Michele Acqui

Intramedullary spinal cord ependymomas — a study of 45 cases with long-term follow-up

SummaryOf the 62 patients with intramedullary spinal cord ependymoma treated surgically at our Neurosurgery Division between January 1951 and December 1990 45 had a follow-up of at least 3 years and the longest 30 years. The 28 conus-cauda equina-filum ependymomas operated during the same period are not considered in this study. An analysis of our cases and of the larger published series shows that favourable prognostic factors, apart of course from total tumour removal, which is now usually possible, are a site below the high cervical segments and a mild pre-operative symptom pattern. Patient age at diagnosis, tumour size and “low dose” (< 40 Gy) radiotherapy seem to have no influence on the prognosis. Aggressive surgical removal is the treatment of choice and also for long-term recurrence.

Neurinoma of the third, fourth, and sixth cranial nerves: A survey and report of a new fourth nerve case

A rare case of trochlear nerve neurinoma is described. Including this case, the number of reported intracranial tumors arising from the sheaths of the third, fourth, and sixth cranial nerves is 38. By site and relationship to the nerve segment, they fall into three groups: cisternal, cisternocavernous, and cavernous. In cisternal tumors of the third and sixth nerves, paresis of the nerve hosting the tumor is the unique nerve deficit; by contrast, in those of the fourth nerve, paresis of the trochlear nerve can be absent and that of the third nerve present. In the latter tumors, a peculiar ataxic hemiparesis syndrome is produced by midbrain compression. Cisternocavernous neurinomas often cause symptoms of intracranial hypertension, while cavernous neurinomas bring about two clinical features: paresis of one or more nerves of the cavernous sinus and a clinicoradiological orbital apex syndrome. At surgery, generally cisternal neurinomas are totally removed and the nerve source of the tumor identified; in cisternocavernous and cavernous neurinomas, total removal of tumor and identification of the parent nerve have been reported in only half of the cases. In the majority of parasellar neurinomas, clinical differences can be found between those arising from the nerves governing eye movement and those arising from the gasserian ganglion.

Cerebral meningiomas in children.

Cerebral meningiomas are rare tumors in children that represent 1.4% of CNS tumors and 1.5% of intracranial meningiomas. We have analyzed 197 cases of cerebral meningiomas under 16: 178 cases were taken from the available literature and 19 from our series. When comparing pediatric meningiomas with those of adults, we noted some differences. Before the age of 16 there is a slight preference for males; the intraventricular variety is more frequent; cystic meningiomas and the absence of dural attachment are more frequent findings; the neuroradiological diagnosis is more difficult.

Cerebral cavernous angioma in children

Cerebral cavernous angioma is a rare vascular malformation at any age and is very rare in childhood. In the literature available to us, we have been able to trace only 50 cases, to which we have added the 6 cases from our own series. The incidence in pediatric group is higher at 0–2 years (26.8%) and at 13–16 years (35.7%). The clinical onset shows epilepsy in 45.4% of cases, hemorrhagic syndrome in 27.3%, intracranial hypertension in 16.4%, and focal neurological deficits in 10.9%. Furthermore, we discuss the neuroradiological features (CT, angiography, and MRI) and the therapy of pediatric cavernous angioma.

Aneurysms of the posterior cerebral artery: Do they present specific characteristics?

SummaryA series of 7 cases of PCA aneurysm treated between 1978 and 1992 were analytically reviewed together with 79 cases culled from the literature.In comparison to those localized elsewhere, PCA aneurysms are more frequently large, more frequently present with tumour-like symptoms and appear at an earlier age.Surgical outcome was evaluated in relation to clinical onset, site and size of the aneurysm, the surgical procedures adopted for excluding it and pre-operative clinical grading. Contrary to aneurysms in other sites, only pre-operative clinical grading appeared to influence outcome. The fact that site, size and surgical technique do not significantly influence prognosis is probably due to the rich collateral flow present in the areas fed by the posterior cerebral artery.The authors conclude that, clinically speaking, PCA aneurysms should be considered as a separate group.

