Bernardo Borovich

The incidence of multiple meningiomas—Do solitary meningiomas exist?

SummarySince the advent of computed tomography (CT) the recognition of the occurrence of multiple intracranial meningiomas (MIM) in the same individual has been on the increase. In our material the incidence of MIM at first assessment of CT films was 20%, with distant multiplicity prevailing over the regional one. This incidence will probably change in the course of time as MIM develop not only concurrently but also consecutively. On the other hand our surgical macroscopic incidence of regional multiplicity alone was 49%. The discrepancy between the CT and surgical findings prompted us to reevaluate the CT studies of 100 consecutive patients. This reevaluation demonstrated: 1. in two cases, small meningiomas were overlooked at first assessment; 2. nineteen cases of solitary globoid meningiomas seemed to be the consequence of the coalescence of adjacent smaller masses. Thus, the CT incidence of MIM increased to 40%, with regional multiplicity prevailing over the distant one.The authors think that the aforesaid findings question the very existence of solitary meningiomas as a pathological entity. They would be the end product of a coalescence of multiple adjacent smaller growths. Accordingly, a more aggressive surgical approach is suggested to include the resection of a generous fringe of dura mater around the main tumour. As this is not always possible, or too risky, a comprehensive complement to surgery like radiotherapy could be given a reasonable randomized trial.

Osmotherapy for increased intracranial pressure: Comparison between mannitol and glycerol

SummaryOsmotic agents are still the most common treatment for controlling intracranial hypertension (ICH). Mannitol, glycerol, sorbitol, and hypertonic serum saline are the agents currently available.This work was designed to compare mannitol and glycerol in a similar population of brain injured patients, randomly divided into two groups of eight. The following mean day parameters were obtained: number of infusions, hydric balance, mean arterial pressure (MAP), and intracranial pressure (ICP). Cerebral perfusion pressure (CPP) was calculated. Brain computed tomographies (CT) were obtained on arrival, at follow-up whenever justified and at discharge. For comparison of both groups a modified therapeutic intensity level (mTIL) was used.Both agents induced a statistically equally effective decrease on ICP and increase on CPP evaluated at one and two hours post infusion but the mean day mTIL showed a statistically significant difference in favour of glycerol. The possible explanations of this difference are discussed. According to our results mannitol would be most indicated as a bolus to control sudden rises in ICP whereas glycerol would be most indicated as a basal treatment.

Brain abscess and its surgical management

A series of 56 patients with brain abscesses who were treated over a period of 23 years is reviewed. Patients with posttraumatic infections were not included. The operative mortality was 11%. Aspiration of purulent material, radical excision of the abscess, drainage of pus, or a combination of these procedures was used according to the patients condition and the location of the abscess. The relatively low mortality may be related to the preoperative condition of these patients, who were operated upon in the subacute or chronic stage of their disease. Conservative surgery, especially when functionally important parts of the brain are involved, helps to keep the postoperative neurological deficit as low as possible. Computerized tomography is of primary importance in localizing, diagnosing, and following the evolution of a brain abscess.

Traumatic carotid aneurysm secondary to cavernous sinus penetration by wood: CT features.

Transorbital penetration of the cranial cavity by a small wooden object can pass unnoticed, while producing severe, life-threatening consequences. The occurrence of a traumatic intracranial aneurysm secondary to a wooden foreign body has not been reported previously in the English literature, to our knowledge. Familiarity with the CT features of this complication is crucial since the CT findings may be the first to suggest penetration of the cavernous sinus by wood, as well as the possibility of a traumatic carotid aneurysm. The CT features of this rare complication are discussed and the pertinent literature is reviewed.

Occipital Aneurysmal Bone Cyst: CT Features

A case of aneurysmal bone cyst arising from the lower occipital squama with intracranial extension is presented. The case is unique in that the cyst showed fluid levels on CT. Another peculiarity of this case was postoperative recurrence.

