Francesco Signorelli

Intracranial ependymomas in adult patients: analyses of prognostic factors

AbstractObjective: The goal of our study is to identify significant prognostic factors for a series of intracranial ependymomas in an adult population. Age, location, histology, preoperative clinical status, extent of resection and radiotherapy were examined.nMethods: Our series includes 34 patients. Ten tumors were located in the brain parenchyma, 5 in the lateral ventricle, 8 in the third and 11 in the fourth ventricle. Seventeen ependymomas were grades 2 and 17 were anaplastic. Surgical resection was gross-total in 27 patients and partial in 7.nResults: At a mean follow-up of 9 years (±1 year) 16 patients died and, among the 18 survivors 14 are in complete remission and 4 present a local recurrence. The 5- and 10-year overall survival rates were respectively 62% and 43%. The 5- and 10-year progression-free survivals were 47% and 43%. Univariate analysis revealed that location in the brain parenchyma and anaplasia are the only statistically significant predictors of poor outcome.nConclusion: We can make out three groups of patients from our series: the first encompasses patients operated on for an intraparenchymal tumor, in all our cases an anaplastic ependymoma, with a 5-year rate of tumor-related deaths of 100%. The second group includes fourth ventricle ependymomas, which are mostly grade 2 tumors. They display a 10-year survival rate of 90%. Last group entails lateral and third ventricle ependymomas, of both low and high grade, with a 10-year survival rate of 60% for lateral ventricle and 35% for third ventricle tumors.

Endovascular treatment of two concomitant causes of pulsatile tinnitus: sigmoid sinus stenosis and ipsilateral jugular bulb diverticulum. Case report and literature review

We describe a rare case of highly invalidating pulsatile tinnitus associated with both stenosis of the sigmoid sinus and ipsilateral jugular bulb diverticulum. Both conditions were successfully treated by positioning a stent across the sigmoid sinus and jugular bulb. To our knowledge, the present clinical case represents the first report of such an approach. The therapeutic decision-making is discussed in relation to the etiopathologic hypothesis put forward.

Radically resected pituitary adenomas: prognostic role of Ki 67 labeling index in a monocentric retrospective series and literature review

Ki-67 Labeling Index is an immunocytochemical marker of cell proliferation. The correlation of Ki-67 expression with pituitary adenomas recurrence has been investigated and is highly debated. Aim of this study was to evaluate whether Ki-67 correlates with recurrence even in patients with an apparently completely removed pituitary adenoma. We retrospectively reviewed the database of the Hypothalamic-Pituitary Disease Unit at the Catholic University of Rome, collected between 2003 and 2011. Inclusion criteria were: patients who underwent surgery at the Department of Neurosurgery with an apparently complete removal of a pituitary adenoma; Ki-67 histological evaluation by the same operator and values of <3xa0%. All patients underwent endocrine evaluation of the hypothalamic-pituitary function, ophthalmologic and neuro-radiological examinations, during the preoperative period and follow-up. Out of 490 patients recorded on the database of the Hypothalamic-Pituitary Disease Unit at the Catholic University of Rome, 191 cases met the inclusion criteria. Recurrence was observed in 49 cases (25.7xa0% of the patients who had undergone radical excision). Optional cut-off value was identified at Ki-67 values of 1.50xa0%. This was associated with worse disease-free survival time, even after correction for age at treatment, gender, positivity to p53, functional classification and Knosp grading. Ki-67 labeling index may be useful in postoperative management, even in patients who underwent radical PA removal. We suggest a Ki-67 cut-off value of 1.5xa0% to plan an adequate clinical follow-up.

The "sandwich phenomenon": a rare complication in adjacent, double-level X-stop surgery: report of three cases and review of the literature.

