Giuseppe Mariniello

Supratentorial cavernous malformations and epilepsy: seizure outcome after lesionectomy on a series of 35 patients

Epilepsy is the most frequent presenting sign in patients with cavernous angiomas and is the major cause of morbility. Persistence of seizures after surgical treatment prompted many authors to examine the possibility of removing the cavernoma and the surrounding tissue. In our series of 53 cavernous angiomas, all the 35 patients with preoperative seizures underwent surgery by means of lesionectomy alone. One hundred percent of patients with less than five preoperative seizures and/or an history under 12 months was seizure free, while only 62.5% of patients with more than five seizures and/or an history longer than 12 months was seizure free. Number and duration of seizures before surgery seems to be the most important factor in the seizure outcome after surgical treatment.

Early clinical and neuroradiological worsening after radiotherapy and concomitant temozolomide in patients with glioblastoma: Tumour progression or radionecrosis?

OBJECTIVES This study investigates the diagnosis and management of patients with resected brain glioblastomas who presented early clinical and neuroradiological worsening after the completion of the Stupp protocol. Its aim is to discuss the occurrence of early radionecrosis. METHODS Fifty patients with brain glioblastoma treated by surgical resection and Stupp protocol were reviewed; 15 among them (30%) had early clinical and neuroradiological worsening at the 6-month follow-up. The MR spectroscopy and surgical findings of these patients are reviewed. RESULTS MR spectroscopy was in favour of tumour recurrence in 14 among 15 patients and showed radionecrosis in one. Among 10 patients who were reoperated on, 7 had histologically verified tumour recurrence or regrowth, whereas in 3 histopathology showed necrosis without evidence of tumour. The 7 patients with tumour progression had prevalence of focal neuroradiological signs (6/7) and a survival of 7.5-12 months (median survival 10 months). The 4 patients with early radionecrosis (including one patient who was not reoperated on) had clinical worsening with mental deterioration, confusion and ataxia, and MR spectroscopy positive for tumour recurrence in 3. Three were alive 24-30 months after the end of the radiotherapy, whereas one died at 40 months. CONCLUSION Early radionecrosis after the Stupp protocol is not a rare event due to the radiosensitization effect of temozolomide. This phenomenon may predict a durable response to radiotherapy. MR spectroscopy may simulate tumour recurrence. A correct diagnosis is necessary to avoid useless reoperations and incorrect withdrawal of temozolomide.

Endovascular treatment of cerebral aneurysms using flow-diverter devices: A systematic review.

Background Flow-diverter devices (FDDs) are new-generation stents placed in the parent artery at the level of the aneurysm neck to disrupt the intra-aneurysmal flow thus favoring intra-aneurysmal thrombosis. Objective The objective of this review article is to define the indication and results of the treatment of intracranial aneurysms by FDD, reviewing 18 studies of endovascular treatment by FDDs for a total of 1704 aneurysms in 1483 patients. Methods The medical literature on FDDs for intracranial aneurysms was reviewed from 2009 to December 2014. The keywords used were: “intracranial aneurysms,” “brain aneurysms,” “flow diverter,” “pipeline embolization device,” “silk flow diverter,” “surpass flow diverter” and “FRED flow diverter.” Results The use of these stents is advisable mainly for unruptured aneurysms, particularly those located at the internal carotid artery or vertebral and basilar arteries, for fusiform and dissecting aneurysms and for saccular aneurysms with large necks and low dome-to-neck ratio. The rate of aneurysm occlusion progressively increases during follow-up (81.5% overall rate in this review). The non-negligible rate of ischemic (mean 4.1%) and hemorrhagic (mean 2.9%) complications, the neurological morbidity (mean 3.5%) and the reported mortality (mean 3.4%) are the main limits of this technique. Conclusion Treatment with FDDs is a feasible and effective technique for unruptured aneurysms with complex anatomy (fusiform, dissecting, large neck, bifurcation with side branches) where coiling and clipping are difficult or impossible. Patient selection is very important to avoid complications and reduce the risk of morbidity and mortality. Further studies with longer follow-up are necessary to define the rate of complete occlusion.

