Michele Rotondo

A rare symptomatic presentation of ecchordosis physaliphora: neuroradiological and surgical management

We report a case of ecchordosis physaliphora, an uncommon benign lesion originating from embryonic notochordal remnants, intradurally located in the prepontine cistern, that unusually presented associated with symptoms. MRI detected and precisely located the small mass. At surgery, a cystic gelatinous nodule was found ventral to the pons, contiguous with the dorsal wall of the clivus via a small pedicle. Histological examination diagnosed the lesion as an ecchordosis physaliphora. Here we focus on the analysis of the neuroradiological aspects that play a crucial role from both a diagnostic and a therapeutic standpoint.

Intrathecal baclofen therapy for severe spasticity: Analysis on a series of 112 consecutive patients and future prospectives

OBJECTIVE Intrathecal baclofen therapy (ITB) is a well-known treatment for spasticity. Despite this fact, several topics have to be still discussed: new indications and screening tools, appropriate surgical timing and complicance avoidance. METHODS A total of 112 consecutive patients all with a severe, progressive and refractory to medical therapy spasticity from different causes were treated using ITB, after a bolus test. Every patient was assessed by means of Modified Ashworth Scale (MAS), Penn spasm frequency scale (SFS) and Visual Analog Scale for pain. Since available, a Gait analysis was also performed. RESULTS There were 63 males (56%) and 49 females (44%). Seventy-four (66%) had a quadriparesis, 34 (30.4%) had a paraparesis and 4 (3.6%) were hemiplegic. Among these patients 77 (68.7%) were non ambulatory, while 35 (31.3%) were ambulatory. These patients suffered from spasticity due to many different diseases. Mean follow-up was 55 months. The mean Modified Ashworth score decreased from 4.5±0.5 preoperatively to 1.2±0.4 on chronic intrathecal baclofen. Daily baclofen dose varied between 23 and 500 mcg. Drug-induced complications and catheter related problems occurred, respectively in 7 (6.3%) and 10 patients (8.9%). CONCLUSIONS Although ITB is a well known and good treatment option in the management of severe spasticity, because of the different goals and subgroups of patients treated, a variety of techniques are needed to evaluate the benefits of this therapy. New indications, effects of ITB on central nervous system and cognitive functions needs yet to be fully clarified.

Post-traumatic peripheral facial nerve palsy: surgical and neuroradiological consideration in five cases of delayed onset

The facial nerve is frequently injured after head trauma with or without temporal bone fractures. Computed tomography (CT) is the best procedure for detecting the fracture line at the level of the facial nerve canal and for assessing any associated lesions within the temporal bone. Magnetic resonance (MR) is required if there is a facial nerve paralysis, unexplained by CT findings. We present five cases of delayed post-traumatic facial nerve palsy without evidence of temporal bone fractures on CT, thus studied on MR. MR was essential for diagnosing the nerve impairment. Neuroradiological findings, clinical presentation, and electrodiagnostic tests influenced the management of the patients.

Ulcerative and mutilating variant of carpal tunnel syndrome.

SummaryCutaneous involvement in severe carpal tunnel syndrome is secondary to damage to sensory and autonomic fibers of the median nerve. We report the case of a 63 year old man who presented skin and bone lesions, confined to the sensory zones of both median nerves. The lesions consisted of dystrophic modifications of the fingernails, progressive sclerosis, skin thickening and ulcerations on the fingers, acro-osteolysis, and purulent inflammation with subsequent auto-amputation of the distal phalanx of the right index finger. Clinical, neurophysiological and surgical findings are reported. The recovery of the ulcerative lesions suggests the reversibility of autonomic disturbances after surgery.

Peripheral median nerve stimulation for the treatment of iatrogenic complex regional pain syndrome (CRPS) type II after carpal tunnel surgery.

We report on the use and follow-up of direct peripheral nerve stimulation of the median nerve for the treatment of iatrogenic complex regional pain syndrome (CRPS). A 56-year-old woman presented with CRPS type II in the right forearm and hand, which had started after multiple carpal tunnel surgeries and had lasted for 2 years. The visual analogue scale (VAS) score was 8-10 out of 10. After a successful 15-day trial of median nerve peripheral nerve stimulation via a quadripolar lead in the right carpal tunnel space, an implantable pulse generator was inserted in the right infraclavicular space. The VAS score decreased to 1-2 out of 10 and the patient regained the ability to sleep. After 36 months of follow-up, the patient was still experiencing good pain relief without other treatment. We conclude that peripheral nerve stimulation is easy to use in pain management and could offer a valid treatment option for iatrogenic CRPS type II.

