Romeo Roselli

Risk Factors and Prognostic Indicators of Bacterial Meningitis in a Cohort of 3580 Postneurosurgical Patients

In order to identify the incidence, risk factors and prognostic indicators of postneurosurgical bacterial meningitis, a 9-y retrospective cohort study was performed. The cohort comprised 3580 individuals who underwent neurosurgical operations at the Department of Neurosurgery of Catholic University, Rome, a 1700-bed university hospital. We observed 52 episodes of postneurosurgical meningitis, with infection rates of 1.4/100 patients, 0.8/100 operations for craniotomies and 2.6/100 operations for internal cerebrospinal fluid (CSF) shunt or ventriculostomy with external drainage. The overall infection rate decreased from 2.5/100 operations in 1989 to 0.9/100 in 1997 (p = 0.03). Logistic regression analysis indicated that duration of ventriculostomy with external drainage [p < 0.01; odds ratio (OR) = 9.67; 95% confidence interval (CI) = 2.44-38.32] and increasing value of the APACHE III score (p < 0.01; OR = 8.51; 95% CI = 2.15-33.68) were independent risk factors for development of meningitis. The overall case fatality rate was 8%. Predictors of mortality were low ( < 1.66 mmol/l) CSF glucose concentration (p = 0.001), increasing value of the APACHE III score (p = 0.002) and Gram-negative aetiology (p = 0.003).In order to identify the incidence, risk factors and prognostic indicators of postneurosurgical bacterial meningitis, a 9-y retrospective cohort study was performed. The cohort comprised 3580 individuals who underwent neurosurgical operations at the Department of Neurosurgery of Catholic University, Rome, a 1,700-bed university hospital. We observed 52 episodes of postneurosurgical meningitis, with infection rates of 1.4/100 patients, 0.8/100 operations for craniotomies and 2.6/100 operations for internal cerebrospinal fluid (CSF) shunt or ventriculostomy with external drainage. The overall infection rate decreased from 2.5/100 operations in 1989 to 0.9/100 in 1997 (p = 0.03). Logistic regression analysis indicated that duration of ventriculostomy with external drainage [p < 0.01; odds ratio (OR) = 9.67; 95% confidence interval (CI) = 2.44-38.321 and increasing value of the APACHE III score (p <0.01; OR = 8.51; 95% CI = 2.15-33.68) were independent risk factors for development of meningitis. The overall case fatality rate was 8%. Predictors of mortality were low ( < 1.66 mmol/l) CSF glucose concentration (p = 0.001), increasing value of the APACHE IIl score (p = 0.002) and Gram-negative aetiology (p = 0.003).

Epileptogenic Cerebral Low-Grade Tumors: Effect of Interstitial Stereotactic Irradiation on Seizures

15 patients with various types of surgically inaccessible epileptogenic cerebral neuroepithelial tumors were treated with stereotactic interstitial irradiation. Epilepsy was improved in all cases, being abolished in 6 and markedly reduced in another 7. The effects which became apparent soon after the radioisotope implant persisted. Possible mechanisms of the phenomenon are discussed.

Interstitial brachytherapy for low-grade cerebral gliomas: analysis of results in a series of 36 cases.

SummaryThe results obtained with interstitial brachytherapy in thirty-six low-grade cerebral gliomas (2 pilocytic astrocytomas, 23 astrocytomas and 11 oligodendrogliomas) are reported (mean follow-up: 75 months, range 37–159). All tumours were situated in locations which did not call for surgical removal as the treatment of choice. Their volume ranged from 4 to 82 cc (m=32); the Karnofsky performance status (KPS) of the treated patients lay between 0.60 and 0.90.The sources utilized (Iridium-192 in 32 cases and Iodine-125 in 4) were implanted permanently in 22 patients and temporarily in 14, using the Talairach stereotactic apparatus. The mean peripheral dose was 89.7 Gy for the permanent implants and and 42.8 Gy with a rate of 32.05 cGy/h for the temporary implants. External beam irradiation was added for tumour volumes greater than 35 cc (19 cases) on a second target volume extending 2 cm beyond the tumoural borders treated with interstitial irradiation.The survival estimates for the entire group showed a probability of 82.9% at 60 months, of 56.8% at 96, 39.4% at 120 (m.s.t.: 112 months). The quality of life in the treated patients was satisfactory, KPS never falling below a mean score of 0.70. The extent of the target volume turned out to be the most significant factor influencing survival at the multivariate analysis. Severe neurological impairment due to radionecrosis occurred in 4 patients (11%), three of them requiring surgical decompression. Target volume and radiation dose showed a direct correlation with the risk of radionecrosis at the regression analysis, the critical values being 35 cc and 100 Gy (permanent implants) or 50 Gy (42 cGy/h, temporary implants) respectively. The analysis of the results indicates that, even though many questions still remain open, brachytherapy can represent a valid alternative to surgery for tumours not suitable for surgical removal.