Relationship between Leukocytosis and Ischemic Complications following Aneurysmal Subarachnoid Hemorrhage

The prognostic significance of admission leukocytosis with respect to ischemic complications of subarachnoid hemorrhage was retrospectively investigated in a series of patients with recently ruptured intracranial aneurysms. The present study concerned 47 consecutive cases admitted within 72 hours following the last hemorrhage, in the years 1982-1984. There was no difference in the admission WBC counts between patients who subsequently deteriorated due to ischemic complications and those who did not. However, the cell count rose significantly at the time of the clinical manifestations of ischemia, possibly as a result of structural damage of brain tissue and/or increased sympathetic and adrenocortical activity. The possible contribution of leukocytes to the pathogenesis of ischemic damage following subarachnoid hemorrhage--perhaps through the release of leukotrienes--will require further investigation.

Cervical synovial cysts: case report and review of the literature

Abstract The authors describe the case of a 58-year-old man with a 6-month history of severe myelopathy. CT scan and MRI of the spine revealed a cystic formation, measuring about 1 cm in diameter, at C7-T1 at a right posterolateral site at the level of the articular facet. At operation the mass appeared to originate from the ligamentum flavum at the level of the articular facet and was in contact with the dura mater. Once the mass had been removed, there was a significant amelioration of the patient’s symptoms. As previously suspected, histological aspect was synovial cyst. Cervical synovial cysts are extremely rare and, as far as we know, only 22 cases have so far been described in the literature. Diagnostic radiological investigations used were CT scan and MRI. At CT scan the most important diagnostic findings are a posterolateral juxtafacet location of the mass, egg-shell calcifications on the wall of the cyst, and air inside the cyst. At MRI the contents of the cyst are iso/hypointense on T1- and hyperintense on T2-weighted images. There may also be a hypointense rim on T2-weighted images, which enhances after i.v. administration of gadolinium. Surgical treatment consists of removal of the mass. Fixation of the vertebral segments involved is not always necessary.

The role of intraoperative ultrasound imaging in the surgical removal of intramedullary cavernous angiomas.

Five intramedullary cavernous angiomas were surgically removed after being localized by intraoperative ultrasound imaging. Two patients were men, and three were women; in three patients, the symptoms had an acute onset, whereas in the other two, it was gradual. The vascular malformation was localized in the dorsal tract in three patients and in the cervical tract in two. Intraoperative ultrasound imaging visualized the lesion, which appeared hyperechogenous in all cases, and showed its relationship with the surrounding anatomical structures. Surgical removal was always total and was confirmed by both intraoperative echography and postoperative magnetic resonance imaging. In our experience, intraoperative ultrasound imaging was useful for localizing intramedullary cavernous angiomas, especially in cases where the lesion did not appear on the posterior surface of the spinal cord. In this way, it was possible to limit posterior myelotomy and confirm radical tumor removal intraoperatively.

Tuberculoma of the ulnar nerve: case report.

A peripheral nerve tuberculoma, the third on record, involved the ulnar nerve, as did the other two. This case report is followed by a discussion of the pathogenesis and diagnosis of this lesion. Its pathogenesis is unclear. Direct infection from a tuberculous sister was disproved, and infection via a local wound is highly unlikely. A previous, silent form of tuberculosis seems to have been the cause.

Subarachnoid haemorrhage of unknown origin

SummaryThis study concerns 64 patients with angiographically negative subarachnoid haemorrhage (SAH) hospitalized in the period 1970–1982. Requisites for inclusion in the study were adequate angiographic demonstration of the carotid and vertebrobasilar systems and no clinical signs of spinal SAH or spontaneous intracerebral haematoma. The clinical data on the 64 cases confirm the close similarity, except for the prognostic factors, between angiographically negative SAH and SAH secondary to rupture of an intracranial saccular aneurysm. The study underlines the benign character of the clinical course and of the medium and long-term prognosis of the condition under study. In view of this, the hypothesis advanced sometime ago relating angiographically negative SAH to the rupture of microaneurysms (Ø<2 mm) of the large cerebral arteries with subsequent complete repair of the artery wall, or to the spontaneous thrombosis of intracranial saccular aneurysms, with the possibility of subsequent recanalization and risk of fresh rupture, would appear to be a reasonable one.