIC CEREBRAL CAVERNOUS MALFORMATIONS: A PILOT STUDY

It is already known that the conditions of increased oxidative stress are associated to a greater susceptibility to vascular malformations including cerebral cavernous malformations (CCMs). These are vascular lesions of the CNS characterized by abnormally enlarged capillary cavities that can occur sporadically or as a familial autosomal dominant condition with incomplete penetrance and variable clinical expression attributable to mutations in three different genes: CCM1(Krit1), CCM2 (MGC4607) and CCM3 (PDCD10). Polymorphisms in the genes encoding for enzymes involved in the antioxidant systems such as glyoxalase I (GLO I) and paraoxonase I (PON I) could influence individual susceptibility to the vascular malformations. A single nucleotide polymorphism was identified in the exon 4 of GLO 1 gene that causes an amino acid substitution of Ala for Glu (Ala111Glu). Two common polymorphisms have been described in the coding region of PON1, which lead to glutamine → arginine substitution at 192 (Q192R) and a leucine → methionine substitution at 55 (L55M). The polymorphisms were characterized in 59 patients without mutations in the CCM genes versus 213 healthy controls by PCR/RFLP methods using DNA from lymphocytes. We found that the frequency of patients carrying the GLO1 A/E genotype among the case group (56%) was four-fold higher than among the controls (14.1%). In the cohort of CCM patients, an increase in the frequency of PON192 Q/R genotype was observed (39% in the CCM group versus 3.7% in the healthy controls). Similarly, an increase was observed in the proportion of individuals with the genotype R/R in the disease group (5%) in respect to the normal healthy cohort (0.5%). Finally, the frequency of the PON55 heterozygotes L/M genotype was 29% in patients with CCMs and 4% in the healthy controls. The same trend was observed in PON55 homozygous M/M genotype frequency (CCMs 20% vs controls 10%). The present study aimed to investigate the possible association of GLO1 A111E, PON1 Q192R and L55M polymorphisms with the risk of CCMs. We found that individuals with the GLO1 A /E genotype, PON192/QR-RR genotypes and PON55/LM-MM genotypes had a significantly higher risk of CCMs compared with the other genotypes. However, because CCM is a heterogeneous disease, other additional factors might be involved in the initiation and progression of CCM disease.

Giant olfactory meningiomas: the pterional approach and its relevance for minimizing surgical morbidity

Olfactory groove meningiomas may attain surprisingly large size. The subfrontal approach is currently the route preferred by most neurosurgeons for their excision. The pterional-transsylvian route represents an alternate exposure for microsurgery of frontobasal tumors. Although this approach has been already described for olfactory meningiomas, tumors of giant size were not specifically addressed in the literature. We report the application of the pterional-transsylvian approach in six patients with giant olfactory meningiomas. This series is unique because it includes only patients with tumors exceeding 6 cm in diameter with bilateral symmetrical development. A radical removal was achieved in all patients and all of them made a full recovery. To investigate the relevance of the pterional-transsylvian approach for minimizing surgical morbidity, a magnetic resonance imaging protocol was designed to characterize even subtle postoperative frontal lobe structural changes. These changes, limited to the frontal lobe ipsilateral to exposure and localized in specific anatomical domains of the prefrontal area, included cystic degenerative alterations, parenchymal gliosis, and associated persistent white matter edema. Results from the present series strengthen the usefulness of the pterional-transsylvian approach as a safe surgical route for lesions affecting the anterior skull base, even with huge bilateral symmetrical expansion, such as giant olfactory meningiomas.

Beneficial effects of antibacterial peptide PR-39 in a neonatal murine model of endotoxic shock

The lethal effects occurring in neonatal (< 24-h old) BALB/c mice after challenge with E. coli lipopolysaccharide (LPS) were significantly counteracted by pretreatment with antibacterial peptide PR-39. Neonatal mice protection was probably related to the depressive effect of PR-39 on production of TNF-alpha known to be the major mediator of the lethal effects of neonatal endotoxic shock. Indeed, TNF-alpha plasmatic levels were consistently lower in pups pretreated with PR-39 compared with controls. Administration 24 h after challenge was no longer effective. Although PR-39 and anti-TNF-alpha doses were ineffective alone, when combined at different ratios protected neonatal mice. The present experiments show the potential use of peptide PR-39 in preventing neonatal endotoxic shock.

An immunohistochemical study of extracellular matrix proteins laminin, fibronectin and type IV collagen in paediatric glioblastoma multiforme

AIMS

In the recent decades many studies have been addressed in the literature to assess specific factors related to glioblastoma multiforme (GBM) invasion. However, few studies have evaluated tumour cell's interaction with specific extracellular matrix (ECM) components, and, moreover, there is a lack of information regarding the occurrence of these phenomena in paediatric GBM.

METHODS AND RESULTS

ECM proteins were evaluated in six cases of paediatric GBM assessing the immunohistochemical expression of laminin, fibronectin, and type IV collagen. We used a semiquantitative scale, ranging from not detected (zero) to marked (3). Laminin expression was minimal in three cases, moderate in one case, marked and generalised in one patient and marked and focal in the last case. Fibronectin expression was minimal in three patients; moderate immunoreactivity was documented in one case. Conversely, one case was classified as marked with generalised distribution and the remaining case as marked with focal immunostaining. Type IV collagen expression was minimal in three cases, moderate in one, marked with focal reaction in one and marked with generalised reaction in the remaining case.

