Pasquale Gallo

The endoscopic trans-fourth ventricle aqueductoplasty and stent placement for the treatment of trapped fourth ventricle: Long-term results in a series of 18 consecutive patients

BACKGROUND Different surgical approaches have been described in the past to treat a trapped fourth ventricle (TFV) but, unfortunately, these techniques showed a high rate of dysfunction and complications. During the last 10 years the development of neuroendoscopy has dramatically changed the outcome of these patients. MATERIALS AND METHODS We conducted a retrospective evaluation of the safety, effectiveness, and long-term outcome of endoscopic aqueductoplasty and stent placement, performed in 18 consecutive patients with symptomatic TFV through a trans-fourth ventricle approach between 1994 and 2010. Thirteen patients underwent endoscopic aqueductoplasty and stent placement and 5 patients underwent aqueductoplasty alone using a tailored suboccipital approach through the foramen of Magendie in prone or sitting position. RESULTS The mean age of the patients at the time of surgery was 15.2 years. All patients but 3 had a supratentorial ventriculoperitoneal shunt. Fifteen patients presented with slit supratentorial ventricles. At a mean followup of 90.8 months all patients experienced a stable clinical improvement. Only two complications were observed: A transient diplopia due to dysconjugate eye movements in one patient and a transient trochlear palsy in another one. CONCLUSIONS Our experience and the literature review suggest that endoscopic trans-fourth ventricle aqueductoplasty and stent placement is a minimally invasive, safe, and effective technique for the treatment of TFV and should be strongly recommended, especially in patients with supratentorial slit ventricles.

Retained medullary cord confirmed by intraoperative neurophysiological mapping

IntroductionA retained medullary cord (RMC) is a rare dysraphic malformation, recently described as a late arrest of secondary neurulation. RMC is also a severely tethering lesion. The critical role of intraoperative neurophysiology to safely manage a RMC has been only anecdotally reported.Case reportWe describe the case of a RMC in a 1.5-year-old child with Currarino syndrome. At surgery, an apparently normal-looking spinal cord, stretched and tethered by a lipoma to the level of S2-S3, was observed. The border between the functional conus and the non functional RMC was defined through neurophysiological mapping. The cord was sharply interrupted at this level and untethered. A specimen was sent for pathology, which confirmed the presence of glial and neural elements. The post-operative neurological exam was normal.ConclusionNeurosurgical procedure for RMC should only be rendered with intraoperative neurophysiological mapping, as the anatomical judgment would not suffice to allow a safe cutting of these “normal-looking” neural structures.

Intraoperative Neurophysiological Monitoring in Posterior Fossa Surgery

Surgical treatment of pediatric posterior fossa tumors has undergone many changes in the past century. The advent of operative magnification and ultrasonic surgical aspirator coupled with the introduction and refinement of MRI technology and with the advances in neuroanesthesia and neurointensive care has facilitated the resection of these tumors.

The role of repeat endoscopic third ventriculostomy after failure of the initial procedure.

DOI: 10.4103/0028-3886.91362 of consecutive ETVs for hydrocephalus of different etiologies from a single institution. The aim of the study is to determine if a second ETV after an early or delayed failure (due to inadequate size of the ostomy or restenosis respectively) allows a durable resolution of the hydrocephalus. Overall, this group performed 296 ETVs over an eight-year period with a success rate of 72% on long-term follow-up. Fifty-one patients had early failure while 32 patients had delayed reoccurrence. The decision to attempt a re-ETV was based on the review of patients’ intraoperative videos where the ostomy was deemed unsatisfactory at the first operation. Six of the 51 patients from the early failure arm of the study underwent reETV with an additional 50% clinical success rate. In the delayed failure group 26 patients underwent re-ETV with clinical improvement in 25 of them. The most impressive finding is definitely the 90% success rate of re-ETV in children less than two years of age. This is in contrast with some previous studies[1] but, in our opinion, is not so surprising and likely reflects the main role of the formation of new arachnoid membranes after the first ETV in infants with obstructive hydrocephalus, besides the optimal patients’ selection of the surgeon. To the best of our knowledge, we do not know why infants below one or two years of age should have a higher failure rate. Probably also the definition of unsuccessful ETV, in these subjects, is too hasty considering the longer time of adaptation in infants. Some authors have described their experience with re-ETV[2-4] reporting an overall success rate ranging from 65–75% but showing worst Endoscopic third ventriculostomy (ETV) is replacing, in many neurosurgical centers, valve-regulated shunts as the initial treatment of obstructive hydrocephalus or at the time of shunt failure,[1] nevertheless only few authors, until now, have addressed the role of repeat ETV (re-ETV) after failure of the initial procedure.[2-4] Since the earliest experiences with ETV, obstruction of the stoma has been recognized as one of the possible reasons for failure and reopening of ostomy by repeating the procedure has been proposed as an alternative to shunt placement.[5] Obliteration of the orifice after a successful ETV is probably a natural healing process that can happen in some patients with a certain degree of subjectivity. More intriguing are, instead, patients who benefited from a primary ETV for long periods of time, underwent re-ETV but failed to improve!

