Spontaneous movement of metallic foreign bodies. Case report

We report a case of missile injury to the brain with an unusual complication. The bullet migrated by its mere weight to a distant location through the brain parenchyma after initially lodged in a superficial site. Movement of the bullet was first detected on CT scan and the significance and treatment of this finding is emphasized.

Glycosylation of RNA polymerase II from wheat germ

RNA polymerase II from wheat germ was analyzed for the presence of sugars. The two largest subunits and the 27 and 25 kDa subunits were found to be glycosylated by a variety of sugars. However, no N-acetylglucosamine was detected, which was found by Kelly et al. (J. Biol. Chem. (1993) 268, 10416-10424) in the largest subunit of RNA polymerase II from calf thymus. Thus it appears that the regulatory function of this sugar, postulated by Kelly et al., is performed in the wheat germ enzyme by other monosaccharides. Carbohydrate analysis of the two largest subunits of the calf thymus enzyme also revealed the presence, beside N-acetylglucosamine, of other sugars. Some similarities in the features of glycosylation of the two polymerases, isolated from very different organisms, suggest that the sugar moieties have an important role in the structure and/or function of these enzymes.

Recurrence from filum terminale ependymoma 42 years after 'total' removal and radiotherapy

The authors describe the unusual case of a patient requiring reoperation for ependymoma of the filum terminale after a symptom-free period of 42 years: treatment of the primary tumor consisted of macroscopically complete surgical excision and postoperative radiotherapy. This case brings to light some interesting observations: a late recurrence, as in the case reported here, appears to be rare especially if the tumor presents in adult age; the long preoperative clinical history (26 months) and the initial aspect of the tumor that infiltrated 2 caudal roots, removed together with the tumor, may have been factors correlated with the risk of recurrence: postoperative radiotherapy may have helped to delay clinical manifestation of the recurrence. Ependymomas of the filum terminale may clinically recur even after complete removal. The latest clinical recurrence described in the literature occurred after 26 years.

Solitary cerebral metastasis from tumor of the testis: some observations about treatment in two cases

The authors describe two cases of solitary cerebral metastasis from non-seminatous germ cell tumors of the testis: in the first case, the histology was teratocarcinoma; in the second, it was embryonal carcinoma. Both patients underwent surgery, whole-brain radiotherapy and chemotherapy, and are still alive and disease-free after respectively 42 and 72 months. Although systemic metastasis from tumors of the testis are relatively common, they rarely involve the nervous system. A review of our cases and those reported in the literature shows that the outcome in these patients can be improved by the combined surgical, radiological and chemotherapeutic treatment of the metastasis.

Dural tail in pituitary adenoma

Although a dural tail has been described in association with meningiomas and, rarely, with other tumors in MR imaging with Gd-DPTA. Recently, a pituitary lesion was evaluated by MRI and presented a tail. For this reason the lesion was thought to be a meningioma of the tuberculum sellae, but at surgery proved to be an adenoma.

Long-term prognosis for atypical and malignant meningiomas: a study of 71 surgical cases

To contribute to a better understanding of the prognostic differences between atypical and malignant meningiomas as defined by the World Health Organization (WHO) and the influence of the grade of initial surgical excision on postoperative course, 42 cases of atypical and 29 of malignant meningioma were studied, along with long-term follow up. The two groups were compared with respect to long-term survival, recurrence-free survival, and median time to recurrence. The prognostic significance of the Simpson grade of surgical resection and tumor location was also considered. Survival at 5 and 10 years was recorded in 95% and 79%, respectively, of patients with atypical meningioma and in 64.3% and 34.5% of patients with malignant meningioma (p = 0.001). Recurrence-free survival and median time to recurrence were also significantly longer in patients with atypical than in those with malignant meningiomas: 11.9 versus 2 years (p = 0.001) and 5 versus 2 years (p < 0.0041), respectively. Six (26%) of the 23 recurring atypical meningiomas became malignant. Simpson Grade I resection and location in the cerebral convexity, which were closely related, were found to be associated with a significantly better clinical course in the entire series (p < or = 0.0016). Patients with atypical meningiomas fared better than those with malignant meningiomas after incomplete surgical excision (Simpson Grades II-III), but the difference was not statistically significant. Multivariate analysis using the Cox model indicated that radical extirpation (Simpson Grade I vs. II-III) and histological findings (atypical meningioma vs. malignant meningioma) were significantly related to prolonged survival (p < 0.0003 and p < 0.0388, respectively). In conclusion, the current study shows that for most patients with atypical meningioma the prognosis was less severe than for those with malignant meningioma, but the risk of a downhill course resulting from malignancy after incomplete resection and recurrence was not negligible (26%). In addition, the WHO classification was found to be inadequate for a minority of the atypical meningioma cases, which currently have the same unfavorable course as cases of malignant meningioma. The results also indicate that objective Simpson Grade I extirpation of convexity meningiomas can be successful despite histological findings of malignancy.