Pituitary macroadenoma and diaphragma sellae meningioma: differential diagnosis on MRI

Abstract Diaphragma sellae meningiomas are unusual tumours often not distinguished from pituitary macroadenomas. Preoperative differentiation is essential, because the trans-sphenoidal approach is used for surgical removal of adenomas, while meningiomas are approached via a craniotomy. We reviewed five patients in whom a diaphragma sellae meningioma was initially diagnosed as a nonsecreting pituitary macroadenoma. MRI criteria for differential diagnosis are discussed. The main findings considered are visibility of the pituitary gland, contrast enhancement, the centre of the lesion and sellar enlargement. These criteria, applied to a blind review, allow correct identification of the tumours.

Treatment of intracranial aneurysms by flow diverter devices: Long-term results from a single center

OBJECTIVES Flow-Diverter Devices (FDD) are a new generation stents designed for the treatment of the intracranial aneurysms. This article reports the long-term results (2-4 years) of this treatment from a single-center. METHODS From November 2008 to January 2012, 35 patients (29 females and 6 males; mean age 53.9 y) with 39 intracranial aneurysms were treated by FDD. Five patients (14.3%) had ruptured aneurysms and 30 (85.7%) had no previous hemorrhage. The procedures were performed in 5 patients (14.3%) with SILK and in 30 (85.7%) with PED. In 3 patients FDDs were used as a second treatment after failure of previous coiling (2 cases) or stenting (one case). The 39 aneurysms were in supraclinoid ICA in 26 (66.7%), cavernous ICA in 2 (5.1%), PCoA in 4 (10.2%), MCA in 5 (12.9%), SCA in 1 (2.6%) and PICA in 1 (2.6%). The aneurysms were small (<10mm) in 32 cases (82%), large (11-25mm) in 6 (15.3%) and giant in 1 (2.6%). The occlusion rate according to the aneurysm location, size and neck and the complications were evaluated. RESULTS Peri-procedural complications included transient dysarthria (2 patients), vasospasm with acute intra-stent aggregation (one), microwire rupture (one) and failure of the stent opening (one). The follow-up was made between 24 and 62 months (mean 41 months); clinical examination and CTA were performed at 1, 3, 6 and 12 months after the procedure. The complete occlusion was confirmed by CTA and DSA. MRI with angiographic-studies was taken every year. Complete occlusion was obtained in 35 aneurysms (92.1%) and subtotal in 3 (7.9%). Complete occlusion occurred at 3 months in 24 cases (68.6%), within 3 and 6 months in 9 (25.7%). The rate and time of complete occlusion were not correlated with the aneurysm size. MCA aneurysms mainly showed partial occlusion (2/3 cases). Besides, large-neck aneurysms and those with a vessel arising from the sac mainly showed late (>6 months) or partial occlusion. CONCLUSION FDD are a safe and efficacious treatment of intracranial aneurysms, resulting in high occlusion rate and low incidence of complications. It should be the treatment of choice for the large-neck aneurysm of the ICA.

Spheno-orbital Meningiomas: Surgical Approaches and Outcome According to the Intraorbital Tumor Extent

OBJECT This study proposes a topographical classification of spheno-orbital meningiomas. Its aim was to define whether the different intraorbital localizations require different surgical approaches and have different recurrence rates and outcomes. MATERIAL AND METHODS Sixty patients with spheno-orbital meningiomas operated upon between 1983 and 2003 were reviewed. Four types were identified according to the extent of intraorbital tumor invasion: I: lateral or superolateral (15 cases); II: medial and inferomedial (8 cases); III: orbital apex (25 cases); IV: diffuse (12 cases). Three surgical approaches were used: lateral orbitotomy (15 cases with lateral or superolateral tumors), supraorbital-pterional approach (42 cases, including all 8 inferomedial cases, all 25 orbital apex cases, and 9 of 12 diffuse tumors), and a fronto-temporal-orbitozygomatic approach (only 3 cases with diffuse meningiomas and large-scale tumor invasion in the infratemporal fossa and cavernous sinus). RESULTS Tumor removal was complete (Simpson grades I and II) in 40 cases, and incomplete in 20 (33.3%). There were two postoperative deaths (3.3%). A sufficient clinical follow-up was obtained in 52 cases. The clinical outcome was excellent in 26 patients (50%), good in 16 (30.8%), moderate in 6 (11.5%), and poor in 4 (7.7%). Twenty-two of 52 patients (42.3%) had tumor recurrence; however, 44 (84.6%) achieved tumor control after surgery alone through two or more operations. The recurrence rate was correlated with the Simpson grade of resection and the intraorbital tumor location. Significantly higher rates of recurrence were recorded for the orbital apex type (50%) and diffuse forms (60%), than for the inferomedial (28.5%) and superolateral forms (23%). CONCLUSIONS Spheno-orbital meningiomas may be classified according to the location and extent of the intraorbital tumor invasion. The different localizations may require different surgical approaches, with different chances of complete removal. The location and extent of the intraorbital tumor results in different recurrence rates, lower for superolateral and inferomedial forms than for orbital apex and diffuse forms.