Acute Cerebellitis in Children: A Variable Clinical Entity

Acute cerebellar ataxia is the most common cause of acute ataxia in children and it usually runs a self-limiting and ultimately benign clinical course. A small proportion of children have evidence of inflammatory swelling in the cerebellum. Many of these children suffer more severe and potentially life-threatening forms of cerebellar ataxia and may need more intensive treatments including urgent neurosurgical treatments. This more severe form of acute cerebellar ataxia is often termed acute cerebellitis. Many children with acute cerebellitis have long-term neurological sequela and evidence of structural cerebellar changes on follow-up imaging. Several patterns of cerebellar inflammation have been described. The authors describe the variabilities in the clinical and radiological patterns of disease in the cases that have been described in the literature.

Comparison of Three Different Cranio-Cervical Decompression Procedures in Children with Chiari Malformation Type I: Does the Surgical Technique Matter

Background/Aims: A broad spectrum of cranio-cervical decompression techniques (CCD) is employed for the treatment of Chiari malformation type I (CM1). The aim of this study was to compare the clinical and radiological outcome of 3 different CCD performed in a single paediatric centre. Methods: A retrospective analysis of children treated between 2008 and 2014 was performed. Three different surgical techniques were offered to the patients: an extradural osseo-ligamentous bony decompression (BD), or a BD plus opening of the dura either without duroplasty (DOWD) or with watertight expansile duroplasty (DOPD). The primary clinical outcome was measured by utilizing the Chicago Chiari Outcome Scale (CCOS). Results: Forty-six children underwent 51 CCD: 17 BD, 17 DOWD, and 17 DOPD. The median follow-up period was 46 months (16-98 months). Patients who underwent BD had a shorter length of hospital stay than those who underwent DPTC and DOWD. Clinical improvement, defined by the mean CCOS score, was comparable in patients receiving BD (n = 14.6) and DOPD (n = 14.5), but lower in patients with DOWD (n = 12). Post-operative complications were noted in 7 DOWD patients (41%) and 3 DOPD patients (17.6%). Conclusions: BD is a safe and effective procedure with comparable clinical and radiological outcomes to DOPD in children with CM1. The risk of post-operative complications and worse clinical outcome was noted to be higher when performing a DOWD.

Autobiographical memory loss following a right prefrontal lobe tumour resection: a case report and review of the literature

IntroductionThe right prefrontal lobe has not traditionally been considered eloquent brain. Resection of tumours within this region does not typically lead to permanent functional impairment. In this report, we highlight the case of a patient who developed autobiographical memory loss following an uncomplicated resection of a right prefrontal tumour.Case materialA previously fit and well 15-year old presented with a persistent right-sided headache. An MRI demonstrated an expanded right mid-frontal gyrus with changes consistent with a low-grade tumour. The patient underwent a right-sided craniotomy and resection of the lesion which was confirmed as a WHO grade II diffuse astrocytoma. Postoperatively, the patient reported profound retrograde amnesia for a range of memory components, in particular autobiographical memory and semantic memory. Postoperative imaging showed a good resection margin with no evidence of underlying brain injury. Over an 18-month period, the patient showed no improvement in autobiographical memory; however, significant relearning of semantic knowledge took place and her academic performance was found to be in line with expectations for her age.ConclusionIn this report, we discuss a case and review the literature on the role of the right prefrontal cortex in memory and caution on the perception of right prefrontal non-eloquence.

Delayed diffuse cerebellar swelling after resection of medulloblastoma: case report and review of literature

IntroductionDelayed diffuse cerebellar swelling is a rare life-threatening complication following medulloblastoma resection.PresentationWe present our experience of managing a 4-year-old who developed diffuse cerebellar swelling with upward herniation 41 days after resection of a large cell anaplastic medulloblastoma.ConclusionEmergency chemotherapy alone was sufficient in promoting regression of swelling and recovery from coma. Reports of similar cases are scant. Chemotherapy may be a critical component of treatment.