High-dose radiation-induced meningiomas

BACKGROUND

Numerous neoplasms within the CNS have been reported as radiogenic in origin; radiation-induced meningiomas are at least five times more numerous than gliomas or sarcomas in the world literature.

METHODS

The authors review 10 cases of cerebral meningiomas following high-dose radiotherapy in patients operated for neoplasm of the nervous system. The pathologic and clinical aspects of this unusual complication are analyzed in all cases in the world literature.

RESULTS

There is a female predominance (F-M ratio: 3:2) and the patients are young (mean age: 33.1 years; median: 29 years). The average latency period is 14.4 years (range: 9-21 years). The first disease is acute lymphocytic leukemia (ALL) in 40% of cases. Radiation induced meningiomas are atypical in four cases. Recurrence was observed in one case without malignant transformation.

CONCLUSION

High-dose radiation-induced meningiomas have the following characteristics: (1) children appear particularly sensitive to the development of this tumor; (2) there is a female predominance, otherwise than is observed in low-dose meningioma; (3) these tumors present a peak frequency in the third decade of life; and (4) frequently, these tumors are atypical and recur. Finally, it is essential that every new case be reported to throw light on this particular pathologic correlation with its many grey areas.

[Neurinomas and ependymomas of the cauda equina. A review of the clinical characteristics]

A retrospective review of 603 cases of intradural benign tumors of the cauda equina are presented (283 schwannomas and 320 ependymomas). For each tumor, the clinical course and long-term postoperative results were analyzed: it emerged that differential diagnosis between neurinomas and non tumoral lesions is not possible if based on clinical findings alone and that neuroradiological diagnosis is more accurate when MRI is employed. Long-term prognosis of neurinomas was always favourable, while in the ependymomas, early diagnosis gives excellent results because prognosis is apparently directly correlated to the length of preoperative clinical history.

[Intramedullary cervical neurinoma. A case report and review of the literature]

A case of intramedullary neurinoma of the cervical spinal cord in a patient with no sign of von Recklinghausen's disease is reported. It was diagnosed by computed tomography and magnetic resonance imaging and treated surgically. Discussion examines etiology, role of diagnostic procedures and surgical treatment of this rare tumor.

Long-term prognosis for atypical and malignant meningiomas: a study of 71 surgical cases

To contribute to a better understanding of the prognostic differences between atypical and malignant meningiomas as defined by the World Health Organization (WHO) and the influence of the grade of initial surgical excision on postoperative course, 42 cases of atypical and 29 of malignant meningioma were studied, along with long-term follow up. The two groups were compared with respect to long-term survival, recurrence-free survival, and median time to recurrence. The prognostic significance of the Simpson grade of surgical resection and tumor location was also considered. Survival at 5 and 10 years was recorded in 95% and 79%, respectively, of patients with atypical meningioma and in 64.3% and 34.5% of patients with malignant meningioma (p = 0.001). Recurrence-free survival and median time to recurrence were also significantly longer in patients with atypical than in those with malignant meningiomas: 11.9 versus 2 years (p = 0.001) and 5 versus 2 years (p < 0.0041), respectively. Six (26%) of the 23 recurring atypical meningiomas became malignant. Simpson Grade I resection and location in the cerebral convexity, which were closely related, were found to be associated with a significantly better clinical course in the entire series (p ¾ 0.0016). Patients with atypical meningiomas fared better than those with malignant meningiomas after incomplete surgical excision (Simpson Grades II-III), but the difference was not statistically significant. Multivariate analysis using the Cox model indicated that radical extirpation (Simpson Grade I vs. II-III) and histological findings (atypical meningioma vs. malignant meningioma) were significantly related to prolonged survival (p < 0.0003 and p < 0.0388, respectively). In conclusion, the current study shows that for most patients with atypical meningioma the prognosis was less severe than for those with malignant meningioma, but the risk of a downhill course resulting from malignancy after incomplete resection and recurrence was not negligible (26%). In addition, the WHO classification was found to be inadequate for a minority of the atypical meningioma cases, which currently have the same unfavorable course as cases of malignant meningioma. The results also indicate that objective Simpson Grade I extirpation of convexity meningiomas can be successful despite histological findings of malignancy.

