Paolo Frassanito

Cranial repair: how complicated is filling a "hole"?

In general, cranioplasty is viewed as a straightforward surgical procedure, and for many years the complications associated with the procedure have been underestimated. We reviewed our 5-year experience consisting of 218 cranioplasties. Study outcomes focused specifically on the occurrence of complications after cranioplasty. Autologous bone-assisted and prosthetic cranioplasties were considered. Variables described by other authors to be associated with complications were studied, including history of previous cranioplasty, wider craniectomy size, bifrontal craniectomy, and delayed cranioplasty. We also analyzed the influence of material used for craniectomy on the occurrence of complications. The overall complication rate was 19.7%. Nineteen cases of infection (8.7%), 5 cases of postoperative wound dehiscence (2.3%), 6 cases of epidural hemorrhage (2.8%), and 13 cases of cranioplasty dislocation (5.9%) were observed. Bifrontal cranioplasties were more frequently associated with complications (p=0.01; Fishers exact test) and infection (p<0.0001; Fishers exact test). Postoperative wound dehiscence was more frequently observed with hand-made or custom-made cranioplasties compared with autologous cranioplasties (p=0.02). Early cranioplasty (<3 months from craniectomy) was significantly associated with cranioplasty dislocation (p=0.03). Logistical regression analysis showed that the only factor independently associated with complication was the site of cranioplasty (p=0.01). In particular, patients with a bifrontal cranioplasty had a 2-fold increased risk of complication (CI 95 1.1-3.6, p=0.017) and a 2.5-fold increased risk of developing infection (CI 95 1.3-4.9, p=0.009) compared with hemispheric/bihemispheric cranioplasty. Our analysis confirms that cranioplasty is burdened by a significant complication rate. In this context, bifrontal cranioplasty is related to a higher risk of complication and, in particular, infection.

Hydrocephalus and Chiari type I malformation

IntoductionHydrocephalus has been related to Chiari type I malformation (CIM) for a long time. The pathogenesis of this association is complex and still debated.DiscussionA supratentorial hypertensive hydrocephalus may cause CIM, exerting pressure from above. Another pathogenetic hypothesis is based on the clinical and radiological data from patients affected by complex craniosynostosis, in which this association is more commonly observed as the consequence of a “cephalo-cranial disproportion” ultimately leading to a secondary hydrocephalus. In some cases, the concomitant presence of a stenosis of the jugular foramina would determine a condition of upward venous hypertension, resulting in the development of CIM and an associated hydrocephalus due to cerebellar parenchyma turgor.ConclusionsThe radiological association of ventricular enlargement and hindbrain herniation would be the result of heterogeneous pathogenetic mechanisms which would then require specific therapeutic approaches. In this context, the endoscopic third ventricle-cisternostomy is gaining an increasing interest because of its more physiologic correction of the altered CSF dynamics and its minor interference on the developmental processes responsible for the association of hydrocephalus and CIM.

Myelomeningocele: the management of the associated hydrocephalus

BackgroundThe pathogenesis of the hydrocephalus associated with myelomeningocele (MMC) has been the subject of an extensive number of studies. The contemporary reduction of the incidence of the Chiari II malformation and of the associated active hydrocephalus after closure of the spinal defect in utero is in line with previous studies suggesting a prominent role of the posterior cranial fossa abnormalities, where even the increased venous pressure might be at least mostly a consequence of the constriction of the posterior cranial fossa structures. Pure absorptive abnormalities however coexist, the main ones documented to be abnormal cisternal spaces and peculiar cerebrospinal fluid chemical features.Materials and methodsWe reviewed the pertinent literature concerning the pathogenesis and management of the hydrocephalus associated to MMC. We also reviewed our personal experience in managing the hydrocephalus in such patients through an endoscopic third ventriculostomy.Results and conclusionsThe literature review demonstrated an overall reduction in more recent series of children with MMC needing to be treated for the associated hydrocephalus postnatally, questioning the role of the prenatal care of the disease in this context. Less severe conditions and a more conservative neurosurgical attitude have certainly contributed to the reduction of the reported active postnatal hydrocephalus rate. Long-term cognitive evaluation of the children with MMC that we managed with an endoscopic third ventriculocisternostomy (ETV) as primary as well as secondary procedure did not demonstrate significant differences in the outcome compared with non-complicated extrathecally shunted children, favouring ETV as a valuable option in this subset of patients.