G112(P) Foetal Neurology: A study of referral pattern and outcomes in a tertiary centre

Introduction Screening for foetal abnormality is an important part of antenatal care. When a neurological abnormality is detected in the foetus the woman is referred to the Paediatric Neurosciences team for counselling.1 This study investigates the pattern of abnormalities found and their outcome. Methods Patients were identified from the Paediatric Neurosciences departmental database, which contained referrals from 2005–2015. Further information on the patients and their outcomes was collected from their electronic notes. Results Of the 68 patients identified in the database, 66 pregnancy outcomes were documented. Ultrasonography (US) was used in all patients, and US combined with Magnetic Resonance Imaging (MRI) were the most used investigation methods. Figure 1 illustrates the gestational age that abnormalities were first detected by US. Myelomeningocele was the most frequent abnormality detected (n = 30) (Figure 2). The pregnancy was terminated in 39% (n = 26) cases (Figure 3). The pattern of decision to terminate was different for the various abnormalities: 75% of open lipped schizencephalies were terminated, in comparison to 0% of Dandy Walker malformations. 32 children were alive at recent follow up of which 31 had the correct diagnosis prenatally; 18 of which had had additions to their diagnosis.Abstract G112(P) Figure 1 The distribution of gestational age when abnormalities were first detected by UltrasonographyAbstract G112(P) Figure 2Abstract G112(P) Figure 3 The pregnancy outcomes in all 68 patients and whether follow up was available for the diagnosis of each out come (TOP = Termination of Pregnancy) Conclusions There is little literature on the patterns of antenatal referrals to the Paediatric Neurosciences teams and their subsequent outcomes. This study describes the pattern of abnormalities detected, their frequency and ultimate outcomes. This study can be used to assist the Paediatric Neurologists and Neurosurgeons when counselling women who have been found to have neurological abnormalities on antenatal screening. Reference Scher, Mark S. “Topical Review: Fetal and Neonatal Neurologic Case Histories: Assessment of Brain Disorders in the Context of Fetal-Maternal-Placental Disease. Part 1: Fetal Neurologic Consultations in the Context of Antepartum Events and Prenatal Brain Development.” Journal of child neurology 2003;18(2):85–92

The dramatic history of the plot against the Dominican friar, Peter from Verona: “a holy craniotomy”

During the Middle Ages, Verona was not only the city of Romeo and Juliet, but also the scene of the gruesome murder of the Dominican friar, Peter, from Verona. Peter is the copatron of Verona with Saint Zeno. He was canonized by Pope Innocent IV on March 1253 after an interval of only 337 days from his death, making him the fastest papally canonized saint in history. In the official iconography, he is always represented calm and with a gash across his head, something that should support our neurosurgical patients! Peter was born in the city of Verona in 1206 from a family, perhaps, sympathetic to the Cathars. This heresy held many adherents in the thirteenth century of Northern Italy. He went to a Catholic school and later to the University of Bologna, where at the age of fifteen, he met Saint Dominic, joined the Order of the Friars Preachers (Dominicans), and became a celebrated preacher throughout the northern and central Italy. In 1252, Pope Innocent IV appointed him Inquisitor in Lombardy. Peter evangelized nearly in the whole of Italy, preaching in Rome, Florence, Bologna, Genoa, and Como. The Cathars, against whom he preached, were a heretical group that had adopted elements of dualism, also called Manichaeism, rejecting the authority of the Pope and many Christian teachings. The hatred and frenzy of the Manicheans increased as they grew more and more obstinate. They knew well that unless they gave up their ungodliness, they could hope for no understanding with Peter whom they looked upon as the scourge and destruction of their sect. Accordingly, they conspired to kill him. The principals in this plot were Stefano Confalonieri, Tommaso da Giussano, a little village between Milan and Como, Guido Sacchella, and Giovanni della Chiusa. The price they agreed to pay the assassins was forty Milanese lire, which were placed in the hands of Tommaso da Giussano. For the execution of the crime, they chose Pietro Balsamone, commonly called Carino; and this man selected Albertino Porro for his assistant. From Milan, the friar went to Como, where he was prior. The conspirators let the Easter festivals pass. On the Saturday, within the octave of Easter, April 6, 1252, Peter left his convent before daybreak to return to Milan on foot.