Radiation-induced sarcoma of the skull: report of two cases

The authors describe two cases of sarcomas of the skull following cranial irradiation in patients treated for other neoplasms, acute lymphatic leukemia, and astrocytoma, respectively. The patients (one man and one woman: mean age 24.5 years) developed sarcomas within the irradiated field after a mean latency period of 11.5 years. Histologically, the tumor proved to be a fibrosarcoma. Despite aggressive surgery and other therapy, the survival of the patients was short (10 and 8 months, respectively). The pathological and clinical aspects of this unusual complication are analyzed with reference to 41 cases taken from the world literature.

Rathke's cleft cyst: a clinical and radiographic review

We report the case of a 62-year-old woman, who had a 4-year history of progressive visual acuity deficit. On neurological examination, visual acuity was 5/20 in the right and 4/20 in the left eye. A hormonal study revealed hypophyseal hypofunction. CT and MRI scans showed an intra-suprasellar cystic lesion, hyperintense in T1 and hyperintense in T2-weighted sequences. At surgery, the cyst wall was opened and the cavity placed in communication with the subarachnoid space. Histological examination showed a Rathke's cleft cyst. After four years of follow-up the patient's visual deficit remained unchanged, whereas the results of the hormonal assays were normal. An MRI scan confirmed the absence of the cyst. We review 216 reported cases of Rathke's cyst and discuss its pathogenesis, clinical features and treatment.

Multicentric and multifocal primary cerebral tumours. Methods of diagnosis and treatment

Forty patients with multifocal and multicentric cerebral tumours were retrospectively studied. The patients were divided into two groups: ten patients with multicentric tumours (group A), and 30 patients with multifocal tumours. As far as their preoperative clinical history and the incidence of the various symptoms and signs are concerned, there were no significant differences between the two groups. CT permitted a correct diagnosis in 90% of the cases. All of the patients underwent the removal of the tumour(s) and received radiotherapy; 30 patients also received chemotherapy. In group A, nine patients died and one was lost to follow-up one year after treatment; the average survival was ten months from the appearance of the multicentric tumour. In group B, 29 patients died and one is still alive two years after treatment; the average survival was six months. We consider the problems of diagnosis and the long-term follow-up of patients.

Prognostic factors in intramedullary astrocytomas

This report presents a retrospective prognostic study of 65 patients with intramedullary astrocytoma surgically treated between 1953 and 1990. Median survival and statistical survival at 5 years were assessed in relation to clinical, histological and therapeutic factors for each patient. Results showed that factors positively influencing the prognosis are low histological grade of the tumour and good pre- and post-operative general conditions. Among the grade II astrocytomas, the fibrillary and protoplasmatic types presented longer survival times regardless of the type of removal performed. In anaplastic astrocytomas the simultaneous presence of certain morphological features indicative of higher malignancy negatively influenced survival. The degree of resection did not influence average survival within each histological grade.

Synovial cysts: clinical and neuroradiological aspects

Lumbar and intraneural synovial cysts are uncommon lesions, although their incidence has increased since the introduction of MRI. The authors describe the results of a study comprising 23 patients with synovial cyst (5 lumbar, 19 intraneural). Neuroradiological investigations included CT scan and MRI; however, it was not always possible to diagnose the nature of the lesion. In 18 cases the lesion was removed totally including its capsule; in the other 5 cases it was removed subtotally. Seven of the 23 patients presented a total remission of symptoms/signs, 11 improved and 5 remained unchanged. The importance of treating synovial cysts as radically as possible is discussed together with their most significant clinical and neuroradiological aspects.

