R. Donzelli

Posterior fossa hemangioblastomas

The authors report 40 personal cases of infratentorial hemangioblastomas and review 36 series from the literature for a total number of 1023 patients. The clinical, pathological, and surgical features of these tumors are discussed, with particular consideration of localizations outside the nervous system, multicentric tumors, recurrences, and long-term results. Although hemangioblastomas are benign tumors, their high growth potential makes their long-term development unpredictable in some cases.

Benign intrasellar cysts

Four cases of benign intrasellar cysts are reported. Three of these were treated surgically. Their origin and typical clinical features are discussed, in particular the altered pituitary function and visual disturbances. Computerized tomography has many advantages over traditional neuroradiological tools in reaching a diagnosis. The indication for active treatment and the surgical techniques and the methods used in the prevention of complications are outlined.

Spheno-orbital Meningiomas: Surgical Approaches and Outcome According to the Intraorbital Tumor Extent

OBJECT This study proposes a topographical classification of spheno-orbital meningiomas. Its aim was to define whether the different intraorbital localizations require different surgical approaches and have different recurrence rates and outcomes. MATERIAL AND METHODS Sixty patients with spheno-orbital meningiomas operated upon between 1983 and 2003 were reviewed. Four types were identified according to the extent of intraorbital tumor invasion: I: lateral or superolateral (15 cases); II: medial and inferomedial (8 cases); III: orbital apex (25 cases); IV: diffuse (12 cases). Three surgical approaches were used: lateral orbitotomy (15 cases with lateral or superolateral tumors), supraorbital-pterional approach (42 cases, including all 8 inferomedial cases, all 25 orbital apex cases, and 9 of 12 diffuse tumors), and a fronto-temporal-orbitozygomatic approach (only 3 cases with diffuse meningiomas and large-scale tumor invasion in the infratemporal fossa and cavernous sinus). RESULTS Tumor removal was complete (Simpson grades I and II) in 40 cases, and incomplete in 20 (33.3%). There were two postoperative deaths (3.3%). A sufficient clinical follow-up was obtained in 52 cases. The clinical outcome was excellent in 26 patients (50%), good in 16 (30.8%), moderate in 6 (11.5%), and poor in 4 (7.7%). Twenty-two of 52 patients (42.3%) had tumor recurrence; however, 44 (84.6%) achieved tumor control after surgery alone through two or more operations. The recurrence rate was correlated with the Simpson grade of resection and the intraorbital tumor location. Significantly higher rates of recurrence were recorded for the orbital apex type (50%) and diffuse forms (60%), than for the inferomedial (28.5%) and superolateral forms (23%). CONCLUSIONS Spheno-orbital meningiomas may be classified according to the location and extent of the intraorbital tumor invasion. The different localizations may require different surgical approaches, with different chances of complete removal. The location and extent of the intraorbital tumor results in different recurrence rates, lower for superolateral and inferomedial forms than for orbital apex and diffuse forms.

Subarachnoid hemorrhage due to a spinal neurinoma

A rare observation of spinal neurinoma associated with subarachnoid hemorrhage is reported and the other 12 cases in the literature are reviewed. The extramedullary location of the tumor and the feeble arachnoidal attachments to the spinal cord favor subarachnoidal bleeding in these cases. When the meningeal signs are evident and signs of spinal cord impairment are still unclear, an intracranial origin of the bleeding must be excluded. In doubtful cases, selective spinal angiography is useful in the differential diagnosis between a bleeding spinal tumor and an arteriovenous malformation of the spinal cord.

One-stage removal of residual intracanalicular acoustic neuroma and hemihypoglossal-intratemporal facial nerve anastomosis: technical note.

OBJECTIVE AND IMPORTANCEIncomplete removal of residual intracanalicular tumor and injury to the facial nerve are the main problems associated with surgery of large acoustic neuromas via the retromastoid suboccipital approach. In patients with residual or recurrent intracanalicular neuromas, the translabyrinthine approach is the preferred surgical route, allowing complete tumor removal; it may eventually also be used for exposure of the intratemporal portion of the facial nerve for a hemihypoglossal-facial nerve anastomosis when a postoperative facial palsy exists This one-stage procedure has not been described previously. CLINICAL PRESENTATIONThree patients with postoperative facial palsy and residual intracanalicular tumor after surgical removal of a large acoustic neuroma via the retromastoid suboccipital approach underwent reoperation via the translabyrinthine approach and one-stage removal of the residual tumor and hemihypoglossal-facial nerve anastomosis. All three patients had a complete facial palsy of House-Brackmann Grade VI and a residual tumor of 8 to 12 mm. TECHNIQUEA classic translabyrinthine approach was used to open the internal auditory canal and remove the residual intracanalicular tumor. The facial nerve was exposed in its mastoid and tympanic parts, mobilized, and transected; then, the long nerve stump was transposed into the neck and used for an end-to-side anastomosis into the hypoglossal nerve. The operation resulted in variable improvement of the facial muscle function up to Grade III (one patient) and Grade IV (two patients). CONCLUSIONReoperation via the translabyrinthine approach is indicated for removal of residual intracanalicular acoustic neuroma and realization of a hypoglossal-facial nerve anastomosis in a single procedure. It is suggested that this type of anastomosis may also be used during the initial operation for acoustic neuroma removal when the facial nerve is inadvertently sectioned.

Role of extracellular matrix components in facial nerve regeneration: an experimental study.