Study Design. Case reports. Objective. To report the atraumatic fracture of the intervening (L4) spinous process (SP) in patients treated with X-Stop at 2 adjacent levels and discuss the potential underlying causes. Summary of Background Data. Limited evidence on complications in double-level X-Stop surgery is available. Methods. Three men, 47, 63, and 75 years old, respectively, underwent surgery with insertion of X-Stop at L3–L4 and L4–L5 because of low back pain and neurogenic claudication due to degenerative lumbar spine conditions. Two 10 mm devices were implanted in the first patient and two 16 mm distractors in the second man. One 10 mm X-Stop at L3–L4 and one 12 mm at L4–L5, respectively, were implanted in the third patient. No intraoperative complications occurred and the postoperative course was uneventful, with symptoms relief. Results. The first 2 patients presented because of recurrent symptoms 4 and 6 months after surgery, respectively. Imaging revealed “spontaneous” fracture of the L4 SP in both of them. Revision surgery was required, with removal of the interspinous devices, decompression and fixation. In the third patient the L4 SP fracture was detected when the patient presented because of recurrent back pain 18 months after the index surgery, but revision surgery was not consented. Conclusion. To our knowledge this is the first report describing the “sandwich phenomenon,” i.e., the atraumatic fracture of the intervening SP in patients with adjacent, double-level X-Stop. Possible underlying theories and anatomic peculiarities which may predispose to this rare event are discussed.

Review of current microsurgical management of insular gliomas

The insular lobe is a functionally complex structure, harbouring peculiar anatomical and vascular features and specific neuronal connectivity with surrounding cerebral structures. It is situated in the depth of the Sylvian fissure and can be affected by either low-grade or high-grade gliomas. Because of its complexity, surgery of insular tumours has been traditionally regarded as hazardous. Nonetheless, currently improved diagnostic, neurophysiological and surgical tools allow the neurosurgeon to perform surgery of insular gliomas in a safer way, thus bringing forward the pioneering work performed by neurosurgeons in the past two decades.The aim of this paper is to provide the reader with an updated review of the anatomy, the clinical picture, diagnosis and surgical management of insular gliomas.

Endoscopic endonasal resection of the odontoid process as a standalone decompressive procedure for basilar invagination in Chiari type I malformation.

BACKGROUNDnThe expanded endonasal approach of the cranio-cervical junction provides comfortable working space while avoiding some of the disadvantages of the transoral route. We report a purely endonasal endoscopic resection of the odontoid process for basilar invagination in a patient with a Chiari type I malformation, without posterior decompression or fusion.nnnCASE REPORTnA 54-year-old female patient presented with cranial nerve and brainstem deficits. CT and MRI showed a Chiari type I malformation and compression of the medulla by basilar invagination of the odontoid process. The tip of the latter was displaced up to the bulbo-pontine sulcus. The odontoid process was resected via the expanded endoscopic endonasal approach, without additional posterior decompression or fusion. The post-operative course was uneventful, including the absence of velopharyngeal insufficiency. Neurological deficits regressed rapidly. The preoperative cervical pain virtually disappeared. At 9 months follow-up, the patient had normal activity with minimal residual neurological deficits. Post-op dynamic radiography and CT showed stability of the cranio-cervical junction.nnnCONCLUSIONnDecompression of the bulbomedullary junction by purely endoscopic transnasal resection of the odontoid process is well tolerated and efficient. Immediate stabilization is not mandatory in all cases of congenital causes of basilar invagination.

De novo malignant craniopharyngioma: case report and literature review.

Malignant or anaplastic craniopharyngioma, first described in 1987 by Akachi and coworkers, is a rare occurring craniopharyngioma characterized by cytologic atypia and poor prognosis. Fifteen cases have been previously reported, two of which have been defined de novo, i.e. not developing from a previously treated benign craniopharyngioma; both these patients died in the early post-operative period. Herein we describe the case of a 66-year-old female who presented with visual disturbance and radiological evidence of a sellar and suprasellar tumor. The patient underwent trans-sphenoidal biopsy followed by pterional craniotomy with partial tumor removal. Histological diagnosis documented a malignant adamantinomatous type craniopharyngioma. The patient received adjuvant radiotherapy with a significant tumor reduction. She remained in good clinical conditions for 10xa0months; she deteriorated and died, due to tumor progression, 15xa0months after diagnosis. Malignant craniopharyngioma is a rare primary malignant tumor of the sellar region. This is the first case of de novo malignant craniopharyngioma with significant follow-up.

