Alessandro Pesce

Diffuse axonal injury and oxidative stress: A comprehensive review

Traumatic brain injury (TBI) is one of the world’s leading causes of morbidity and mortality among young individuals. TBI applies powerful rotational and translational forces to the brain parenchyma, which results in a traumatic diffuse axonal injury (DAI) responsible for brain swelling and neuronal death. Following TBI, axonal degeneration has been identified as a progressive process that starts with disrupted axonal transport causing axonal swelling, followed by secondary axonal disconnection and Wallerian degeneration. These modifications in the axonal cytoskeleton interrupt the axoplasmic transport mechanisms, causing the gradual gathering of transport products so as to generate axonal swellings and modifications in neuronal homeostasis. Oxidative stress with consequent impairment of endogenous antioxidant defense mechanisms plays a significant role in the secondary events leading to neuronal death. Studies support the role of an altered axonal calcium homeostasis as a mechanism in the secondary damage of axon, and suggest that calcium channel blocker can alleviate the secondary damage, as well as other mechanisms implied in the secondary injury, and could be targeted as a candidate for therapeutic approaches. Reactive oxygen species (ROS)-mediated axonal degeneration is mainly caused by extracellular Ca2+. Increases in the defense mechanisms through the use of exogenous antioxidants may be neuroprotective, particularly if they are given within the neuroprotective time window. A promising potential therapeutic target for DAI is to directly address mitochondria-related injury or to modulate energetic axonal energy failure.

Factors Leading to a Poor Functional Outcome in Spinal Meningioma Surgery: Remarks on 173 Cases

BACKGROUND Spinal meningiomas are common spinal tumors, in most cases benign and with a good surgical prognosis. However, specific location, infiltration of spinal cord, vascular encasement, or spinal root involvement can bring a less favorable prognosis. OBJECTIVE To correlate these data with clinical/functional outcome. METHODS Two hundred twenty-four consecutive patients with spinal meningiomas treated from 1976 to 2013 in our institution were analyzed; among these, 51 were excluded for incomplete clinical data or follow-up. The remaining 173 cases were classified in regards to sex, age, symptoms, axial location, Simpson grade resection, and functional pre-/postoperative status. RESULTS Most recurring onset symptoms were pain (32.9%) and motor deficit (31.8%); thoracic spine was the most severely affected (69.8%). Functional improvement on the follow-up was observed in 86.7% of cases; 6.4% of patients resulted stable and 6.9% worsened. A low functional grade before surgery was connected to a lesser improvement after. Anterolateral meningiomas were the most represented (42.2%); a gross total resection (Simpson grades I and II) was conducted in 98.8%, and a macroscopically complete removal without dural resection or coagulation (Simpson grade III) was performed in 1.2%. Of the meningiomas, 98.3% were classified as WHO grade I. Recurrence rate was 2.3%, and 7 cases presented complications (4 of 7 required surgical procedure). CONCLUSION We can affirm that negative prognostic factors in our study were anterior or anterolateral axial location, prolonged presentation before diagnosis, WHO grade >I, Simpson grade resections II and III, sphincter involvement, and worse functional grade at onset.

Acute Spinal Epidural Hematoma After Acupuncture: Personal Case and Literature Review

BACKGROUND Spinal acupuncture is a relatively safe and common analgesic treatment, but it may be complicated by serious adverse effects, such as direct spinal cord and nerve root injury, subdural empyema, and epidural abscesses. In this report we compare our case of an extremely uncommon spinal epidural hematoma, which appeared after treatment by acupuncture, with other similar documented cases. CASE DESCRIPTION This is the case of a 64-year-old man who presented a left hemiparesis associated with paraesthesia. This appeared several hours after acupuncture treatment for left lumbosciatic pain. The cervicothoracic spine magnetic resonance imaging (MRI) scan showed a cervicothoracic spinal epidural hematoma from C2 to T12. The rapid improvement of the patients neurologic symptoms justified the adoption of a conservative treatment strategy. This gave excellent long-term results. CONCLUSIONS Although a post-acupuncture spinal epidural hematoma (paSEH) is very rare, there are only 6 documented cases, it is a possible complication from acupuncture on the back. The use of very thin needles can produce bleeding, probably venous, in the epidural space. In general, this evolves more slowly than other kinds of epidural hematomas. The symptoms are also less severe, warranting less frequent surgical intervention, and in general there is a good outcome. The possibility of hematoma makes acupuncture contraindicated in patients who have coagulation disorders. The onset of severe spinal pain after spinal or paraspinal acupuncture treatment should lead to the suspicion of a paSEH, and a spinal MRI should be carried out.

