Bernardo Fraioli

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.

Intracranial arterial aneurysms in early childhood

Cerebral saccular aneurysms are rare in early childhood. Seventy-one cases in children under 5 years of age found in the literature, plus one case of our own, are analyzed. In early childhood these aneurysms seem to have features that distinguish them from the same variety in adults. In children a congenital pathogenesis appears more convincing because of the higher frequency in the first 2 years of life, the often peripheral site (41.6%), the high frequency of large (50%) or giant (26.8%) aneurysms, and the association with other cerebral and vascular congenital abnormalities. Onset was nonhemorrhagic in 18.1% of cases compared with 2.5% in adults. The surgical outcome seems better in children than in adult patients in terms of both morbidity and mortality.

Glossopharyngeal neuralgia with cardiac syncope.

Glossopharyngeal Neuralgia is an uncommon craniofacial pain syndrome that is occasionally associated with cardiac syncope. Involvement of the glossopharyngeal nerve may be painless or may be marked by true episodic neuralgia, and this justifies the term neuralgia reported here. We present 5 cases of this uncommon syndrome, of a total of 15 observed cases of glossopharyngeal neuralgia, successfully treated by section of the rootlets of Cranial Nerves IX and X or by microvascular decompression in the posterior cranial fossa. We also analyze the relevant literature and discuss the pathogenesis and treatment of the syndrome.

Effects of stereotactic lesions of the dentate nucleus of the cerebellum in man.

In a series of 50 patients, 94 stereotactic lesions involving different parts of the dentate nuclei of the cerebellum were performed. 47 patients exhibited various dyskinetic syndromes; among these, 7 were also affected by epilepsy. In 3 patients epileptic disorders were exclusively present. Favourable results were obtained in dystonic and dystonic-athetoid infantile syndromes, more than in spastic syndromes. Some interesting effects on the epilepsy and ocular motility are also noted.

Hemorrhagic pituitary adenomas: clinicopathological features and surgical treatment.

Forty-five (9.9%) of 453 pituitary adenomas operated on between January 1973 and November 1988 demonstrated hemorrhagic changes at surgery: 24 had a blood collection, 12 had a blood collection associated with hemorrhagic necrosis, and 9 had hemorrhagic necrosis. Thirteen patients (28.9%) experienced the acute symptoms of pituitary apoplexy, whereas another 32 had an asymptomatic hemorrhage, that is, the clinical course was comparable to an uncomplicated adenoma. Nineteen tumors (42.2%) showed marked suprasellar extension, 8 (17.8%) showed moderate extension, and 11 (24.5%) showed slight extension; another 2 (4.4%) were laterosellar and 5 (11.1%) were intrasellar. Invasive behavior was present in 32 cases (71.1%) and this may suggest another hypothesis to explain the pathogenesis of tumoral hemorrhage. The incidence of hemorrhagic complications in invasive adenomas with marked suprasellar extension was particularly impressive; therefore, we do not suggest preoperative bromocriptine treatment in this type of tumor. Two of 14 patients operated on by the transcranial route died after surgery, whereas there was no operative mortality in the 31 patients operated on by the transsphenoidal route. It proved advantageous to operate as early as possible, even during the acute phase of pituitary apoplexy. The transsphenoidal approach gave the best results, but to achieve satisfactory late results multidisciplinary treatment was necessary, namely, postoperative radiotherapy in 23 patients, bromocriptine in 12, and endocrine replacement therapy in almost all. In an average follow-up period of 6.2 years, 5 (11.1%) symptomatic recurrences were observed.

Intrasellar tuberculoma: case report.

We report a unique case of exclusively intrasellar tuberculoma. The patient was operated on by the transsphenoidal approach, which allowed total removal of the lesion and prevented cerebrospinal fluid contamination. After histological diagnosis, the patient was treated with isoniazid, 300 mg daily for 3 months, as prophylaxis against tuberculous meningitis.

Glossopharyngeal Neuralgia with Cardiac Syncope: 58

Glossopharyngeal Neuralgia is an uncommon craniofacial pain syndrome that is occasionally associated with cardiac syncope. Involvement of the glossopharyngeal nerve may be painless or may be marked by true episodic neuralgia, and this justifies the term neuralgia reported here. We present 5 cases of this uncommon syndrome, of a total of 15 observed cases of glossopharyngeal neuralgia, successfully treated by section of the rootlets of Cranial Nerves IX and X or by microvascular decompression in the posterior cranial fossa. We also analyze the relevant literature and discuss the pathogenesis and treatment of the syndrome.

Microsurgical treatment of glossopharyngeal neuralgia: case reports

Three patients with excruciating glossopharyngeal neuralgia underwent microsurgical operations in the posterior cranial fossa. In each patient, neurovascular compression was found involving the posteroinferior cerebellar artery and involving the 9th and 10th cranial nerves. In two of the patients, the compression was caused by arachnoiditis and in the other by an arterial loop. In each patient, neuralgia was successfully eliminated by microvascular decompression and by section of the upper rootlets of the vagus nerve. In one patient, partial section of the 9th cranial nerve was also performed. Because of the frequent involvement of the vagus nerve in the pathogenesis of this condition, open surgery should be preferable to percutaneous thermorhizotomy, which is unable to act selectively on the 10th cranial nerve.

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.

Pituitary apoplexy in an acromegalic woman operated on during pregnancy by transphenoidal approach

We report a rare case of pituitary apoplexy in a woman, acromegalic at the sixth month of pregnancy, who suddenly complained of visual acuity disturbances.