Complications of delayed cranial repair after decompressive craniectomy in children less than 1 year old

SummaryBackgroundDecompressive craniectomy is an effective treatment option in case of refractory intracranial hypertension after severe head injury. The incidence of complications following cranial repair after decompressive craniectomy for traumatic brain injury is not negligible, particularly in infants and young toddlers. However, only a few dedicated papers can be found in the literature.MethodWe describe the complications observed in two boys and one girl under 1 year of age that were treated in the last decade by hemicranial decompressive craniotomy and enlarging hemispheric duraplasty, and subsequent cranial repair by means of autologous bone-flap replacement.FindingsDespite good clinical and neurological outcome, the postoperative clinical course was complicated in all cases by early or late evidence of subdural fluid collections associated to the occurrence of hydrocephalus and causing recurrent dislocation and progressive resorption of the autologous bone flap.ConclusionsInfants less than 1 year old, undergoing decompressive craniectomy after traumatic brain injury, experience a high rate of complications following subsequent cranial repair. Subdural collections and resorption of the autologous bone flap are to be considered as extremely common complications.

Molecular pathogenesis of craniopharyngioma: switching from a surgical approach to a biological one.

Craniopharyngioma has long been considered a benign tumor because of its pathological aspect. This primordial view of craniopharyngioma fit with the primitive treatment attempts based on blind resection of the tumor each time it recurred. The limits of this management strategy were proven early by the high morbidity related to the resection and recurrence risk despite radical lesion removal. Nowadays, craniopharyngioma must be considered a complex molecular disease, and a detailed explanation of the mechanisms underlying its aggressive biological and clinical behavior, despite some benign pathological features, would be the first step toward defining the best management of craniopharyngioma. Indeed, advances in the knowledge of the molecular mechanisms at the base of craniopharyngioma oncogenesis will lead to comprehension of the critical checkpoints involved in neoplastic transformation. The final research target will be the definition of new biological agents able to reverse the neoplastic process by acting on these critical checkpoints. This biological approach will lead to a refined therapy combining higher efficacy and safety with lower morbidity. In this paper the authors reveal state-of-the-art comprehension of the molecular biology of craniopharyngioma and the consequent therapeutic implications.

The fate of a macroporous hydroxyapatite cranioplasty four years after implantation: Macroscopical and microscopical findings in a case of recurrent atypical meningioma

Reconstruction of calvarial bone defects can be achieved using utologous bone or awide range of prostheticmaterials [1].Macroorous hydroxyapatite (MH) has histologically proven its potential steointegration in animal models [2–4]. Recent radiological and linical data in human subjects are in favour of good osteointegraion of MH cranioplasty [5,6]. However, the MH implant has weak echanic stability and is prone to fractures [7]. Furthermore, it is ot known how fast and to which extent the implant is ossified n vivo. We report a case with limited ossification of a MH prosthesis our years after implantation.