Spinal cord compression in Paget's disease of bone with reference to sarcomatous degeneration and calcitonin treatment

Four cases of spinal cord compression stemming from Pagets disease of bone tissue are reported. Sarcomatous degeneration was proved in one case and in another one malignancy was deduced by computed tomography (CT) scanning. Clinical and radiologic manifestations as well as surgical management are discussed. The value of CT scanning of the spine as an aid in the evaluation of structural changes and the size of the soft tissue mass in sarcomatous degeneration of the lesion is stressed. After calcitonin administration, alleviation of pain and improvement in neurological status have occurred in two treated patients.

Use of Vasopressors to Raise Cerebral Perfusion Pressure in Head Injured Patients

Cerebral ischemia due to low cerebral perfusion pressure (CPP) is the most important secondary effect of severe head injury. There is consensus regarding the maintenance of this pressure at levels above 70 mm Hg. One way to elevate CPP is by increasing mean arterial pressure (MAP). In this study, the authors attain this target by using adrenergic vasopressors investigating the effectiveness of dopamine, noradrenaline and methoxamine in 16 severe head injured patients. The results were: a) the increase of MAP effectively increased CPP without changes in intracranial pressure (ICP) and cerebral extraction of oxygen (CEO2); b) noradrenaline at a dose of 0.5 mg to 5 mg/h was effective and safe and might be considered the drug of choice; c) dopamine was not as effective at a high dose of 10 to 42.5 micrograms/kg/min; d) methoxamine given as a bolus was an effective way to control sudden decreases in MAP. It made the patients more responsive to dopamine. No important undesirable reactions occurred during the study.

Aneurysmal bone cyst of spine.

SummaryFour patients (aged 5, 7, 18, and 42) suffering from spinal cord involvement due to an aneurysmal bone cyst are reported. In two cases only a preoperative radiological diagnosis was made, one of them by a CT scan. Combined surgical and radiological treatments were done in three cases with a follow-up of 16 years in one patient and 9 years in the other two. In the fourth case, presenting with a C1 lesion, after radical excision and curettage X-ray therapy was not instituted. Pathological and radiological manifestations are discussed. Therapeutic measures are reviewed.

The syndrome of the central L-3-herniated disc with special emphasis on motor involvement.

SummaryLiterature about the clinical characteristics of herniation of the lumbar intervertebral disc is profuse. Due to their predominant frequency, attention was almost entirely devoted to the L-4 and L-5 prolapses. As clinical accuracy still remains a very important target, specially in departments where myelography is not used for the diagnosis of this entity, the authors thought it of interest to describe the clinical picture of the L-3-herniated disc. Special stress is placed on the motor involvement.Fourteen cases form this series. They were all central soft herniations. Cases of spondylotic narrow spinal canal were excluded. The special features were their predominance in people above 50 years old and the compromise of the hip abductors and internal rotator muscle groups making it impossible for the patient to stand on the affected limb (Trendelenburg sign). An abnormal knee jerk was a frequent accompaniment. Contrary to common knowledge the quadriceps muscle strength was almost unaffected. Sensory disturbances were not useful for location. The L-3 section of the lower lumbar spine is the narrowest explaining the reason why 3/4 of the patients had a more or less complete cauda equina syndrome. It was therefore a very dangerous herniation that crippled quidkly, needing usually an emergency operation with all the risks involved in this older age group of patients.

Spinal intradural metastases of extraneural origin

SummaryThree cases of intradural extramedullary (spinal subdural) metastases, originating from outside the central nervous system, are presented. Two were located at the cervico-dorsal junction, and one was mid-dorsal. A breast ductus carcinoma, a cervical neuroblastoma, and an apoduma of unknown origin, were the primary neoplasms. All presented clinically with a short history typical of cancerous spinal cord compression. Plain X-rays of the spine did not show areas of destruction. Myelography in two cases clearly suggested the intradural location of the tumour. The relative frequency of these tumours and their pathogenesis are briefly reviewed. It is stressed that primary tumours are mainly in the breast or lung. Their metastases are mainly found in the cervico-dorsal region. It is assumed that they really are metastases of the dura mater itself, growing inward. The importance of the lymphatic and venous pathways in their spread into the dura mater is emphasized.