Solitary olfactory groove schwannoma

Intracranial schwannomas that do not involve major cranial nerves in the posterior fossa are uncommon, especially if they are not associated with neurofibromatosis type II (NF-2). Subfrontal olfactory groove schwannomas are extremely rare. We report a cystic schwannoma arising from the olfactory groove in a 38-year-old Caucasian male who presented with headache, vomiting and visual impairment. We briefly review the pertinent literature, stress the distinctive clinical and neuroradiological findings and discuss the surgical planning and theories about the pathogenesis of schwannomas in this unusual location.

Post traumatic retropharyngeal pseudomeningocele

SummaryThe authors report a case of a 33-year-old man who presented, during recovery from coma due to severe head injury, dysphagia and respiratory failure. Magnetic resonance, retrograde radionuclide myelography and computerized tomographic myelography identified a pseudomeningocele in the retropharyngeal space due to a tear of the left C2 radicular sleeve. After failed medical management, the patient underwent lumbo peritoneal shunt. Magnetic resonance controls showed progressive collapse of the collection. After 3 months the patient was able to breathe spontaneously and to swallow. The authors describe pathogenesis, diagnostic strategy and principles of treatment of traumatic retropharyngeal pseudomeningoceles.

Long-term effects of intrathecal baclofen in multiple sclerosis

OBJECTIVES Spasticity is associated with various neurological conditions. In this study the authors analyzed the long term effects of intrathecal baclofen therapy in multiple sclerosis and evalued the benefits of the treatment on spasticity, disability, pain, spasm frequency and rated the incidence of side effects. PATIENTS AND METHODS A records of 123 patients, with a severe, progressive and refractory to medical therapy spasticity from different causes, underwent baclofen pump placement, after a bolus test, from 2000 to 2012,under Department of Neurosurgery at the Second University of Naples/Italy. We present our experience in treating 28 subjects that was affected by multiple sclerosis. For all patients we reviewed long-term response to therapy, surgical technique, surgery- and pump-related complications. Every patients were evaluated by means of the Modified Ashworth Scale (MAS), Penn Spasm Frequency Scale (SFS), Visual analogue Scale For Pain (VAS), Barthel index (BI) and Self Rating Depression Scale (SDS) RESULTS: During follow up the mean MAS score for upper and lower extremities decrease significantly. Also SFSs decrease was statistically significant. This resulted in a dramatic improvement of BI. Furthermore, we observed a marked improvement in VAS and SDS. CONCLUSIONS Intrathecal baclofen provides effective long-term treatment of spasticity multiple sclerosis related. ITB therapy increases the quality of lifestyle and functional independence in appropriately selected cases.

Giant dilatations of virchow-robin spaces in the midbrain. MRI aspects and review of the literature.

Virchow-Robin spaces are lesions often seen in the brain parenchyma but their etiopathogenesis remains unsettled. Giant Virchow-Robin spaces placed in the midbrain are extremely rare. We describe three patients with a diagnosis of giant Virchow-Robin spaces in the midbrain, and their clinical and radiologic findings. We reviewed the literature in terms of the etiopathology, anatomic and radiologic appearance and differential diagnosis of the giant Virchow-Robin spaces. The diagnostic role of the high Tesla magnetic resonance devices and new sequences techniques such as three dimensional isotropic acquisition and diffusion tensor imaging were also evaluated in this case series.

Solitary lumbar osteochondroma presenting with spinal cord compression

We report a case of a middle-aged woman with a solitary osteochondroma of the L2 right lamina with intraspinal extension and spinal cord compression. The case is unusual in terms of localisation and age at clinical presentation. In fact, spinal osteochondromas as solitary lesions—especially when affecting the lumbar segment—are rare tumours of a maturing adolescent skeleton, infrequently affecting the neurological structures, because most of the lesions grow out of the spinal canal. Although unusual, they should be considered in the differential diagnosis. Prompt and accurate radiological investigations are important in planning appropriate management. Surgical total excision is the best treatment modality to remove spinal cord and/or nerve root compression, and to avoid the risk of recurrence or malignant transformation.