A Poorly Known Cerebrospinal Fluid Shunt Complication: Miyazaki Syndrome

We studied a poorly known form of cerebrospinal fluid hypotension characterized by cervical myelopathy, a considerable growth in volume of the venous plexus of the cervical spine, and absence of headache. This form was first described by Miyazaki. We reported a case brought to our attention, reviewed the literature, and formulated etiopathogenic theories that might explain all the various clinical aspects of this pathology.

Chondromyxoid Fibroma of the Skull Base: Our Experience with an Elusive Disease

Abstract Chondromyxoid fibroma (CMF) is an extremely rare lesion of the skull base. This histologic type typically predilects metaphysis of the long bones. It is locally invasive/infiltrative, and this tendency is more concerning in the skull base, where a radical resection is often technically impossible because of the presence of vital neurovascular structures. We present a case of a 19‐year‐old woman who presented with a sudden onset of right facial weakness, progressively worsening to a severe disfiguring motor weakness. Gadolinium‐enhanced brain magnetic resonance imaging showed an osteolytic lesion located in the right mastoid involving the stylomastoid foramen and the right seventh cranial nerve. A partial mastoidectomy was performed, with an excellent rate of tumor resection and complete local control of the disease at follow‐up. The analysis of current literature indicates that a radiologic diagnosis is rarely strictly convincing of CMF. Histologic diagnosis is often difficult due to the lack of a specific immunohistochemical pattern of chondrosarcoma. Surgery is currently recognized as the mainstay to manage this lesion, although a trend toward adjuvant radiation therapy (RT) currently is seen. Although a tendency of local recurrence is well recognized in the literature, the very slow and indolent behavior of this lesion plus the trend to enhance local control of the disease with high‐dose RT pushed us to a reappraise the role of radical skull base surgeries burdened by the risks of major complications, cosmetic deformities, and additional neurologic deficits.

Preoperative Volumetric Assessment Matched with High-Field Intraoperative Magnetic Resonance Imaging-Guided Stereotactic Evacuation of Brain Abscesses

OBJECTIVE AND BACKGROUND Stereotactic evacuation is currently accepted as a minimally invasive surgical procedure for the management of brain abscesses. Intraoperative magnetic resonance imaging (Io-MRI) is well established in neuro-oncology but its role has not been completely outlined for brain abscess surgery. The objective of this work is to analyze radiologic, clinical, and laboratory results in a cohort of patients with brain abscesses treated with an original protocol in which the minimally invasiveness of a stereotactic technique is matched with preoperative volumetric evaluation and Io-MRI. METHODS For each of the 12 patients included in this cohort, the following data were recorded: age, sex, location, presentation, grade of evacuation, duration of follow-up, mean preoperative and postoperative Glasgow Outcome Scale score, functional outcome, number of abscess loculations, number of Io-MRI, duration of antibiotic therapy, preoperative and postoperative laboratory findings, pathogen strains and possible recurrences. RESULTS The operative time was in 10/12 patients under 90 minutes. A total of 8/12 patients needed no more than 30 days of antibiotics; 9/12 patients had minor or no sequelae and returned to normal activities; only 1 recurrence of brain abscess was recorded in the sample. Only 1 death was recorded in the sample. CONCLUSIONS Although this work is intended to present preliminary results of an original protocol for the management of brain abscess, the role of a precise preoperative volumetric evaluation matched with Io-MRI in the treatment of this disease seems of great benefit, as in surgical neuro-oncology.

