Cytokeratin profile and neuroendocrine cells in the glandular component of cardiac myxoma

Glandular cardiac myxomas are very rare tumors of uncertain histogenesis that display glandular structures within otherwise typical myxomatous tissue. The origin of the glands has been attributed to epithelial differentiation of a totipotent cardiomyogenic precursor cell or to entrapped embryonal rests in the tumor. We studied four cases of glandular myxomas (three sporadic and one familial) to define the immunophenotypic profile of the glandular elements. The glands were either single and located within the myxoma cell islands (three cases) or in groups embedded in the myxomatous matrix. In the latter case, the glands featured villous projections, irregular profile, active inflammation or focal reactive cellular atypia (case 3) and had acidic and neutral mucins (mostly sialomucins). The cytokeratin expression profile (cytokeratin 7 and 20 co-expression) was similar to that of foregut derivatives. Scattered chromogranin-positive neuroendocrine cells were observed in case 3. Our findings indicate that the glandular component in cardiac myxoma is morphologically heterogeneous. In some cases, the scattered glands may derive from a divergent (epithelial) differentiation of myxoma cells; in others, entrapment of embryonic gastrointestinal rests (with mature neuroendocrine and mucous cell populations) could be the case.

Management of benign craniovertebral junction tumors

BACKGROUND

We report our surgical experience in the treatment of fifteen consecutive patients with benign craniovertebral junction tumors, observed from 1993 to 2000 at our department.

METHOD

We treated 7 meningiomas, 3 epidermoids, 3 C1 neurinomas and 2 neurinomas of the lower cranial nerves. Clinical results were evaluated by Karnofsky Performance Scale and all patients underwent preoperative neuroradiological evaluation with CT, MRI and MRA; angiography was not routinely performed and was considered for each individual case.

FINDINGS

11 partial transcondilar and 4 retrocondilar approaches were performed. Total removal was achieved in 11 cases (73,3%) and subtotal removal in 4 patients (26,7%). None of the patients required occipitocervical fusion. Patients were followed for an average period of 24+/-31 months. Clinical and radiological follow-up showed no recurrence in cases with total removal. In all patients a statistically significant postoperative increase of KPS scores was recorded. The treatment of epidermoid tumors presented particular issues: debulking the lesion, we obtained a surgical window, avoiding a large removal of bone. In Nakasu grade 1 or 2 meningiomas, we carried out total removal by piecemeal resection and without complete condylectomy and bone fixation.

INTERPRETATION

The choice of these approaches and the extent of bone resection should be defined according to the tumor's location and size. Moreover we emphasize that preoperative neuroradiological evaluations on presumptive tumor type could be helpful to the surgeon in order to tailor the technique to different lesions, providing the required exposure, without unnecessary surgical steps.

Duplicated abducent nerve and its course: microanatomical study and surgery-related considerations

OBJECT

The anatomy of the abducent nerve is well known; its duplication (ranging from 5 to 28.6%), however, has rarely been reported in the literature. The authors performed a microanatomical study in 100 cadaveric specimens (50 heads) to evaluate the prevalence of this phenomenon and to provide a clear anatomical description of the course and relationships of the nerve. The surgery-related implications of this rare anatomical variant will be highlighted.

METHODS

The 50 human cadaveric heads (100 specimens) were embalmed in a 10% formalin solution for 3 weeks. Fifteen of them were injected with colored neoprene latex. A duplicated abducent nerve was found in eight specimens (8%). In two (25%) of these eight specimens the nerve originated at the pontomedullary sulcus as two independent trunks: in one case the superior trunk was thicker than the inferior and in the other it was thinner. In the other six cases (75%) the nerve originated as a single trunk, splitting in two trunks into the cisternal segment: in two of them the trunks ran below the Gruber ligament, whereas in four specimens one trunk ran below and one above it. In all the specimens, the duplicated nerves fused again into the cavernous sinus, just after the posterior genu of the internal carotid artery.

CONCLUSIONS

Although the presence of a duplicated abducent nerve is a rare finding, preoperative magnetic resonance imaging should be performed to rule out this possibility, thus tailoring the operation to avoid postoperative deficits.