CONCLUSIONS

This study provides additional insights into tumour invasion features of paediatric GBM, as ECM plays a pivotal role in numerous cellular functions during normal and pathological processes. Although based on a limited number of patients, this investigation may serve as a challenge for the management of paediatric GBM, stimulating trials with larger patient numbers aimed at documenting specific factors influencing GBM prognosis.

Does early decompression improve neurological outcome of spinal cord injured patients? Appraisal of the literature using a meta-analytical approach

STUDY DESIGN

Definitive and unequivocal evidence to support the practice of early or late surgery is still lacking in clinical studies. Accordingly, meta-analysis is one of the few methods that offer a rational, statistical approach to management decision. A review of the clinical literature on spinal cord injury with emphasis on the role of early surgical decompression and a meta-analysis of results was performed.

OBJECTIVES

To determine whether neurological outcome is improved in traumatic spinal cord-injured patients who had surgery within 24 h as compared with those who had late surgery or conservative treatment.

METHODS

A Medline search covering the period 1966-2000, supplemented with manual search, was used to locate studies containing information on indication, rationale and timing of surgical decompression after spinal cord injuries. The analysis included a total of 1687 eligible patients.

RESULTS

Statistically, early decompression resulted in better outcome compared with both conservative (P<0.001) and late management (P<0.001). Nevertheless, analysis of homogeneity showed that only data regarding patients with incomplete neurological deficits who had early surgery were reliable.

CONCLUSIONS

Although statistically the percentage of patients with incomplete neurological deficits improving after early decompression appear 89.7% (95% confidence interval: 83.9, 95.5%), to be better than with the other modes of treatment when taking into consideration the material available for analysis and the various other factors including clinical limitations; early surgical decompression can only be considered as practice option for all groups of patients.

Traumatic acute subdural haematomas of the posterior fossa: clinicoradiological analysis of 24 patients

BACKGROUND

We report 24 patients with a traumatic acute subdural haematoma of the posterior fossa managed between 1997 and 1999 at 8 Italian neurosurgical centres.

METHOD

Each centre provided data about patients' clinico-radiological findings, management, and outcomes, which were retrospectively reviewed.

FINDINGS

A poor result occurred in 14 patients (58.3%). Ten patients (41.7%) had favourable results. Patients were divided into two groups according to their admission Glasgow Coma Scale (GCS) scores. In Group 1 (12/24 cases; GCS score, > or =8), the outcome was favourable in 75% of cases. In Group 2 (12/12 cases; GCS score, <8), the outcome was poor in 91.6% of cases. Nineteen patients underwent posterior fossa surgery. Factors correlating to outcome were GCS score, status of the basal cisterns and the fourth ventricle, and the presence of supratentorial hydrocephalus. Multivariate analysis showed significant independent prognostic effect only for GCS score (P<0.05).

INTERPRETATION

acute posterior fossa subdural haematomas can be divided into two distinct groups: those patients admitted in a comatose state and those with a moderate/mild head injury on admission. Comatose patients present usually with signs of posterior fossa mass effect and have a high percentage of bad outcomes. On the contrary, patients admitted with a GCS of 8 or higher are expected to recover. In these patients the thickness of the haematoma (<1 cm) seems to be a guide to indicate surgical evacuation of the haematoma.

Large sphenocavernous meningiomas: is there still a role for the intradural approach via the pterional-transsylvian route?

BACKGROUND

Large-sized sphenocavernous meningiomas represent a surgical challenge. Although the role of skull base techniques with combined extra- and intradural steps has been recently emphasized, pure intradural resection tactics via the pterional route constitute the traditional microsurgical approach for resection of such tumours.

METHOD

We report the application of the pterional-transsylvian approach in 13 patients with sphenocavernous meningiomas. This series is unique because it includes only patients with tumours exceeding 5 cm in their greatest dimension.

FINDINGS

A gross total resection was accomplished in 10 patients (77%). Eight patients had a good outcome, one had a persistent mild hemiparesis, and one died. No recurrences occurred in this group. Three patients (23%) had subtotal resections owing to invasion of the cavernous sinus in one instance and encasement of the middle cerebral artery in the others. Two had a good outcome and one died. In these patients minimal asymptomatic tumour progression was seen 3 and 6 years after surgery. The overall surgical outcome was good in 10 patients (77%), fair in one, and death in two.

INTERPRETATION

In our experience, large sphenocavernous meningiomas may be operated on adopting pure intradural resection tactics via the pterional-transsylvian route with rates of gross total removal and surgical complications related to brain retraction or vascular manipulation comparable to those of extensive skull base approaches. The traditional intradural pterional transsylvian approach continues to have a place in the treatment of these lesions.

Growing skull fracture of the posterior cranial fossa and of the orbital roof

BACKGROUND

Growing Skull Fractures (GSF) are rare complications of head trauma, primarily reported in infancy and early childhood. GSF are commonly located on calvaria, and rarely in other locations, including the skull base.

