Beniamino Guidetti

Treatment of trigeminal neuralgia by thermocoagulation, glycerolization, and percutaneous compression of the gasserian ganglion and/or retrogasserian rootlets: long-term results and therapeutic protocol.

From 1976 to 1986, 681 patients with drug-refractory trigeminal neuralgia (TN)--typical in 641, symptomatic of multiple sclerosis in 23 and of tumor in 10, atypical in 5, and postherpetic in 2--were treated with various percutaneous procedures. Controlled differential thermocoagulation of the gasserian ganglion and/or retrogasserian rootlets was performed in 533 patients; glycerolization of the trigeminal cistern in 32; and compression of the gasserian ganglion by balloon catheter in 159. Results and complications of each procedure are assessed at a mean follow-up of 6.5 years for thermocoagulation, 5 years for glycerolization, and 3.5 years for compression. The following therapeutic protocol is proposed: 1) in TN patients at first operation: a) gasserian compression (or glycerolization, if experience warrants it) is indicated in all cases of typical TN, unless the 3rd division alone is affected; b) in the latter case and in symptomatic TN, we suggest thermocoagulation; 2) in recurrences: a) after glycerolization or gasserian compression, gasserian compression (or glycerolization) is indicated; b) after thermocoagulation or open surgery, thermocoagulation is suggested.

Relationship between Leukocytosis and Ischemic Complications following Aneurysmal Subarachnoid Hemorrhage

The prognostic significance of admission leukocytosis with respect to ischemic complications of subarachnoid hemorrhage was retrospectively investigated in a series of patients with recently ruptured intracranial aneurysms. The present study concerned 47 consecutive cases admitted within 72 hours following the last hemorrhage, in the years 1982-1984. There was no difference in the admission WBC counts between patients who subsequently deteriorated due to ischemic complications and those who did not. However, the cell count rose significantly at the time of the clinical manifestations of ischemia, possibly as a result of structural damage of brain tissue and/or increased sympathetic and adrenocortical activity. The possible contribution of leukocytes to the pathogenesis of ischemic damage following subarachnoid hemorrhage--perhaps through the release of leukotrienes--will require further investigation.

Prostaglandin E2 as an immunomodulating factor released in vitro by human glioma cells

SummaryCultured human glioma cells were found to produce soluble factors that can modulate the in vitro proliferative response of purified T lymphocytes stimulated by phytohemagglutinin (PHA). Neoplastic tissue was removed during surgery for brain glial tumors and cultured in vitro. The glial nature of the neoplastic cells was verified by means of anti-glial fibrillary acidic protein immunohistochemical staining. Serum-free supernatants from these cultures proved capable of suppressing in vitro proliferation of PHA-stimulated T lymphocytes. Suppression was reduced when indomethacin or aspirin was added to the culture medium. Thin-layer chromatography revealed the presence of prostaglandins and other arachidonic acid derivatives in the supernatants. The radioimmunoassay used to quantify the prostaglandin E2 (PGE2) in the supernatants showed detectable amounts of PGE2, which disappeared after the cultures had been treated with anti-inflammatory drugs. These data support the hypothesis that tumoral glial cells can play a role in the host immune response in the central nervous system, namely by producing soluble factors.

Meningiomas of the lateral ventricles. Clinical, neuroradiologic, and surgical considerations in 19 cases

The clinical and neuroradiologic findings and surgical results in a series of 19 patients with lateral ventricle meningioma, operated on during a 33-year period, are described. This experience is compared with that of previous workers and the following conclusions are drawn: these tumors have no characteristic symptoms; preoperative diagnosis requires both computed tomography scans and carotid and vertebral angiography; the safest surgical approach is through a sagittal or oblique parietooccipital cortical incision to avoid damage to motor, visual, and speech areas of the cortex.

Results of surgical management of 319 pituitary adenomas

SummaryOf the 510 patients with pituitary adenoma treated surgically at our hospital in the period 1956–1984 319 were treated by the microsurgical technique, in the period 1973–1984, 235 by transsphenoidal approach and 84 by subfrontal-pterional approach. The transsphenoidal route was used almost exclusively in microadenomas, in intrasellar adenomas, in suprasellar adenomas with midline development, in adenomas invading the sphenoidal sinus and in haemorrhagic adenomas with considerable suprasellar development. In some giant adenomas the transsphenoidal route was used in a first stage operation for debulking the tumour, later removed by transcranial route. The latter route was preferred in large adenomas and especially in adenomas with laterosellar development. In some patients with PRL secreting adenomas post-operative treatment with bromocriptine proved useful when the hormone levels failed to noramlize. Post-operative radiotherapy was of value in invasive adenomas and in cases in which tumour removal was not radical.

