Josip Paladino

Reducing the incidence of infection in pediatric cerebrospinal fluid shunt operations

We reviewed our experience with shunt implantation during two time periods. From June 1985 to December 1990, 201 children with hydrocephalus underwent 382 operations. Among these children 36 (18%) developed a proven shunt infection, with an incidence rate per procedure of 9.4%. As a result of this study, a new effective protocol for shunt procedures involving modifications to the perioperative (antibiotic prophylaxis) and intraoperative management (meticulous surgical technique, complete shunt revision) of children undergoing initial shunt implantation or revision was initiated. With this new protocol 75 children underwent a total of 112 procedures between January 1991 and December 1995. The incidence of shunt infection decreased, with a per patient rate of 8% and a per procedure rate of 5.3%. The majority of infections in our study were caused by Staphylococcus epidermidis,which was found in 22 (52.3%) patients.

Treatment of giant and large fusiform middle cerebral artery aneurysms with excision and interposition radial artery graft in a 4-year-old child: case report.

BACKGROUND AND IMPORTANCE: We report an unusual case of complex giant and large fusiform aneurysms not amenable for clipping or coiling in a 4-year-old child managed with aneurysm resection and radial artery interposition graft. CLINICAL PRESENTATION: A 4-year-old child presented with repeated severe headache and vomiting. Computed tomography, magnetic resonance imaging, and magnetic resonance angiography and digital subtraction angiography showed a giant fusiform aneurysm on the right middle cerebral artery (MCA). Because of the complex shape, endovascular treatment or clip reconstruction was not possible, and a bypass procedure was planned. Right frontotemporal craniotomy and orbitotomy was performed. Two aneurysms involving the M1 segment of the MCA were found in line, 1 giant, and the other large in size. The aneurysms were resected and treated with short radial artery interposition graft, which was narrower than the proximal or distal MCA. The child recovered normally, and the bypass was patent after 1 year. CONCLUSION: Large fusiform MCA aneurysms may be difficult to treat, but there are treatment options that include a bypass procedure. Resection and short interposition radial artery graft is an excellent but rare treatment option in a very young child. This was a very successful treatment in this child. ABBREVIATIONS: ICA, internal carotid artery MCA, middle cerebral artery RA, radial artery RAG, radial artery graft STA, superficial temporal artery

Leptomeningeal and intramedullary metastases of glioblastoma multiforme in a patient reoperated during adjuvant radiochemotherapy

Despite huge advances in medicine, glioblastoma multiforme (GBM) remains a highly lethal, fast-growing tumour that cannot be cured by currently available therapies. However, extracranial and extraneural dissemination of GBM is extremely rare, but is being recognised in different imaging studies. To date, the cause of the GBM metastatic spread still remains under discussion. It probably develops at the time of intracranial progression following a surgical procedure. According to other hypothesis, the metastases are a consequence of spontaneous tumour transdural extension or haematogenous dissemination. We present a case of a 59-year-old woman with symptomatic leptomeningeal and intramedullary metastases of GBM who has been previously surgically treated with primary subtotal resection and underwent a repeated surgery during adjuvant radiotherapy and chemotherapy with temozolomide. Today, the main goal of surgery and chemoradiotherapy is to prevent neurologic deterioration and improve health-related quality of life. With this paper, we want to present this rare entity and emphasise the importance of a multidisciplinary approach, a key function in the management of brain tumour patients. The prognosis is still very poor although prolongation of survival can be obtained. Finally, although rare, our case strongly suggests that clinicians should be familiar with the possibility of the extracranial spread of GBM because as treatment improvements provide better control of the primary tumour and improving survival, metastatic disease will be increasingly encountered.

Cranial base kyphosis and the surface morphology of the anterior cranial fossa

We investigated the relationship between the surface morphology of the anterior cranial fossa and cranial base kyphosis (sphenoid angle) in 52 cephalometric craniograms. Among them there were 25 female (mean age 54 +/- 15; range 31-82) and 27 male (mean age 43 +/- 18, range 19-85) skulls. The sphenoid angle and the altitudes of the highest elevation of the endofrontal eminence (cranial base over the orbital roof in the anterior cranial fossa) and the middle point of the sphenoid planum, measured according to the Frankfort horizontal, were analysed using classical cephalometric and morphometric analysis. Statistical analysis was performed by Pearsons product-moment correlation and simple linear regression. The sphenoid angle ranged from 97 degrees to 137 degrees (mean 118 +/- 9 degrees). The altitude ratio of the highest elevation of the endofrontal eminence and the middle point of the sphenoid planum ranged from 1.5 to 1.8 (mean 1.6 +/- 0.1). A significant correlation was found between this ratio and the sphenoid angle (r = -0.65; p < 0.001; coefficient of determination = 0.43). The elevation of the endofrontal eminence relative to the sphenoid planum was higher in skulls with increased cranial base kyphosis, whereas reduced sphenoid angle was associated with an increase in the elevations of the endofrontal eminence. Although the sphenoid angle has a significant effect on the morphology of the anterior cranial fossa, only 43% of the variance in altitude of the endofrontal eminence is likely to be explained by its relationship with the sphenoid angle.

