Giampietro Pinna

Cystic meningiomas—An update

Eighteen unusual cases of intracranial meningioma associated with a cyst are considered. Three patients were operated upon before the introduction of computed tomography scanning, and the discovery of a peritumoral cyst was unexpected. Among 15 patients studied with computed tomography, 8 had a peritumoral cyst, 6 had an intratumoral cyst, and 1 had a totally cystic meningioma (hypodense on computed tomography). Computed tomography permitted a correct preoperative diagnosis only in four cases. In six additional cases diagnosis was reached by selective angiographic studies. In the remaining cases diagnosis was impossible or incorrect. Different pathogenetic mechanisms underlie different radiologic patterns. The authors comment on the complex processes that lead to cyst formation in meningiomas and stress the necessity of an accurate preoperative study to avoid misdiagnosis.

Right Personal Neglect Following a Left Hemisphere Stroke. a Case Report

Neglect phenomena may occur in both extrapersonal and personal space. Whereas extrapersonal neglect has been found associated with both right- and left-sided brain lesions, no case of right personal neglect following a left-sided lesion has been so far reported. We describe a right-handed female patient who, after two left-hemisphere strokes, exhibited a florid personal neglect, but no extrapersonal neglect, anosognosia or somatoparaphrenia. The symptom persisted for a few weeks and then gradually disappeared. At least in the early phase of disease, a personal neglect can also be observed in patients with left brain damage.

Adenosine extracellular levels in human brain gliomas: an intraoperative microdialysis study

Adenosine present in human brain glioma extracellular spaces is a marker of astrocyte purine metabolism. In this study, we evaluated adenosine levels in the extracellular fluid of 21 human gliomas of high-grade malignancy using brain microdialysis techniques coupled to high-performance liquid chromatography. The adenosine concentration (mean+/-SEM) within the control tissue was 2.99+/-0.37 microM and in the tumour tissue 1.56+/-0.46 microM. The reduction was statistically significant. It is concluded that the adenosine concentrations reached in the tumour tissue are sufficient to stimulate all adenosine receptor subtypes, suppress local anti-tumour immune responses and affect glial and endothelial cell proliferation.

Surgical management of ruptured aneurysms in the eighth and ninth decades

Summary¶Background. The surgical management of elderly patients with aneurysmal subarachnoid haemorrhage (SAH) is controversial. The present study was performed to more clearly define issues facing elderly SAH patients undergoing surgical repair of their aneurysms. Method. Between 1990 and 2000, 100 patients, aged 70 years or older, were managed consecutively with aneurysmal surgical repair at Verona City Hospital. Ninety-seven of these were analysed with regard to age, clinical grade on admission, radiological features, and specific management components (3 patients were excluded from further analysis because of inadequate follow up data). Surviving patients were followed up for a minimum of 6 months and clinical outcome was assessed. Findings. Hydrocephalus requiring permanent CSF diversion occurred in 44% of cases surviving beyond 10 days from their SAH. The development of hydrocephalus requiring shunting was delayed more than 6 weeks in 7% of these cases. Medical complications occurred in 22% of cases. Clinical grade of haemorrhage (p<0.001), early hydrocephalus requiring ventriculostomy (p=0.003) and the development of medical complications (p=0.03) were significantly associated with poor outcome. Clinical vasospasm was not a major determinant of outcome in this group. The need for permanent CSF diversion was significantly associated with increasing age (p=0.03), intraventricular haemorrhage (p<0.001), early hydrocephalus requiring ventriculostomy (p=0.003) and the development of medical complications (p=0.05). Interpretation. Elderly patients experience a different range of complications following aneurysmal subarachnoid haemorrhage than their younger counterparts. Clinicians should remain alert to the development of hydrocephalus, especially of delayed onset.

Long-term results after posterior fossa decompression in syringomyelia with adult Chiari Type I malformation

OBJECT There is little information about the long-term effectiveness and complications following decompressive surgery for syringomyelia related to Chiari malformation Type I (CM-I). METHODS Examining long-term clinical and radiological follow-up, the authors studied a mixed retrospective and prospective single-institution cohort of 109 consecutive surgically treated adult patients with syringomyelia and CM-I. All patients underwent a standardized surgical protocol: decompression of the craniocervical junction, arachnoid exploration, and shrinkage of the cerebellar tonsils. Factors predicting outcome were investigated. RESULTS The retrospective arm consisted of 41 cases treated between 1990 and 1994, and the prospective arm comprised 68 patients treated between 1994 and 2001. The mean overall age was 45.9 years, and 58.8% of the population was female. The median follow-up period was 12.7 years. The most frequent initial symptoms were pain and sensory and gait disturbances. There was no perioperative death or neurological deterioration. The comprehensive perioperative complication rate was approximately 11%, with 3 cases (2.7%) of CSF leakage. Regression analysis showed that the best combination of clinical and radiological outcome predictors was age and duration of symptoms. Clinical follow-up confirmed surgical result stability with clinical improvement of greater than 90% of the spinal and cranial manifestations over a long-term period. Two patients had radiological recurrences of syringomyelia without clinical signs 85 and 124 months after surgery. CONCLUSIONS Certain clinical predictors of poor clinical and radiological prognosis were identified-namely, age at time of surgery and symptom duration. The results of the study provide additional long-term data that support the effectiveness and safety of relieving CSF block at the craniocervical junction in CM-I-related syringomyelia.