Surgical treatment of intracavernous trigeminal schwannomas via a fronto-temporal epidural approach

The purpose of this study is to evaluate the efficacy of the fronto-temporal epidural approach in managing intracavernous trigeminal schwannomas. Five unselected patients harboring an intracavernous trigeminal schwannoma were operated on. Each of them was cured by a single craniotomy. In all cases the skull base approach described by Dolenc [Acta Neurochir. (Wien) 130 (1994) 55] was performed. The complete resection of the tumor and its capsule was gained in all five cases. There was no surgical mortality. No patient developed postoperative major complications. The fronto-temporal epidural approach can be applied for parasellar type trigeminal schwannomas, thus avoiding the exposure of the temporal lobe, and resulting in good chance for total excision of the tumor together with minimal surgical complications.

Connections of sympathetic fibres inside the cavernous sinus: a microanatomical study

A microanatomical study has been designed to investigate the pattern of arrangement of the sympathetic fibres inside the cavernous sinus. The course of these fibres has been examined in 60 fresh specimens of parasellar region from autopsy cadavers. Apart from the thin branches arising at different intervals along its course, the sympathetic plexus of the carotid artery gives rise to a large division that usually joins the abducens nerve and leaves it to combine with the ophthalmic branch of the fifth. In 10% of specimens we have found a direct connection between sympathetic fibres and the ophthalmic branch of the trigeminal nerve. We did not recognise similar connections with oculomotor and trochlear nerves.

Cellular dumbbell schwannoma of the hypoglossal nerve presenting without hypoglossal nerve palsy

A rare case of cellular schwannoma of the hypoglossal nerve, with intraspinal extension, presenting without any recognisable impairment of the function of the hypoglossal nerve is presented.

Lateral orbitotomy for removal of sphenoid wing meningiomas invading the orbit.

OBJECTIVE This study defines the indications, results, and limits of lateral orbitotomy coupled with resection of the sphenoid wing for removing lateral sphenoid wing meningiomas with intraorbital extension. METHODS Eighteen patients with lateral sphenoid wing meningiomas and tumor extension into the lateral or superolateral compartments of the orbital cavity were treated by microsurgical lateral orbitotomy and resection of the sphenoid wing without craniotomy. The approach consisted of a linear skin incision along the upper eyelid crease extending to 2 cm from the canthal angle and resection of the lateral orbital rim, lateral orbital wall, and infiltrated sphenoid wing. RESULTS A complete resection (Simpson I), including the infiltrated bone, dura, and periorbita, was obtained in 13 patients (72%); in the other 5 cases (28%), the tumor mass and most infiltrated dura were removed, but the entity of dural resection up to the normal tissue could not be exactly defined (Simpson II). Follow-up ranged from 5 to 17 years (mean 9.7 years). CONCLUSION A select group of lateral sphenoid wing meningiomas with tumor extension in the lateral or superolateral compartments of the orbital cavity may be successfully approached and removed through a lateral orbitotomy with resection of the sphenoid wing and without craniotomy. Cases with tumor extension to the anterior clinoid process and superior orbital fissure and those with extension medial to the axis of the optic nerve require a transcranial approach.