Radical surgery of a giant Galen's vein aneurysm using total circulatory arrest: case report.

BACKGROUND Arteriovenous malformations of Galens vein are a rare type of vascular anomaly. The complex anatomy of these lesions creates an extremely difficult management dilemma. We report successful surgical treatment of a 7-year-old patient with a Galens vein aneurysm. METHODS AND RESULTS A 7-year-old patient with slowly progressing gait disturbance, emotional instability, and strange behaviour is presented. A computed tomography scan revealed a high-density mass in the pineal region and cerebral angiography showed an aneurysm of Galens vein. We decided to perform surgical excision of the aneurysm. The operation was performed under hypothermic circulatory arrest with barbiturate cerebral protection. The patient had no signs of postoperative ischemic deficits, hemorrhage, or neurologic deterioration. CONCLUSIONS Various techniques have been described for the obliteration of Galens vein aneurysms, including direct surgical approach, staged operation, and transarterial, transvenous or transtorcular embolization. We present this patient to illustrate the use of hypothermic circulatory arrest and barbiturate cerebral protection for successful surgical excision of this complex vascular lesion. The combination of these techniques allowed us, in this case, to operate with reasonable safety on otherwise, difficult to treat aneurysm of Galens vein.

Treatment of Giant and Large Fusiform MCA Aneurysms With Excision and Interposition Radial Artery Graft in a Four Year Old Child.

BACKGROUND AND IMPORTANCE: We report an unusual case of complex giant and large fusiform aneurysms not amenable for clipping or coiling in a 4-year-old child managed with aneurysm resection and RA interposition graft. CLINICAL PRESENTATION: A 4-year-old child presented with repeated severe headache and vomiting. Computed tomography, magnetic resonance imaging and magnetic resonance angiography and digital subtraction angiography showed a giant fusiform aneurysm on the right MCA. Because of the complex shape, endovascular treatment or clip reconstruction was not possible, and a bypass procedure was planned. Right frontotemporal craniotomy and orbitotomy was performed. Two aneurysms involving the M1 segment of the MCA were found in line, one giant, and the other large in size. The aneurysms were resected and treated with short radial artery interposition graft, which was narrower than the proximal or distal MCA. The child recovered normally, and the bypass was patent after 1 year. CONCLUSION: Large fusiform MCA aneurysms may be difficult to treat but there are treatment options that include a bypass procedure. Resection and short interposition radial artery graft is an excellent but rare treatment option in a very young child. This was very successful treatment in this child.

Lipoastrocytoma: A case report

Lipidized tumours of the central nervous system are very rare. Lipidization of tumour cells is a histological hallmark of pleomorphic xanthoastrocytoma and cerebellar neurolipocytoma and has been described in some other primary neuroepithelial tumours such as glioblastoma, cerebral primitive neuroectodermal tumour, central neurocytoma and ependymoma. However, a few cases of lipidized low-grade glial tumours that could not be classified to the fore mentioned categories have been reported, as well. We report a new case of such a tumour occupying the right temporal lobe in a 23-year old woman. Histologically, the tumour was composed of GFAP positive glial cells with areas of complete cell lipidization. More than a two years after the surgery, the patient is well and asymptomatic supporting presumed favourable clinical course of these rare tumours. The recommended treatment plan for these presumably benignant tumours should be continued with radiographic surveillance after the gross total resection.