METHOD

In this study, we report two cases of GSF occurring in unusual locations. The first, a 8-month old girl, with a GSF of the suboccipital posterior fossa region, and the second, a 4-year old boy with a GSF of the right orbital roof. Both cases underwent operative treatment of the GSF, with microsurgical dissection and excision of the protruding gliotic brain tissue, watertight duraplasty and autologous bone cranial repair. The authors conducted a Medline search of the relevant English literature from 1966 to 2002.

FINDINGS

From the search, three cases of suboccipital posterior fossa region GSF and twelve series of orbital GSF, describing a total of 22 cases, have been found.

INTERPRETATION

A survey of the pathogenic mechanisms underlying this entity in these locations is reported. A review of suboccipital posterior fossa and orbital roof GSF cases, of nosological, ophthalmological and neurological data, neuroradiological and operative findings, and results of different treatment strategies are described.

Different methods for anatomical targeting

AIM

Several procedures are used in the different neurosurgical centers in order to perform stereotactic surgery for movement disorders. At the moment no procedure can really be considered superior to the other. We contribute with our experience of targeting method.

METHODS

Ten patients were selected, in accordance to the guidelines for the treatment of Parkinson disease, and operated by several methods including pallidotomy, bilateral insertion of chronic deep brain electrodes within the internal pallidum and in the subthalamic nucleus (18 procedures).

INTERVENTIONS

in each patient an MR scan was performed the day before surgery. Scans were performed axially parallel to the intercommissural line. The operating day a contrast CT scan was performed under stereotactic conditions.

MEASURES

after digitalization of the MRI images, it was possible to visualize the surgical target and to relate it to parenchimal and vascular anatomic structures readable at the CT examination. The CT scan obtained was confronted with the MR previously performed, the geometrical relation between the different parenchimal and vascular structures and the selected targets were obtained. Stereotactic coordinates were obtained on the CT examination.

RESULTS

It was possible to calculate the position of the subthalamic nucleus and of the internal pallidum on the CT scan, not only relating to the intercommissural line, but considering also the neurovascular structures displayed both on the MRI and the CT scans.

CONCLUSION

The technique that our group presents consist in an integration between information derived from the CT and the MR techniques, so that we can benefit from the advantages of both methods and overcome the disadvantages.

Assistance of intraoperative microvascular Doppler in the surgical obliteration of spinal dural arteriovenous fistula: cases description and technical considerations

BACKGROUND

Intraoperative microvascular Doppler may be valuable in assisting in the surgical obliteration of dural arteriovenous fistula of the spinal cord. It enables identification, through flow spectrum analysis, of the anatomic components and haemodynamic features of this type of vascular malformation.

METHODS

In two cases, intraoperative microvascular Doppler was used to assist in the surgical obliteration of dural arteriovenous fistula of the spinal cord. The fistulas were identified prior to the dura opening, and for this only minimally invasive surgery was required. Direct recordings of the arterialised draining vein and the nidus of the fistula demonstrated a pathological spectrum caused by the arterial supply and the disturbed venous outflow in which a high-resistance flow pattern and low diastolic flow resembling an arterial-like flow velocity were observed.

FINDINGS

The fistulas were obliterated by interruption of the draining vein, and Doppler measurements provided information on flow velocity changes in the medullary veins from an arterial to a venous pattern. The absence of any residual flow in the draining vein confirmed successful haemodynamic treatment.

INTERPRETATION

Intraoperative microvascular Doppler recording is valuable assistance in surgical closure of spinal arteriovenous fistula.

Endoscopic fenestration of symptomatic septum pellucidum cysts: three case reports with discussion on the approaches and technique

OBJECTIVES

We describe three patients with symptomatic septum pellucidum cysts treated by endoscopic fenestration and discuss the different endoscopic approaches to these cysts.

CLINICAL PRESENTATION

The patients are an 8-year-old boy, a 7-year-old boy and a 21-year-old woman; this last also had a right frontal cavernous angioma and a pituitary microadenoma. All patients presented with headache, associated with vomiting in two and behavioral changes in one. In all cases magnetic resonance showed a septum pellucidum cyst.

INTERVENTION

Two patients were operated upon by posterior approach through a right occipital burr hole and underwent fenestration from the right occipital horn to the cyst, with a second fenestration from the cyst to the left lateral ventricle in one. Another patient underwent microsurgical removal of a right frontal cavernoma and endoscopic cyst fenestration with both lateral ventricles through a right frontal craniotomy. Postoperatively, headache and vomiting resolved in all cases and behaviour changes improved in one.

CONCLUSIONS

Endoscopic fenestration is the treatment of choice for septum pellucidum cysts, where it results in immediate relief of the mass effect of the cyst and in the remission of the associated symptoms. We suggest a posterior approach through a right occipital burr hole. It allows one to easily cannulate the occipital horn, which is usually larger than the frontal one, thus avoiding the risk of damaging the vascular and neural structures surrounding the foramen of Monro. Besides, the endoscopic trajectory is in our opinion more direct. The two-window technique, with fenestration of the cyst into both lateral ventricles, improves the chances of long-term patency.