Lumbosacral dural ectasia in type 1 neurofibromatosis. Report of two cases

Dural ectasia denotes circumferential expansion or dilatation of the dural sac, and has been frequently reported in association with type 1 neurofibromatosis (NF1). The pathogenesis has not been defined, but its correlation with NF1 infers a congenital malformative hypothesis. The neural elements in the dilated sleeve typically are not enlarged or abnormal, nevertheless the enlarged area contain an increased amount of cerebrospinal fluid. The dura in the area of ectasia is extremely thin and fragile, and erodes the surrounding bony structures destabilising the spine and permitting spectacular spinal deformities. We present two cases with lumbosacral dural ectasia, enlargement of the intervertebral foramina and posterior scalloping of vertebral bodies. Neurological examination showed sciatic nerve irritation. As the etiology of this malformation remains uncertain and dysplastic changes of the spine may be intrinsic or secondary controversies remain about optimum treatment. We conclude that patients affected by NF-1 require an accurate neuroradiological study of the whole spine in order to detect possible dural and spinal anomalies. Surgical treatment is indicated only in patients with progressive neurological deterioration. The thin dural sac predisposes to a high morbidity if surgery is undertaken.

Traumatic subependymal hematoma during endoscopic third ventriculostomy in a patient with a third ventricle tumor: case report

Endoscopic third ventriculostomy has become a routine intervention for the treatment of non-communicating hydrocephalus. This technique is largely considered safe and a very low incidence of complications is reported. However, hemorrhage in the course of neuroendoscopy is still a problem difficult to manage. The authors present a case in which endoscopic third ventriculostomy and tumor biopsy were performed in a young patient with a huge tumor growing in the posterior part of the third ventricle. The surgical approach to realize the stoma was difficult because the tumor size reduced the third ventricle diameter. Surgical manipulation produced a traumatic subependymal hematoma. This hematoma drained spontaneously after few minutes into the ventricle and the blood was washed away. The postoperative neurological course was uneventful and the ventriculostomy showed to work well by reducing the size of the lateral ventricles and the intracranial pressure in three days. This complication during endoscopic third ventriculostomy has never been reported before. We emphasize the difficulty of endoscopic procedures in patients with huge tumors in the third ventricle. Where reduction in size of the third ventricle and of the foramen of Monro ist present we suggest a careful approach to the third ventricle.

Tolosa-Hunt syndrome preceded by facial palsy

The Tolosa-Hunt syndrome consists of a painful ophthalmoplegia related to a granulomatous inflammatory process in the cavernous sinus, which may be documented by cerebral magnetic resonance imaging with gadolinium enhancement. Two cases of Tolosa-Hunt syndrome preceded by facial palsy observed in 1998 at the Department of Neurosurgery of the Second University of Naples are presented here. Both patients developed Tolosa-Hunt syndrome following an ipsilateral facial palsy that resolved in about 15 days with medical treatment. Cerebral magnetic resonance imaging with gadolinium enhancement showed, in both cases, inflammatory tissue in the cavernous sinus. The patients underwent corticosteroid therapy (prednisolone, 80 mg per day, intravenously) with pain regression. In the first case, the patient experienced recurrence of the syndrome that was definitively resolved with further corticosteroid treatment. The rare reports of facial palsy in patients with Tolosa-Hunt syndrome suggest the inclusion of this disease in the so-called multiple cranial nerve palsy syndrome. It is probable that Tolosa-Hunt syndrome has an inflammatory pathogenesis.

Habitual snoring and obstructive sleep apnea syndrome in children: effects of early tonsil surgery

Habitual snoring and obstructive sleep apnea syndrome (OSA) in children are important in determining disturbed sleep, daytime symptoms and haemodynamic modifications. Moreover, chronic snoring is often associated with enlarged tonsils and adenoids. We studied 60 children (mean age 42.2 months) with habitual snoring, defined as a positive answer to the question 'does the child snore every night', by nocturnal or diurnal polysomnography in order to evaluate breathing disorders and choose surgical correction of upper airway stenosis. In more than half the children habitual (every night) snoring begin before the first year of life and is associated with obstructive apneas. Both nocturnal and, with some limits, diurnal recordings may be a good tool for diagnosis of sleep-related upper airway obstruction. Early adenomonotonsillectomy, in mild to moderate form and in children before 4 years of age, and adenotonsillectomy in the others seems to show a clinical and polysomnographic resolution of snoring and OSA during a short-term follow up.

Transtympanic drains in the treatment of serous otitis in children; anatomical versus functional long term results

The long term results are reported of transtympanic drains in 391 ears of 258 children affected by serous otitis; 150 ears have been evaluated at the end of a 3-7-year observation period. (1) A high percentage of ears with major anatomical lesions was found (46.6%), especially in the higher age group (greater than 7 years). (2) Functional hearing results are better than anatomical results; 84.6% of the subjects had a hearing level better than 20 dB (0-10 dB: 53.3%; 11-20 dB: 31.3%). (3) Anatomical and functional results are worse in case of recurrence (2 or more drains). (4) It is imperative to control periodically those children with major tympanic lesions and present good hearing.