Abstract Objective: The aim of this study is to evaluate the role of extracellular matrix components in nerve regeneration. Matrigel, a complex of extracellular matrix components such as laminin (the most abundant) heparan sulphate proteoglycans (HSPG), type IV collagene and fibronectin, was used. Methods: Forty male rabbits, which had undergone section of the right facial nerve, were later treated by reinnervation through an artificial graft of expanded polytetrafluoroethylene (ePTFE). In 20 animals the tubes of ePTFE were filled with Matrigel; in 20 control animals the tubes were filled with saline solution. Results: The Matrigel group showed a better axonal organization and a significantly higher number of regenerated axons in the early phases (at days 15 and 30 respectively) than the control group, whereas the difference of the axons number at day 60 was less significant; besides, the axon diameter and the myelin thickness were not significantly improved by Matrigel. Discussion: Our data suggest that Matrigel is an important factor in promoting and enhancing the early phases of the regeneration after nerve injuries. Tree neurite promoting agents, such as laminin, fibronectin and collagen, allow a more systematic and agonized regeneration. Extracellular matrix components may represent a direction guidance for axonal pathway.

Lumbar disk surgical tricks for safeguarding the “root's ecology”

Restoration of a physiologic periradicular environment is a fundamental step toward improving the results of surgical procedures on the herniated lumbar disk. Combined with the preservation of periradicular fat (or free transplant of subcutaneous fat), reconstruction of the yellow ligament, recreating the interlaminar plane, may act as a barrier against postoperative adhesions. An operative technique is described that is aimed toward preserving the yellow ligament with the purpose of reconstructing it at the end of the surgical procedure on the root.

Glioblastoma in the Elderly: The Impact of Advanced Age on Treatment and Survival

OBJECTIVE To evaluate the effects of combined treatments on the outcome and survival of elderly (≥ 65 years) patients with glioblastoma as compared with younger ones. MATERIAL AND METHODS Fifty consecutive elderly (≥ 65 years) patients (group A) who underwent complete or subtotal (> 80%) resection of brain glioblastoma followed by irradiation and chemotherapy with temozolomide between 2004 and 2009 were retrospectively reviewed and compared with 50 glioblastoma patients aged < 65 years, treated in the same period (group B). Patient sex, tumor location, size and side, combined treatments, reoperation, progression-free survival, and overall survival were compared in the two groups by using the Kaplan-Meyer method. RESULTS There were no significant differences between the two groups for tumor location, size and side, and Ki-67 Li. Forty-four of 50 group B patients were treated by the Stupp protocol, whereas all group A patients underwent irradiation and adjuvant temozolomide. Second-line chemotherapy was administrated in 32% of group A and 76% of group B cases, and reoperation was performed in 16% and 36%, respectively. The median survival of the overall series of 100 patients was 15.6 months. Group A patients (≥ 65 years) had a median survival of 14.5 months, significantly lower than group B cases (17 months) (p = 0.02). CONCLUSION Elderly patients with glioblastoma may benefit from combined treatments, including surgery, radiotherapy, and chemotherapy. Although younger patients do survive longer than older ones, the difference of survival is less significant if several criteria of selection to surgery, such as good Karnofsky performance status (KPS), largely resectable tumor, and no significant comorbidity, are respected.

Local versus diffuse recurrences of meningiomas: factors correlated to the extent of the recurrence.

OBJECTIVE The aim of this study is to evaluate the factors correlated with the different patterns (local, peripheral and diffuse) of meningioma recurrence. MATERIAL AND METHODS 55 patients with benign (WHO I) meningiomas which recurred after seemingly complete removal were reviewed; 40 (Group I) had local or peripheral recurrences (< 3 cm from the initial dural attachment) and 15 (Group II) had distant and diffuse recurrences. Patient age and sex, tumor location, interval of recurrence, tumor shape, type of brain-tumor interface, histological subtype, mitotic index (MI) and progesterone receptor (PR) expression of the initial tumor, histological WHO Grade of the recurrent tumor and patient outcome were analyzed and correlated with the pattern of recurrence. RESULTS Flat-shaped meningiomas with large dural attachment showed a significantly higher rate of diffuse recurrences than round tumors, whereas the brain-tumor interface and the tumor location were not relevant (excepting the lack of convexity meningiomas in the group of diffuse tumors). There were no significant differences of histology, MI and PR expression of the initial tumor and histological grade of the recurrent tumor between the two groups. CONCLUSIONS The different patterns of meningioma recurrences (local, peripheral, diffuse) are not correlated with the tumor location and histology and do not represent a different biological tumor progression. We agree that most unexpected extensive recurrences result from a more extensive microscopic dural involvement.

Vascularized nerve grafts: an experimental study

Objective: The aim of this study is to define an experimental model in order to promote the functional recovery of the nerves using grafts with vascular support (Vascular Nerve Grafts – VNG). The aim of this study is to define, on an experimental model in normal recipient bed, whether the functional recovery with VNG is superior to that obtained non-vascularized graft (NNG). Methods: Twenty male rabbits, which underwent dissection of sciatic nerve, were later treated by reinnervation through an autograft. In 10 animals the reconstruction of sciatic nerve was realized with VNG; in 10 control animals the reconstruction of sciatic nerve was realized with NNG. Results: The VNG group showed a better axonal organization and a significantly higher number of regenerated axons in the early phases (after 30 days) than the NNG group, whereas the difference in the axonal number at day 90 was less significant; besides, the axon diameter and the myelin thickness were not significantly improved by VNG group. Discussion: Our data suggests that the use of VNG leads to a faster regeneration process and a better functional recovery, although the final results are comparable to those of the NNG. VNG improve the quality of the axonal regeneration (axonal diameter and Schwann cells), although the increase in the axonal number is not significant and does not improve the long-term functional outcome.