How old is your cervical spine? Cervical spine biological age: a new evaluation scale

PurposeThis article aims at presenting a scale that, through the analysis of MRI images, clearly charts the various degenerative stages of the cervical spine and establishes its biological age. We have created this scale by summing together various scores linked to a selection of parameters according to which MRI images are analyzed.MethodWe examined 423 cervical spine MRI scans, belonging to patients who had been admitted to the Medical Imaging Service of the Military Hospital of Rome between January 2010 and July 2011. We selected 6 parameters for the analysis of the MRI scans of the cervical spine: (1) the degeneration of the intervertebral discs, (2) the degeneration of the yellow ligaments, (3) the degeneration of the vertebral bodies, (4) the possible presence of spondylolistheses, (5) the presence or absence of foraminal stenosis, and (6) the diameter of the spinal canal. We assigned to each parameter a score system based on a graduated scale. The cervical spine physiological age can be determined by summing up the scores obtained for each parameter.ResultsWe submitted the data obtained from the study to a statistical enquiry. The results of the enquiry confirmed the suitability of the parameters selected for the evaluation of the aging process of the cervical spine.ConclusionsThe effectiveness of the various treatments for cervical spine degenerative disorders is influenced by the overall anatomical conditions of the cervical spine. Up until now there has been no objective criterion for the evaluation of these anatomical conditions. We believe that this scale will be a useful tool to homogenize retrospective studies and to correctly set up prospective studies on the degenerative conditions of the cervical spine and relative treatments.

Surgical Treatment of Spinal Meningiomas

Spinal meningiomas are common spinal tumors; in most cases they are benign and with a good surgical prognosis. However, specific location, infiltration of spinal cord, vascular encasement, or spinal root involvement can bring to a less favorable progno‐ sis. We reviewed a series of 173 consecutive patients with spinal meningiomas treated from 1976 to 2011 in our institution, and data were stratified according to sex, age, symptoms, axial location, Simpson resection grade, and functional pre-/postoperative status. Particular attention was paid to description of those factors leading to a poor outcome. Functional improvement at follow-up was observed in 86.7% of cases, 6.4% of patients resulted stable, and 6.9% worsened; a low functional grade before surgery was connected to a lesser improvement after. Anterolateral meningiomas were the most represented (42.2%); a gross total resection (Simpson grade I and II) was conducted in 98.8% and a macroscopically complete removal without dural resection or coagula‐ tion (Simpson grade III) was performed in 1.2%. According to data from our series, negative prognostic factors seem to be: anterior or anterolateral axial implant, longlasting symptoms before diagnosis, WHO grade > I, Simpson grade II and III resec‐ tion, sphincter involvement, and worse functional grade at onset.

Ancient Schwannoma of the Cauda Equina: Our Experience and Review of the Literature

Ancient schwannomas (AS) are exceedingly rare variant of common schwannomas (CS). Only two cases involving the cauda equina region have been previously reported in literature. AS are typically associated with a higher histological degree of degenerative changes (Antoni B areas). It is of peculiar importance, according to our opinion, to outline that, because of their extremely slow growth (which explains the increase of the degenerative changes in respect to the CS) and their typical soft consistency in respect to their standard counterparts, AS usually imply an even better prognosis.

Brain Abscess after Percutaneous Therapy for Trigeminal Neuralgia

We report a case of brain abscess following the percutaneous treatment for trigeminal neuralgia. This procedure envisages the access with a needle into the middle cranial fossa through the oral cavity. Thus, in this case, the bacterial infection can be more likely ascribed to the possible contamination of the needle inside the oral cavity rather than to other frequent and more controllable causes of infection like an imperfect sterilization of surgical instruments or an inadequate antiseptic preparation of both operators hands and patients skin. The subsequent brain abscess was treated with antibiotic therapy (Vancomycin 2 gr a day and Meropenem 8 g a day for 22 days before the surgical procedure and 30 days after, until complete normalization of laboratory parameters, clinical parameters, and neurological symptoms) and surgical drainage, although the culture of the abscess capsule and the purulent material resulted sterile. In conclusion, the percutaneous therapy for trigeminal neuralgia can be objectively related to risks, even if performed by expert hands. Therefore, it is important that the patient should be advised regarding risks/benefits and/or septic complications of such procedures, even if they occur very seldom. An association of surgery and antibiotic therapy results as effective treatment for this pathologic condition.