Pink and blue: the color of gender

Assigning color to gender is mostly a twentieth-centurytrait. It should be noted that it is a practice limited mostoften to Western Europe and the Americas. It would alsoseem that the effect of color-coded gender differences (pinkfor girls, blue for boys) existed oppositely initially [10].In fact, this reversal of what we consider “normal” wasconsidered conventional, even in the early twentiethcentury. The debate of when and why pink and blue cameinto fashion to designate gender rages on, but almost everyargument alludes to a passage in the novel Little Women,published in 1868: “Amy ties a pink bow and a blue bowon Meg’s twins Daisy and Demi, so people will know thedifference between the girl and the boy.” This is said to bedone in the “French style,” suggesting that it might havebeen possible in France that pink and blue were alreadygender-specific.However, there is evidence that this practice was notalways common or always done throughout much ofEurope. In fact, in the nineteenth century, parents dressedinfants in white dresses, suggesting that color and dresseswere not used to distinguish between girls and boys [3].At one point, pink was considered more of a boy’s color,as a watered-down, bold, dramatic red, which is a fiercecolor. Instead, blue was considered more for girls. Probablythis choice was affected by the fact that blue, especiallydark blue, was associated with the Virgin Mary in ChristianEurope. In fact, painters often mixed lapis lazuli into paintsto depict what was considered the most sacred feminineicon.The Sunday Sentinal, an American newspaper, in 1914advised mothers: “If you like the color note on the littleone’s garments, use pink for the boy and blue for the girl, ifyou are a follower of convention” (March 29, 1914).Similarly, Ladies Home Journal informed: “There has beena great diversity of opinion on the subject, but the generallyaccepted rule is pink for the boy and blue for the girl. Thereason is that pink being a more decided and stronger coloris more suitable for the boy, while blue, which is moredelicate and dainty, is prettier for the girl” (June, 1918).The current pink for girls and blue for boys was notuniform until the 1950s [11]. It would seem that NaziGermany had something to do with the association of pinkwith femininity: catholic traditions in Germany andneighboring countries reverse the current color coding,because of the strong association of blue with the VirginMary; the Nazis in their concentration camps use a pinktriangle to identify homosexuals. The Nazi’s choice of pinksuggests that, by the 1930s, it was a color that in Germanyhad become associate with girls.Thus, Dress Maker Magazine stated: “The preferredcolor to dress young boys in was pink! Blue was reservedfor girls as it was considered the paler, more dainty of thetwo colors, and pink was thought to be the stronger (akin tored). It was not until WWII that the colors were reversedand pink was used for girls and blue for boys...”After World War II, blue was used extensively for men’suniforms. Therefore, blue became associated as more of amasculine color. From the 1940s onward, pink was pushedas a woman’s color. “Think pink” was the marketing sloganto convince women to embrace their femininity.The 1950s featured a virtual color explosion, not only inclothing, but also in things like appliances and furniture.Dressing children in pink and blue to specifically denotegender suggested the rising middle class and above. In

Recurrent and self-remitting sixth cranial nerve palsy: pathophysiological insight from skull base chondrosarcoma.

Palsy of the abducens nerve is a neurological sign that has a wide range of causes due to the nerves extreme vulnerability. Need of immediate neuroimaging is a matter of debate in the literature, despite the risks of delaying the diagnosis of a skull base tumor. The authors present 2 cases of skull base tumors in which the patients presented with recurrent and self-remitting episodes of sixth cranial nerve palsy (SCNP). In both cases the clinical history exceeded 1 year. In a 17-year-old boy the diagnosis was made because of the onset of headache when the tumor reached a very large size. In a 12-year-old boy the tumor was incidentally diagnosed when it was still small. In both patients surgery was performed and the postoperative course was uneventful. Pathological diagnosis of the tumor was consistent with that of a chondrosarcoma in both cases. Recurrent self-remitting episodes of SCNP, resembling transitory ischemic attacks, may be the presenting sign of a skull base tumor due to the anatomical relationships of these lesions with the petroclival segment of the sixth cranial nerve. Physicians should promptly recommend neuroimaging studies if SCNP presents with this peculiar course.

Pathological enlargement of midbrain Virchow–Robin spaces: a rare cause of obstructive hydrocephalus

Midbrain multiloculated cystic formations can rarely origin by enlargement of Virchow-Robin spaces surrounding mesencephalo-thalamic artery and branches of the collicular and accessory collicular arteries. They can determine several pictures of midbrain syndrome and obstructive hydrocephalus. The authors describe a 38 year-old man affected by a Benedikts syndrome related to a midbrain multicystic formation. Clinical course, differential diagnosis, and therapeutic choice are here also briefly discussed.

Retrieval of ventricular catheter with the aid of endoscopy: technical note.

Multilocular hydrocephalus usually requires placement of multiple ventricular catheters for the treatment of secondary cysts and intraventricular septation. The formation of strong adhesions can embed the catheters so that they cannot be removed without a higher risk of intraventricular hemorrhage. Moreover, the devices could represent a nidus for infection and a risk for formation and enlargement of intraventricular secondary cysts. Neuroendoscopy allows the surgeon safely to reach the ventricular catheters that have been left or lost in the ventricular cavity, and to remove them via a minimally invasive approach. In this paper, the authors document another application of ventricular endoscopy in the management of this kind of hydrocephalus. The removal of an unnecessary and no longer useful prosthetic device that is a possible focus of infection justifies endoscopic treatment, which, in this experience, is not associated with morbidity.