Radicular compression by lumbar intraspinal epidural gas pseudocyst in association with lateral disc herniation. Role of the posterior longitudinal ligament

Among unusual abnormalities of the lumbar spine reported since the introduction of Computed Tomography (CT), the presence of gas lucency in the spinal canal, known as vacuum phenomenon, is often demonstrated. On the contrary, epidural gas pseudocyst compressing a nerve root in patients with a lateral disc herniation has rarely been reported. We report a case of a 44-year-old man who experienced violent low back pain and monolateral sciatica, exacerbated by orthostatic position, one week before admission. A lumbosacral spine CT showed the presence of vacuum phenomenon associated with a degenerated disc material and a capsulated epidural gas collection with evidence of root compression. A microsurgical interlaminar approach was carried out and, before the posterior longitudinal ligament was entered, a spherical "bubble" compressing the nerve roots was observed. The capsulated pseudocyst was dissected out, peeled off and excised en bloc. A large part of the posterior longitudinal ligament and the lateral disc herniation were removed. Postoperatively the patient was completely free of symptoms. The mechanism of exacerbation of pain was probably due to the increased radicular compression in the upright posture and, besides the presence of a lateral disc herniation, could be related to a pneumatic squeezing of gas from the intervertebral space into the well capsulated sac by the solicitated L4-L5 motion segment. Histological study of the wall of the pseudocyst showed the presence of fibrous tissue identical to the ligament. We conclude that, in case of a lumbar disc herniation, it is recommended to perform a complete microdiscectomy and an accurate removal of the involved portion of posterior longitudinal ligament in order to prevent pseudocystic formations.

A preliminary study of angiogenesis in paediatric glioblastoma multiforme and its correlation with survival

OBJECTS

There is a distinct challenge in bringing modern insights into glial tumour genesis to bear on improved outcomes for patients. Insights provided by neuroncological, neuroradiological, neuropathological, and neurosurgical investigations may offer significant advantages in the management of paediatric GBM. The goal of this study was to evaluate angiogenesis as a potential indicator of survival in paediatric glioblastoma multiforme (GBM).

METHODS

Angiogenesis was evaluated in six cases of paediatric GBM with multiple criteria, including contrast enhancement on preoperative CT scan, histological vascular hyperplasia (VH) and endothelial proliferation (EP) and immunohistochemical tenascin-C (TN-C) expression. We employed a semiquantitative scale, ranging from not detected (zero) to marked (+3), for each investigational parameter. We evaluated the influence of angiogenesis on survival in each case.

CONCLUSIONS

In this preliminary study, angiogenesis provided information that correlated with survival, albeit in a limited number of patients. As we gain better understanding of the molecular biology of brain tumours, with the multitude of genetic alterations and growth factors new therapeutic approaches may emerge, which may hold the promise for cure.

Trigeminal pain caused by a cerebellopontine-angle lipoma. Case report and review of the literature

A 16-year-old girl complained of 2-year history of right facial pain, episodic vertigo and progressive hearing loss in the right ear. The facial pain was described as an episodic lancinating event confined to the second and third branch of the right trigeminal nerve. Computed tomography and magnetic resonance imaging revealed a 2 cm lesion in the right cerebellopontine-angle. At surgery, a soft, yellowish mass was found incorporating the 7th and 8th cranial nerves. The anterior-inferior cerebellar artery (AICA) was displaced medially and pushed into the sensory portion of the trigeminal nerve root, causing vascular compression. The hearing loss remained unchanged. The trigeminal pain disappeared over a period of several weeks. Patients can be harmed in an attempt to remove these neurovascular nonmalignant, generally non growing, fatty vascular lumps. Only a partial, meticulous removal should be performed with a maximum effort to decompress the affected nerve.

Immunohistochemical TRF1 expression in human primary intracranial tumors

BACKGROUND

The telomeric-repeat binding factor (TRF1) participates in a physiological homeostatic mechanism controlling telomere shortening by inhibiting telomerase activity: down-regulation of TRF1 expression results in telomere elongation and may be involved in cell immortalization.

PATIENTS AND METHODS

To determine the TRF1 expression by immunohistochemistry (IHC) in human brain tumors, a cohort of 20 consecutive flash-frozen surgical specimens (14 meningiomas and 6 anaplastic astrocytomas (AA)) were collected.

RESULTS

Variable levels of TRF1 expression in 12 out of the 14 (87.5%) meningioma samples were observed. By contrast, no expression of TRF1 in tissue samples from AA (p = 0.008) was detected. Positive TRF1 cells were usually more differentiated (less atypical features) and Ki67 negative (inverse statistical association, chi2 = p < 0.001).

CONCLUSION

We demonstrated, for the first time, that routine IHC techniques are capable of identifying TRF1 expression in intracranial tumors, which is heterogeneously expressed in meningiomas, but absent in AA. Although these preliminary observations need confirmation from larger studies, the TRF1 status in intracranial tumors might become of prognostic value.

Posterior fusion compared with posterior interbody fusion in segmental spinal fixation for adult spondylolisthesis

OBJECT

Clinical and radiographic results in 30 consecutive patients who underwent posterior lumbar fixation and posterior facet joint or posterior interbody fusion for Meyerding Grade II/III spondylolisthesis were assessed: 1) to address the suitability of a dynamic stabilization; and 2) to investigate whether there are differences in terms of clinical and functional results and biomechanical properties between these two types of arthrodesis.