Differential Expression of Somatostatin Receptors in Medulloblastoma

AbstractObject. Somatostatin receptors have been found on a variety of tumours like neuroendocrine breast or brain tumours. Their detection opens new diagnostic and therapeutic paths. The aim of this work was to investigate their expression in medulloblastomas.nMethods. Using both techniques, reverse transcriptase-polymerase chain reaction and immunohistochemistry, we analysed mRNA of different subtypes of somatostatin receptors in 15 medulloblastomas and the localisation of the subtype SSTR2 receptor at the cellular level in 13 medulloblastomas. All five subtypes mRNA were variably expressed in each medulloblastoma. The signal obtained after Southern blotting for SSTR2 receptor amplification was the highest as compared to the signal obtained for the other receptor subtypes. Immunostaining for SSTR2A receptor was present in every tumour specimen and was specifically located to the cellular membrane of neoplastic cells. No staining was identified at the level of peritumoral veins.nConclusion. The evidence of predominant expression of SSTR2 receptors in medulloblastomas opens interesting prospects for their diagnosis and therapy.

Endovascular treatment of bifurcation intracranial aneurysms with the WEB SL/SLS: 6-month clinical and angiographic results

Background The WEB device is a recent intrasaccular flow disruption technique developed for the treatment of wide-necked intracranial aneurysms. To date, a single report on the WEB Single-Layer (SL) treatment of intracranial aneurysms has been published with 1-months safety results. The aim of this study is to report our experience and 6-month clinical and angiographic follow-up of endovascular treatment of wide-neck aneurysm with the WEB SL. Methods Ten patients with 10 unruptured wide-necked aneurysms were prospectively enrolled in this study. Feasibility, intraoperative and postoperative complications, and outcomes were recorded. Immediate and 6-month clinical and angiographic results were evaluated. Results Failure of WEB SL placement occurred in two cases. Eight aneurysms were successfully treated using one WEB SL without additional treatment. Three middle cerebral artery, four anterior communicating artery, and one basilar artery aneurysms were treated. Average dome width was 7.5u2009mm (range 5.4–10.7u2009mm), and average neck size was 4.9u2009mm (range 2.6–6.5u2009mm). No periprocedural complication was observed, and morbi-mortality at discharge and 6 months was 0.0%. Angiographic follow-up at 6 months demonstrated complete aneurysm occlusion in 2/8 aneurysms, neck remnant in 5/8 aneurysms, and aneurysm remnant in 1/8 aneurysm. Conclusions From this preliminary study, treatment of bifurcation intracranial aneurysms using WEB SL is feasible. WEB SL treatment seems safe at 6 months; however, the rate of neck remnants is not negligible due to compression of the WEB SL. Further technical improvements may be needed in order to ameliorate the occlusion in the WEB SL treatment.

Intraoperative Probe-Based Confocal Laser Endomicroscopy in Surgery and Stereotactic Biopsy of Low-Grade and High-Grade Gliomas: A Feasibility Study in Humans.

BACKGROUNDnThe management of gliomas is based on precise histologic diagnosis. The tumor tissue can be obtained during open surgery or via stereotactic biopsy. Intraoperative tissue imaging could substantially improve biopsy precision and, ultimately, the extent of resection.nnnOBJECTIVEnTo show the feasibility of intraoperative in vivo probe-based confocal laser endomicroscopy (pCLE) in surgery and biopsy of gliomas.nnnMETHODSnIn our prospective observational study, 9 adult patients were enrolled between September 2014 and January 2015. Two contrast agents were used: 5-aminolevulinic acid (3 cases) or intravenous fluorescein (6 cases). Intraoperative imaging was performed with the Cellvizio system (Mauna Kea Technologies, Paris). A 0.85-mm probe was used for stereotactic procedures, with the biopsy needle modified to have a distal opening. During open brain surgery, a 2.36-mm probe was used. Each series corresponds to a separate histologic fragment.nnnRESULTSnThe diagnoses of the lesions were glioblastoma (4 cases), low-grade glioma (2), grade III oligoastrocytoma (2), and lymphoma (1). Autofluorescence of neurons in cortex was observed. Cellvizio images enabled differentiation of healthy normal tissue from pathological tissue in open surgery and stereotactic biopsy using fluorescein. 5-Aminolevulinic acid confocal patterns were difficult to establish. No intraoperative complications related to pCLE or to use of either contrast agent were observed.nnnCONCLUSIONnWe report the initial feasibility and safety of intraoperative pCLE during primary brain tumor resection and stereotactic biopsy procedures. Pending further investigation, pCLE of brain tissue could be utilized for intraoperative surgical guidance, improvement in brain biopsy yield, and optimization of glioma resection via analysis of tumor margins.nnnABBREVIATIONSn5-ALA, 5-aminolevulinic acidpCLE, probe-based confocal laser endomicroscopyPpIX, protoporphyrin IX.