Etomidate in neuroanesthesia for aneurysmal clipping in child with confirmed allergies to general anesthetics

Background: Etomidate may be given in continuous infusion for maintenance of general anesthesia, although that practice is rarely seen due to beliefs that it has possibility of interfering with cortisol synthesis. However, etomidate is sometimes preferable choice as it has least influence on hemodynamics and rarely causes allergic reactions. Case Description: We describe a case of 13-year-old boy with aneurysm of left middle cerebral artery, planned for aneurysmal clipping, and previously treated for ruptured aneurysm of right middle cerebral artery. As he was tested and proved allergic to most of the anesthetic drugs, and stable hemodynamic conditions were of most importance during planned neurosurgery, general anesthesia was maintained with etomidate infusion. He was prepared with metilprednisolon, antihistaminic, and ranitidine before the surgery. Cortisol and adrenocorticotropic hormone levels were measured on three consecutive postoperative days. Only cortisol value, in the morning the day after the surgery, was below reference range, with the values back to normal until that evening. He was dismissed from the intensive care unit with Glasgow Coma Score 15. Conclusion: Etomidate may be a choice for neuroanesthesia in specific group of people. We have good experience with our algorithm for continuous infusion of etomidate, with serum cortisol values in the reference range, if corticosteroids were not given before the surgery. Administration of metilprednisolon may diminish influence of perioperative stress on cortisol synthesis inhibition.

Tentorial alignment and its relationship to cisternal dimensions of the pineal region: MRI anatomical study with surgical implications using the new clivotentorial method

OBJECTIVES Tentorial alignment and dimensions of posterior fossa cisterns are measurements whose variability can decrease surgical freedom if not taken into account when choosing the approach to the pineal region. The aim is to provide quantitative anatomical information regarding these dimensions, and to discuss their relevance in two most commonly used approaches to this region: the occipital transtentorial and supracerebellar-infratentorial approach. PATIENTS AND METHODS A retrospective study of midsagittal T1-weighted MRI images of 410 randomly selected healthy subjects was performed. The clivus-tentorium (C-T) angle was measured to assess tentorial alignment. The following distances were used as craniocaudal cisternal measurements: quadrigeminal cistern = superior colliculi - inferior part of the splenium of corpus callosum (SC-ISCC), and superior cerebellar cistern = vermis - inferior part of the splenium of corpus callosum (VER-ISCC). RESULTS Median C-T angle value was 19 ± 7°, the quadrigeminal cistern height 6.7 ± 1.6 cm, and the superior cerebellar cistern height 10.4 ± 2.6 cm. The C-T angle was negatively correlated with the SC-ISCC distance (r = -0.271; p <  0.001) and the VER-ISCC distance (r = -0.052, p >  0.001). The SC-ISCC distance was positively correlated with the VER-ISCC distance (r = 0.282; p < 0.001). CONCLUSION Our new method of measuring tentorial alignment provides a simple and effective aid in preoperative planning. For the first time, we present data on craniocaudal dimensions of posterior fossa cisterns, their relationship with tentorial alignment, and discuss their relevance in SCIT and OT approaches.

Extranodal right-optic nerve Rosai-Dorfman disease: A rare localization case report

Background: Rosai–Dorfman is a rare disease that usually occurs in young adults. It is characterized with massive painless cervical lymphadenopathy and histiocyte proliferation. Isolated intracranial involvement is extremely rare. Our aim is to present a new rare case of extranodal Rosai–Dorfman disease that involved the right optic nerve in a 4-year-old boy. Case Description: A 4-year-old boy with right-sided convergent strabismus and amblyopia lasting for 1 year was treated at the Department of pediatric ophthalmology. Initial optical fundus examination was normal. Examination repeated after 1 year noted the atrophy of the optic nerve papilla. Visual evoked potentials of the right eye showed normal findings of prechiasmatic visual pathway with severe dysfunction of the right optic nerve. Magnetic resonance imaging (MRI) of the brain and orbits showed expansive changed and elongated right optic nerve with contrast enhancement, and smaller lesion in the right temporal operculum region visible in T2 and fluid-attenuated inversion recovery sequence. Through small eyebrow “keyhole” osteoplastic frontoorbital craniotomy the fusiform enlarged (to 2 cm) right optic nerve was identified, resected between the eyeball and optic chiasm, and transferred for pathohistological analysis. Early postoperative course had no complications. Histological, immunohistochemical, and ultrastructural analyses revealed extranodal Rosai–Dorfman disease. Right periorbital edema was verified on the 7th postoperative day and regressed to supportive therapy. Control multi slice computed tomography (MSCT) and MRI of endocranium and orbits showed total tumor removal with no signs of complications. Conclusion: Although rare, extranodular intracranial Rosai–Dorfman disease should be taken into account in the differential diagnosis of intracranial and intraorbital lesions, especially in the pediatric age group.