METHODS

Between June 1998 and April 2000, 16 patients underwent posterior interfacet fusion and implantation of the SOCON-SRI system. In 14 patients posterior lumbar interbody fusion (PLIF) and placement of the same system were performed. Clinical, economic, functional, and radiographic data were recorded pre- and postoperatively. The average changes in the Prolo Scale economic and functional scores were 1.25 and 1.62, respectively, in patients who underwent posterior fusion; the average measured preoperative vertebral slippage was 47.8% (range 30-65%), and postoperatively it was 18.5% (range 15-25%). In patients in whom PLIF was performed, the average changes in economic and functional score were 1.21 and 1.36, respectively, and the average preoperative vertebral slippage was 43.5% (range 30-55%) compared with 20% (range 15-25%) postoperatively.

CONCLUSIONS

The use of a segmental pedicle screw fixation with the SOCON-SRI system successfully combines the goal of solid fusion with the requirements of nerve root decompression. When the two fusion techniques were compared, an overall superior reliability and resistance of the systems was associated with the PLIF procedure (p = 0.04) but clinical outcomes did not differ greatly (p < 0.05).

Traumatic intracerebellar hemorrhagic contusions and hematomas

BACKGROUND

Traumatic intracerebellar hemorrhagic contusions and hematomas (TIHC) are unusual lesions and their surgical management remains controversial.

METHODS

From January 1990 to July, 1998, 3290 patients underwent computed tomography for acute head trauma at our Institution. Eighteen patients (0.54%) were retrospectively identified as harboring TIHC. Patients were divided into two groups. In Group I (n=78) GCS at admission was > or = 9. Seven patients presented with isolated TIHC and one with an associated supratentorial lesion. Three patients exhibited an evolving clinico-radiological course. In Group II patients (n=10) GCS at admission was < or = 7. All but one presented with severe supratentorial lesions and associated brainstem signs.

RESULTS

In group I six patients had their TIHC managed conservatively, and two were operated on, and all recovered completely. In group II, two patients were operated on. The outcome was poor in 90% of cases.

CONCLUSIONS

TIHC constitute a protean clinico-pathological entity. Non-comatose patients with intracerebellar clots less than 3 cm in diameter should be treated conservatively and expected to make a good recovery. Surgery is indicated for larger hematomas causing cisternal and IV ventricle compression ab initio or as a result of their secondary evolution. In severely ill patients admitted comatose, it is generally the primary brain stem damage and the concomitant severe supratentorial lesions to dictate the prognosis. In these cases obliteration of the posterior fossa cisterns is the most reliable indicator of poor outcome.

Intraoperative microvascular Doppler monitoring of blood flow within a spinal dural arteriovenous fistula: a precious surgical tool

The authors describe a case of spinal arteriovenous fistula (AVF) treated by a microvauscular Doppler–assisted surgical interruption of the arterialized vein. Microvascular Doppler monitoring represents a valid, widely available, non-invasive tool that enables identification, through flow spectrum analysis, of components of this type of vascular malformation. In this case because the location of the fistula was identified prior to opening the dura only minimally invasive surgery was required. Direct recordings of the arterialized draining vein and the nidus of the fistula demonstrated a pathological spectrum caused by the arterial supply and the disturbed venous outflow in which a high-resistance flow pattern and low diastolic flow resembling an arterial-like flow velocity were observed. The fistula was obliterated by interruption of the draining vein, and Doppler measurements provided information on flow velocity changes in the medullary veins from an arterial to a venous pattern. The absence of any residual flow in the AVF confirmed successful hemodynamic treatment.

Intraoperative microvascular Doppler recording during surgical closure of spinal AVF is a widely available and reliable monitoring modality that helps to produce excellent clinical results.

Lumbosacral congenital dermal sinus presenting in a 52-year-old man. Case report

Spinal congenital dermal sinus is a rare entity which results from failure of the neuroectoderm to separate from cutaneous ectoderm during the process of neurulation. This epithelium-lined tract forms a potential communication between the skin surface in the midline along the spine and the deeper tissues. We describe a case of an asymptomatic lumbosacral congenital dermal sinus in a 52-year-old man. Microsurgical excision of dermal tract was performed with no postoperative complications and with a satisfactory cosmetic result. The authors stress the importance of an early neuroradiological and neurosurgical management of the lesion. The embryogenesis of this pathological condition and the possible complications are also discussed.