Sewing Needles in the Brain: Infanticide Attempts or Accidental Insertion?

BACKGROUND:Placing of sewing needles in the brain through the anterior fontanelle was first described in Germany in 1914. Forty cases have been reported in the scientific literature; most of them were identified in Turkey and Iran, with only a few cases in the Far East, North and Eastern Europe, and the United States. The only case observed in Italy was recorded in 1987. In nonmedical literature, this practice was frequently described in Persian novels, and it has been thought that this ritual could have been diffused with the Persian Empire domination over the centuries. OBJECTIVE:We report on a new Italian case of an 82-year-old woman admitted for progressive right hemiparesis and gait disturbance. METHODS:Brain computed tomography scan showed a left frontoparietal chronic subdural haematoma and, surprisingly, three 4-cm-long sewing needles inserted through the region of the anterior fontanelle. The patient and her friends and family did not remember any event justifying their presence. RESULTS:Subdural collection was evacuated by craniotomic approach, and the sewing needles were left in place and followed up. CONCLUSION:The rare cases of intracranial needling reported in the literature may represent only the tip of the iceberg. The phenomenon is usually reported as an incidental finding in asymptomatic adults, whereas many babies could not have been diagnosed because they died. The therapy remains controversial, although many authors suggest only follow-up for asymptomatic patients. In this article, all the pertinent literature is reviewed and the most important clinical aspects are discussed, along with a historical assessment of the problem.

Ultrasound evaluation in traumatic peripheral nerve lesions: from diagnosis to surgical planning and follow-up

Surgical treatment of traumatic nerve lesions is a matter of debate, mostly about the timing and technical aspects of the procedure. In deciding about and planning the operation, it is often necessary to repeat the electrophysiological and neuroradiological studies several times. Here we present our experience with ultrasonography taken before and after surgery: this simple and handy tool allowed clear visualization of the preoperative anatomy, thorough preparation and fast carrying out of surgery, and accurate postoperative monitoring of the graft’s vitality at follow-up. Though this is a limited series, the importance of ultrasonographic evaluation in traumatic peripheral nerve lesions appears remarkable.

Comments on brachycurie therapy of cerebral tumours.

Between 1980 and 1987 thirty patients harbouring cerebral neuroepithelial tumours have been treated with stereotactic brachycurie therapy (18 males, 12 females), either alone (n = 16) or combined with surgery (n = 7) and/or external radiotherapy (n = 10). There were 25 slowly growing tumours (grade I n = 1; grade II n = 24). The remaining 5 were malignant tumours (grade III n = 3; grade IV n = 2). The radioactive sources utilized were 192Ir in 26 cases and 125I in 4. Twenty-eight patients underwent permanent implantation, the other two received temporary irradiation with removable after-loaded catheters. Target volume was less than 15 cm3 in 6 cases, between 16-60 cm3 in 17 and more than 60 cm3 in 7. Tumour dose at the periphery of the target volume was: 70-100 Gy in 19 and 100-130 Gy in 9 of the cases treated with permanent implantation; the patients irradiated with removable implants received 40-60 Gy in 5-7 days. General follow-up ranged between 0.3 and 6.9 years (mean = 2.5 years). The results are analyzed with reference to the following aspects: 1) natural history of the disease; 2) modalities and goal of the treatment; 3) place of brachy therapy as sole treatment and combined with the other available therapeutical means.