Carotid-ophthalmic aneurysms. A series of 16 cases treated by direct approach.

SummaryA series of 16 cases of carotid-ophthalmic aneurysm treated by direct approach is reported and the following points are emphasized:the aneurysm was associated with signs of optic nerve compression in half of the cases.angiography did not always disclose the possibilities and the hazards of direct surgery.indirect surgery (common carotid ligation) did not prevent the aneurysm from growing or restore useful vision. On the other hand, ligation of the aneurysmal neck or local trapping, where necessary, followed by removal of the aneurysm resulted in marked improvement of impaired vision. The hazard of ophthalmic artery occlusion is stressed.

Choroid plexus papillomas in infancy and childhood

The present study deals with 15 cases of choroid plexus papilloma, out of approximately 500 cases of brain tumors observed in children up to 16 years old. Several features are considered, including clinical symptoms and signs—mostly related to increased intracranial pressure—radiological diagnosis, pathology and surgical treatment, and results. Surgery may be radical in most cases, with the exception of histologically malignant papillomas. The management results are usually satisfactory. An adequate choice of surgical approach is mandatory and surgical technique should be meticulous, also in order to avoid the risk of intraoperative tumoral seeding.

The role of antifibrinolytic therapy in the preoperative management of recently ruptured intracranial aneurysms.

In a retrospective study of the use of antifibrinolytic therapy in a series of patients with recently ruptured intracranial aneurysms, 131 patients were selected based on the following criteria: commencement of therapy within 3 days of the last subarachnoid hemorrhage (SAH); continuation of therapy for at least 6 days; and apparently uncomplicated surgery. Two main modalities of antifibrinolytic therapy were used: Group A, tranexamic acid (AMCA) 3 gm daily plus aprotinin k.i.u. (kallikrein inactivating units) daily (82 cases); Group B, AMCA 6 gm daily (41 cases). The remaining 8 patients were treated with epsilon-aminocaproic acid alone or in combination with aprotinin and were not considered to constitute a large enough group for statistical comparison. The rest of the preoperative treatment consisted of bed rest; mild sedation; antihypertensives, if the blood pressure exceeded 160 mm Hg; and osmotic diuretics as needed. The mean interval between last SAH and operation was about 13 days in both groups. The rates of rebleeding and thromboembolism were similar in the two groups but the rates of ischemic complications and post-SAH hydrocephalus were higher in Group B. The difference in the rate of severe cerebral ischemic complications was statistically significant (11 of 82 in Group A versus 12 of 41 in Group B, p less than 0.02), and in the main they were present preoperatively. The rates of rebleeding (approximately 10%) and of death from rebleeding (approximately 5%) are lower than in other published series on the natural history of this condition. In cases in which antifibrinolytics are indicated, present evidence indicates that low-dose AMCA plus aprotinin seems to be a rational combination for lowering the rebleeding, ischemic complication, and post-SAH hydrocephalus rates.

Modern trends in surgical treatment of trigeminal neuralgia

From 1955 to July 1978, 560 patients suffering from trigeminal neuralgia, who had not responded to medical treatment underwent various alternative procedures. Considering some of these to be out of date, some as showing too high a number of relapses and some as having potentially unjustified risks in an affection in itself not fatal, the authors report only the results observed in a series of 175 patients operated on by retrogasserian rhizotomy according to Frazier (1931), and the results of a series of 184 patients treated by controlled thermocoagulation according to Sweet and Wepsic (1974).

Electron-microscopic visualization of binding of antibodies from sera of glioma patients on cultured glioma cells

SummarySeveral human cell lines (normal and neoplastic glia, cerebral metastases from adenocarcinoma, fibroblasts) were incubated with sera from patients with well and poorly differentiated glioma and with sera from healthy donors and then stained with PAP complex to define and localize the antibody reaction with cell surface antigens by means of electron microscopy. The sera of glioma patients proved to contain antibodies which bound the tumor-associated antigenic determinants on the cell membranes of gliomas and of cerebral metastases from adenocarcinoma in tissue cultures. Further, absorption testing of the reactive sera on normal brain, well-differentiated astrocytoma and cultured glioblastoma cells, together with cross-reactivity experiments suggests that at least two antigens or groups of antigens are expressed on the glioma cell surface: one shared by well and poorly differentiated glioma cells and the other by poorly differentiated glioma cells and the cells of cerebral metastases from adenocarcinoma.