Time-course of blood-brain barrier permeability changes after experimental subarachnoid haemorrhage

An increase in blood-brain barrier (BBB) permeability after subarachnoid haemorrhage (SAH) has been described in humans and has been correlated with delayed cerebral ischemia and poor clinical outcome. Few studies examined in the laboratory the relationship between SAH and BBB, with contrasting results due to limitations in experimental probes adopted and in timing of observation. The aim of this study was to quantify the time-course of BBB changes after experimental SAH. Groups of eight rats received injections of 400 microl of autologous arterial blood into the cisterna magna. BBB was assessed 6, 12, 24, 36, 48, 60, and 72 hours after SAH and in sham-operated animals separately for cerebral cortex, i.e. frontal, temporal, parietal, occipital, subcortical gray matter (Caudate-Putamen-Thalamus), cerebellar cortex and nuclei, and brain stem by a spectrophotofluorimetric evaluation of Evans Blue dye extravasation. As compared to sham-operated controls, SAH determined a significant BBB permeability change beginning 36 hours after SAH, peaking at 48 hours, and normalizing on day 3. This study provides a quantitative description of the temporal progression and recovery of BBB dysfunction after SAH. These results have implications for the management of aneurysm patients and for assessing the rationale and the therapeutic window of new pharmacological approaches.

Effect of recombinant human erythropoietin on cerebral ischemia following experimental subarachnoid hemorrhage

Erythropoietin exerts a neuroprotective effect during cerebral ischemia. We investigated the effect of systemic administration of recombinant human erythropoietin in a rabbit model of subarachnoid hemorrhage-induced acute cerebral ischemia. The animals were divided into three groups: group 1, subarachnoid hemorrhage; group 2, subarachnoid hemorrhage plus placebo; group 3, subarachnoid hemorrhage plus recombinant human erythropoietin (each group, n=8). Experimental subarachnoid hemorrhage was produced by injecting autologous blood into the cisterna magna. Treatment with recombinant human erythropoietin and placebo was started 5 min after subarachnoid hemorrhage and was continued every 8 h for 24 h. Before the animals were killed, erythropoietin concentration was measured in the cerebrospinal fluid. The rabbits were killed 24 h after subarachnoid hemorrhage and ischemic brain injury was histologically evaluated. In group 3, the concentration of erythropoietin in the cerebrospinal fluid was significantly increased and a significant reduction in cortical necrotic neuron count was also observed. These findings may encourage the use of erythropoietin in the treatment of cerebral ischemia that often occurs in the early stage of subarachnoid hemorrhage.

Spasmodic torticollis due to neurovascular compression of the spinal accessory nerve by the anteroinferior cerebellar artery: case report

OBJECTIVE AND IMPORTANCE

Spasmodic torticollis is a neuromuscular disorder characterized by uncontrollable clonic and intermittently tonic spasm of the neck muscles. We report a case of spasmodic torticollis attributable to neurovascular compression of the right XIth cranial nerve by the right anteroinferior cerebellar artery (AICA).

CLINICAL PRESENTATION

A 72-year-old man with a 2-year history of right spasmodic torticollis underwent magnetic resonance imaging, which demonstrated compression of the right XIth cranial nerve by an abnormal descending loop of the right AICA.

INTERVENTION

The patient underwent microvascular decompression surgery. During surgery, it was confirmed that an abnormal loop of the right AICA was compressing the right accessory nerve. Compression was released by the interposition of muscle between the artery and the nerve.

CONCLUSION

The patient's postoperative course was uneventful, and his symptoms were fully relieved at the 2-year follow-up examination. This is the first reported case of spasmodic torticollis attributable to compression by the AICA; usually, the blood vessels involved are the vertebral artery and the posteroinferior cerebellar artery.

Beta 2 integrins are involved in cytokine responses to whole Gram-positive bacteria

Proinflammatory cytokines have an important pathophysiologic role in septic shock. CD14 is involved in cytokine responses to a number of purified bacterial products, including LPS. However, little is known of monocyte receptors involved in cytokine responses to whole bacteria. To identify these receptors, human monocytes were pretreated with different mAbs and TNF-alpha was measured in culture supernatants after stimulation with whole heat-killed bacteria. Human serum and anti-CD14 Abs significantly increased and decreased, respectively, TNF-alpha responses to the Gram-negative Escherichia coli. However, neither treatment influenced responses to any of the Gram-positive bacteria tested, including group A and B streptococci, Listeria monocytogenes, and Staphylococcus aureus. Complement receptor type III (CR3 or CD18/CD11b) Abs prevented TNF-alpha release induced by heat-killed group A or B streptococci. In contrast, the same Abs had no effects when monocytes were stimulated with L. monocytogenes or S. aureus. Using either of the latter bacteria, significant inhibition of TNF-alpha release was produced by Abs to CD11c, one of the subunits of CR4. To confirm these blocking Ab data, IL-6 release was measured in CR3-, CR4-, or CD14-transfected Chinese hamster ovary cells after bacterial stimulation. Accordingly, streptococci triggered moderate IL-6 production (p < 0.05) in CR3 but not CD14 or CR4 transfectants. In contrast, L. monocytogenes and S. aureus induced IL-6 release in CR4 but not CR3 or CD14 transfectants. Collectively our data indicate that beta 2 integrins, such as CR3 and CR4, may be involved in cytokine responses to Gram-positive bacteria. Moreover, CD14 may play a more important role in responses to whole Gram-negative bacteria relative to Gram-positive ones.