Post-Operative Monitoring of Contical Taurine in Patients with Subarachnoid Hemorrhage: A Microdialysis Study

Intracerebral MD enables the retrieval of endogenous substances from the extracellular fluid (ECF) of the brain and has been demonstrated to be a sensitive technique for early detection of subtle vasospasm-induced neurometabolic abnormalities in patients with subarachnoid hemorrhage (SAH). The aim of this study was to monitor cortical extracellular concentrations of energy metabolism markers, such as glucose and lactate, neurotransmitter amino acids, such as glutamate, aspartate, GABA and taurine to identify any neurochemical patterns of cerebral ischemia. A prospective clinical study was conducted on a group of 16 patients with non-severe SAH operated on within 72 hours after initial bleeding. Following aneurysm clipping, an MD catheter was inserted in the cortical region where vasospasm could be expected to develop, and perfused with artificial CSF at 0.3 microl/min flow rate. Dialysate was collected every 6 hours and then analyzed on High Performance Liquid Cromatography (HPLC) for glucose, lactate, pyruvate, glutamate, aspartate, GABA and taurine. Mean ECF taurine concentrations ranged from 1.4 + 0.7 to 12.3 + 7.8 micromol/l in single patients: global mean value was 5.8 + 3.8 micromol/l. In this series, the highest absolute taurine value was 25.7 micromol/l, observed in a patient who developed clinical and radiological signs of cerebral ischemia. Nine patients presented clinical disturbances related to cerebral vasospasm. In this setting, representing a mild-to-moderate hypoxic condition, MD data demonstrated that lactate is the most sensitive marker of cellular energy imbalance. Increased lactate levels positively correlated with glutamate (P<0.0001), aspartate (P<0.0001), GABA (P<0.0001) and taurine (P<0.0001) concentrations. These results suggest that also in humans increased taurine levels reflect a condition of cellular stress. This study confirms that MD is a sensitive technique to reveal subtle metabolic abnormalities possibly resulting in cell damage.

Monitoring Subtle Neurometabolic Changes in Subarachnoid Hemorrhage Patients Using Microdialysis: A Study on 16 Cases

Monitoring subtle neurometabolic changes in subarachnoid hemorrhage patients using microdialysis: a study on 16 cases

Intraoperative Measurement of Arterial Blood Flow in Aneurysm Surgery

Intraoperative flowmetry (IF) has been recently introduced during cerebral aneurysm surgery in order to obtain a safer surgical exclusion of the aneurysm. This study evaluates the usefulness of IF during surgery for cerebral aneurysms and compares the results obtained in the joined surgical series of Verona and Padua to the more recent results obtained at the neurosurgical department of Verona.In the first surgical series, between 2001 and 2010, a total of 312 patients were submitted to IF during surgery for cerebral aneurysm at the neurosurgical departments of Verona and Padua: 162 patients presented with subarachnoid hemorrhage (SAH) whereas 150 patients harbored unruptured aneurysms. In the second series, between 2011 and 2016, 112 patients were submitted to IF during surgery for cerebral aneurysm at the neurosurgical department of Verona; 24 patients were admitted for SAH, whereas 88 patients were operated on for unruptured aneurysms.Comparison of the baseline values in the two surgical series and the baseline values between unruptured and ruptured aneurysms showed no statistical differences between the two clinical series. Analysis of flowmetry measurements showed three types of loco-regional flow derangements: hyperemia after temporary arterial occlusion, redistribution of flow in efferent vessels after clipping, and low flow in patients with SAH-related vasospasm.IF provides real-time data about flow derangements caused by surgical clipping of cerebral aneurysm, thus enabling the surgeon to obtain a safer exclusion; furthermore, it permits the evaluation of other effects of clipping on the loco-regional blood flow. It is suggested that-in contribution with intraoperative neurophysiological monitoring-IF may now constitute the most reliable tool for increasing safety in aneurysm surgery.

The Posterior Approach in the Treatment of Lower Cervical Spine Subluxations

Traumatic disruption of the posterior ligaments of the cervical spine, generally caused by hyperflexion of the neck, whether associated or not with hyperextension — the whiplash injury —, may result in vertebral instability. This condition is not always recognized when injured patients are seen in the emergency room. X-ray examination of the cervical spine usually discloses minor abnormalities that are easily overlooked. However, the appearance of the spine may be normal even to the experienced eye. Some radiological findings have been suggested to represent clues to impending vertebral instability due to posterior ligament lesions [3]: a) widening of the articular surfaces; b) increase of the interspinous distance; c) initial kyphotic appearance with a hinge at the lesion level; and d) reduction of the intervertebral disc space. Dynamic studies may confirm the diagnosis, showing an abnormal mobility of the vertebral bodies with loss of the normal articular relationships. If this condition is not recognized, the continuous movements of the neck lead to anterior subluxation, sometimes weeks or months after the injury [2, 3].

A New Device for Occipito-cervical Fixation

Atlanto-axial instability and dislocation, due to cranio-cervical malformations, trauma, inflammatory or neoplastic diseases, are best treated by occipito-cervical fusion. The arch of the atlas, in fact, is often unsuitable for fixation and needs to be removed to decompress the spinal cord. Several techniques have been proposed for occipitocervical fusion. Among them, the onlay construct [4], occipito-axial wiring, with or without the use of acrylic resins or bone graft [2, 3, 7, 8], and implants of various metallic devices [1, 5, 6].