10 Levels thoracic no-intrumented laminectomy for huge spontaneous spinal subdural hematoma removal. Report of the first case and literature review.

Highlights • In this article, reporting on the case of a huge 10 levels spontaneous spinal subdural hematoma treated with decompressive thoracic no-instrumented laminectomy in a 45-year-old woman with good neurological recovery, we would like to underline the importance of a timely surgical decompression as the mainstay option in the management of strongly symptomatic spontaneous idiopathic acute spinal subdural hematomas.• To our knowledge, 10 levels thoracic laminectomy for a SSDH removal have never been described. We performed “conservative” laminectomy by sparing of articular processes with no need to posterior fixation also considering the intrinsic stability of thoracic chest.

Natural History of Neuroepithelial Tumours: Contribution of Stereotactic Biopsy

Quantitative tumour growth into the brain (stage of the disease) and qualitative tumour evolution in the time (progression) are the two basic aspects of the natural history of the cerebral neoplastic disease. Recently the development of neuroradiological imaging (CT and MR) and the progress in biopathology of the nervous system tumours introduced new concepts like heterogeneity of neuroepithelial tumours or evolution to anaplasia. The findings obtained in 159 neuroepithelial tumours studied with stereotactic biopsy from 1980 to 1987 are presented. Most of them were glioblastomas (n = 43; 27%) and astrocytic tumours (n = 81; 50.9%). Twenty-nine cases of fibrillary astrocytomas (35.8% of all astrocytic tumours) showed focal anaplasia (progression). In 10 out of the 43 glioblastomas (23.3%) signs of astrocytic differentiation were clearly evident (secondary glioblastoma?). Our data confirm that neuroectodermal tumours, particularly of astrocytic series, undergo progression through anaplasia, which may be at the beginning a circumscribed phenomenon (focal anaplasia). The staging of the disease (tumour growth) into cerebral nervous system in some cases can not be correctly expressed through the neuroradiological imaging. Sometime CT scan may underestimate the true extension of the lesion. On the contrary, MR may overrate the extension of the lesion. Such mistakes in evaluation of tumour staging may be corrected through seriate stereotactic biopsy.

Role of stereotactic biopsy in the surgical treatment of cerebral tumors.

Out of 664 intracranial tumors subjected to surgical procedures since 1980, 163 underwent stereobiopsy. On the basis of this experience, we devised a scheme to help decide whether and why stereobiopsy is advisable.

Interstitial Irradiation for Newly Diagnosed or Recurrent Malignant Gliomas: Preliminary Results

The preliminary results obtained in 19 patients treated with interstitial irradiation for malignant gliomas are reported. Three different groups are included in the study: I Newly diagnosed tumours not suitable for surgery: 13 cases (10 anaplastic astrocytomas (AA) and 3 glioblastomas (GBM), mean volume 46.56 cc, source Ir 192) were implanted permanently (n = 11, mean peripheral dose 93.54 Gy) or temporarily (n = 2, 50 Gy = 0.5 Gy/hr). External beam irradiation was additionally applied in all cases. II Residual or recurrent tumours: 5 patients (2 AA and 3 GBM, mean volume 7.2 cc, source Ir 192) received temporary implants (150 Gy peripheral dose = 1.5 Gy/hr) after surgery and conventional radiotherapy. III Newly diagnosed surgically removable tumours: only one patient with AA (15 cc volume, source Ir 192) received temporary implantation with the same dose regimen used in Group II before surgery and external beam irradiation. A median survival time of 26.75 mos (34.62 mos for AA, with 3 long-term survivors) was observed in the patients of Group I. Three patients of Group II are still alive after 8, 12 and 12 mos after brachytherapy, the other 2 (GBM) survived 7 and 12 mos. The single patient so far included in Group III is still alive after 6 mos. Although the study is still in progress, these preliminary data seem to indicate that interstitial radiotherapy can be effective in prolonging survival of patients with malignant gliomas.