Immunohistochemical tenascin-C expression in paediatric supratentorial glioblastoma multiforme

Tenascin-C (TN-C) plays an important part in the growth of neoplastic tissue, leading to new vessel development. TN-C has been assessed in adult glioblastoma multiforme (GBM) and has been evaluated as anti-neoplastic therapy. No studies have focused on this tissue in paediatric GBM. Tissues were obtained from six paediatric supratentorial GBMs. Immunohistochemistry was performed using a mouse antibody directed against human TN-C, and expression in tumour vasculature was described on the basis of TN-C immunoreactivity. The expression was minimal in three, moderate in two, and intense in one specimen. TN-C was not correlated with clinical history, neurological findings, or with tumour site. Although based on a limited number of patients, this study provides additional insights into tumour growth modulation and cytogenetic profile of paediatric GBM. The detailed understanding of events responsible for GBM growth is a prerequisite for the development of therapeutic modalities leading to improved prognosis and cure.

Pituitary metastasis from uterine cervical carcinoma: a case presenting as diabetes insipidus

The authors report a case of symptomatic pituitary metastasis from an adenocarcinoma of the uterine cervix. Only two cases of intrasellar metastasis from an adenocarcinoma of the uterine cervix have been previously reported; both were identified at autopsy. Our patient presented with clinical features of diabetes insipidus and a right sixth nerve palsy. Trans-sphenoidal surgery was performed and partial removal of the tumour was achieved. The tumour was an epidermoidal carcinoma of the uterine cervix located primarily in the posterior lobe of the pituitary. The patient's neurological symptoms were relieved following surgery. The possibility of a secondary location must always be considered in a differential diagnosis when treating an intrasellar lesion in a patient with a documented primary malignancy.

In vivo evidence that erythropoietin has a neuroprotective effect during subarachnoid hemorrhage

To ascertain in vivo whether recombinant human erythropoietin has a neuroprotective effect on the cortex during subarachnoid hemorrhage, 56 rabbits were divided into the following groups: Group 1 control sham operated plus placebo (n=14; saline solution - NaCl 0.9%); Group 2 control sham operated plus recombinant human erythropoietin (n=14); Group 3 subarachnoid hemorrhage plus placebo (n=14); Group 4 subarachnoid hemorrhage plus recombinant human erythropoietin (n=14; intraperitoneal administration of recombinant human erythropoietin immediately after inducing subarachnoid hemorrhage). In none of the Groups 1 and 2 animals was subarachnoid hemorrhage induced. In Group 3 rabbits, an increase in locomotor activity (open field apparatus) was observed 24, 48 and 72 h after surgery, and the mortality rate was 42.9% within 72 h after surgery, and, no increase in locomotor activity was observed in Group 4 rabbits, which survived for at least 72 h. Our findings suggest that recombinant human erythropoietin may be of benefit in the treatment of subarachnoid hemorrhage.

Effects of the radical scavenger AVS on behavioral and BBB changes after experimental subarachnoid hemorrhage

Free radicals are important contributors to the global brain dysfunction that follows subarachnoid hemorrhage (SAH). We evaluated the effects of hydroxyl radical scavenger AVS [(+/-)-N,N'-propylenedinicotinamide; Nicaraven] after experimental SAH on rodent behavioral deficits (employing a battery of well-characterized assessment tasks over a 2-day observation period) and blood-brain barrier (BBB) permeability changes two days after SAH (quantifying the microvascular alterations according to the extravasation of protein-bound Evans Blue using a spectrophotofluorimetric technique) in dose-response and time-window experiments. Groups of 10 rats were injected with 400 microl of autologous blood into the cisterna magna, and followed by intravenous continuous infusion of saline or 0.1, 03 or 1 mg/kg/min of AVS beginning within 5 minutes or 6 or 12 hours after SAH. The results were compared with sham-operated saline-treated and with SAH saline-treated animals. AVS significantly ameliorated performances on Beam Balance (p < 0.01) and decreased BBB permeability changes in frontal, temporal, parietal, occipital and cerebellar cortices and subcortical and cerebellar nuclei and brainstem (p < 0.01), but did not significantly affect changes in Beam Walking. This study demonstrates the neuroprotective effects of AVS when administered after experimental SAH in rats. These effects were dose-dependent and, moreover, were evident within the therapeutic window of 6-12 hours after SAH. These results reinforce the concept of a participation of reactive oxygen intermediates in the cerebral dysfunction following SAH.

Posterior fusion and implantation of the SOCON-SRI system in the treatment of adult spondylolisthesis

Surgery for adult patients with lumbar and lumbosacral spondylolisthesis is reserved for those with intractable radiculopathy, claudication, or symptomatic spinal instability. Internal fixation, in which posterior fusion, transpedicular screw fixation, and implantation of titanium devices are performed, has been advocated to improve fusion rates and clinical results. Fourteen consecutive patients with Grade II to III lumbar and lumbosacral spondylolisthesis who underwent posterior decompression, reduction, autologous posterior facet joint arthrodesis, and SOCON-SRI implantation are retrospectively reviewed.

All patients underwent complete preoperative clinical and neuroradiological evaluation. Treatment consisted of posterior decompressive surgery and implantation of the SOCON-SRI system (transpedicular screws, prebent longitudinal rods, and one locking-screw clamps). Distraction of the interbody space and rotation were performed to achieve an optimum spinal realignment. The facet joints were fused by using autologous bone graft. The authors obtained detailed clinical, functional, economic, and neuroradiological follow-up data for up to 14 months (range 8–18 months).

The efficacy of the treatment was evaluated by comparing pre- and postoperative data. Pain was decreased in all cases, neurological dysfunction ameliorated in 50%, and functional and economic status was improved in 78% and 100%, respectively. No cases of fusion failure or instrumentation-related complications occurred. The authors describe their results of treating patients with spondylolisthesis in the light of the rationale for surgery and the more recent pertinent literature.

Does lamina terminalis fenestration reduce the incidence of chronic hydrocephalus after subarachnoid hemorrhage?

OBJECTIVE

The incidence of chronic hydrocephalus requiring cerebrospinal fluid shunting was analyzed for a prospective series of 52 consecutive patients with ruptured cerebral aneurysms who underwent fenestration of the lamina terminalis during early microsurgical aneurysm repair. We hypothesized that, by creating an anterior ventriculocisternostomy, fenestration of the lamina terminalis would facilitate cerebrospinal fluid dynamics and decrease the risk of subsequent hydrocephalus.

METHODS

Patients were enrolled according to the following criteria: 1) age more than 40 years; 2) admission Hunt and Hess Grade 2 to 4; 3) initial subarachnoid hemorrhage severity of Fisher Grade 3 or 4; and 4) early microsurgical repair of an anterior circulation aneurysm.

RESULTS

The mortality rate in this series was 9.6%. Of the 47 surviving patients, 32 (68%) were discharged with a Glasgow Outcome Scale score of 5, 10 (21%) with a Glasgow Outcome Scale score of 4, and 5 (11%) with a Glasgow Outcome Scale score of 3. The follow-up period ranged from 12 to 60 months. Chronic hydrocephalus was radiographically and clinically evident in 3.8% of the total population. Shunt surgery was performed for two patients who exhibited symptoms resulting from hydrocephalus, corresponding to 4.2% of the surviving patients.

CONCLUSION

Estimates from the most recently published studies indicate that an incidence of chronic post-subarachnoid hemorrhage hydrocephalus (requiring shunt surgery) of 15 to 20% is representative for an average contemporary population of patients with aneurysmal subarachnoid hemorrhage. The lower incidence of chronic hydrocephalus observed in this series possibly reflects the favorable effect of lamina terminalis fenestration on cerebrospinal fluid dynamics.

Transverse microincisions of the outer layer of the dura mater combined with foramen magnum decompression as treatment for syringomyelia with Chiari I malformation

Numerous surgical procedures have been proposed for treatment of syringomyelia associated with Chiari I malformation, but the optimal treatment has not yet been uniformly standardised. The main aim of the surgical treatment of syringomyelia/Chiari I complex is directed toward restoration of physiological cerebrospinal fluid dynamic at the craniovertebral junction. We report the surgical results of eight patients, affected by syringomyelia and Chiari I malformation, age range from 18 to 62 years, treated by bony foramen magnum decompression combined with transverse microincisions of the outer layer of the dura mater. In an average postoperative follow-up period of two years neurological symptoms and signs improved in seven patients. Postoperative Magnetic Resonance showed a decrease in size of the syrinx in seven patients. These results suggest that foramen magnum decompression combined with transverse microincisions of the outer layer of the dura 1) is an effective and safe treatment option for syringomyelia and Chiari I malformation, 2) corrects the circulatory disturbances of cerebrospinal fluid dynamic, 3) leads to a decrease in size of the syrinx and to a significant improvement in neurological signs and symptoms, 4) avoids complications of intradural approaches and syringosubarachnoid shunting.

Magnetic resonance imaging-monitored conservative management of traumatic spinal epidural hematomas. Report of four cases

Spinal epidural hematomas (SEHs) are uncommon complications of traumatic injury to the spine. Emergency surgical evacuation is the standard treatment. Although it is recognized in the literature, the possibility of nonsurgical treatment of traumatic SEH is far from being codified. The authors report excellent outcomes in four conservatively managed patients who had sustained a severe spine injury with fracture of the lumbar vertebral body and in whom traumatic SEHs were diagnosed by magnetic resonance imaging. Although in the authors' experience a good spontaneous outcome in this subgroup of minimally symptomatic patients harboring moderate-sized SEHs has been achieved, further studies are necessary to understand the real spectrum of nonsurgical treatment of such lesions.

Transsphenoidal microsurgical selective removal of multiple (triple) adenomas of the pituitary gland

This is the first case of multiple (triple) pituitary micro-adenomas documented by magnetic resonance imaging (MRI) in a living patient and treated by a transsphenoidal microsurgical approach. The patient, a 37-year-old woman, complained of a long history of bifrontal headache, weight gain and oligomenorrhea. Physical examination revealed moderate hirsutism and a slight fat pad overlying the vertebrae. Routine laboratory studies and endocrinological biochemical investigations were normal. A gadolinium-enhanced MRI of the pituitary region revealed three intrapituitary micro-adenomas. A transsphenoidal microsurgical approach to the pituitary gland was carried out and micro-adenomas were completely removed one at a time. One year follow-up showed complete resolution of clinical symptoms and signs and normal biochemical parameters of pituitary function.