Primary spinal epidural non-Hodgkin's lymphomas in childhood: a review of 6 cases

We report a retrospective study regarding 6 children with primary epidural non-Hodgkin's lymphomas and analyse the factors influencing prognosis with emphasis on treatment. Four patients were females and 2 males. The neurological condition of patients was assessed pre- and postoperatively according to Shaw's classification for neurological disability. All patients were submitted to surgery, radiotherapy and chemotherapy. Histologically, the tumour proved to be a high-grade non-Hodgkin's lymphoma in all cases. At follow-up, all patients are alive after a median interval of 52 months (range 24-72 months). This study showed that the outcome of patients depends on the gravity of pre-operative deficits whereas the survival is influenced by the type of treatment.

Central neurocytoma: clinical features of 8 cases

The authors report 8 cases of central neurocytoma with a minimum follow-up of 3 years. Five patients were males and 3 females with average age of 21 years. All patients underwent surgical removal of tumor, and radiotherapy was delivered to 2 of the 3 patients in whom removal had been partial. At an average follow-up of 5 years, all patients are alive and none of them has presented signs of recurrence or progression of the disease. Some typical clinical and histological features of this tumor are pointed out.

Idiopathic normal-pressure hydrocephalus in adults: result of shunting correlated with clinical findings in 18 patients and review of the literature

The authors describe their findings in a study aimed at identifying clinical-prognostic factors in treatment of idiopathic normal-pressure hydrocephalus. The study comprised 18 adult patients submitted to surgery for ventriculo-peritoneal shunting. The findings that emerged from this series of patients were compared with those reported for the 381 published cases. In our group of 18 patients, average age was 65 years and the average duration of clinical history was 47 months (median 18 months). Follow-up ranged from 3 to 5 years (median 4.2 years): 12 patients improved (9 completely) and 6 presented stable neurological deficits. The factors that had a statistically significant influence on outcome were a short clinical history (less than 6 months) (p = 0.05) and a clinical onset without dementia (p = 0.03). Patients with medium-grade preoperative ventricular enlargement always made a complete functional recovery after surgery (p = 0.2).

Osteoblastoma of the calvaria: report of two cases diagnosed with MRI and clinical review

The authors describe 2 cases of osteoblastoma of the calvaria and review the clinical features of the 28 cases reported in the world literature. Benign osteoblastoma is a rare tumor that effects young patients, most frequently at temporal level. On the basis of its neuroradiological appearance, it is difficult to formulate a differential diagnosis against other osteoblastic tumors or against osteoid osteoma. In only a few cases MRI findings are reported. In our cases, MRI was more effective than CT scans and radiographs for evaluating the intracranial and intraosseous extension of the tumor. The definitive diagnosis was obtained by combining the histopathological features of the tumor with the clinical and radiological data. The prognosis of this tumor is very good regardless of the type of treatment performed, although both relapse and, more rarely, malignant tumor evolution are possible.

Primary spinal epidural non-Hodgkin's lymphomas: a clinical study

BACKGROUND

The spinal epidural space is an uncommon presenting site in primary non-Hodgkin's lymphoma. The occurrence of spinal epidural disease ranges from 0.1%-6.5% among patients with non-Hodgkin's lymphoma.

METHODS

We report a retrospective study regarding 19 patients with primary epidural non-Hodgkin's lymphomas analyzing the factors influencing prognosis of this tumor with emphasis on treatment.

RESULT

Ten patients were females and nine males. The neurologic conditions of patients were assessed preoperatively and postoperatively according to Shaw's classification for neurologic disability. All cases underwent surgery accompanied by radiotherapy in 16 cases as well as chemotherapy in 13 cases. Histologically, the tumor proved to be a low-grade non-Hodgkin's lymphoma in three cases, intermediate-grade in four cases and, high-grade in 12 cases. At average follow-up of 7.2 years (range 5-15 years), 15 patients had died after an average interval of 31 months from treatment (range 3-130 months) and four patients are alive after an average interval of 61 months (range 32-86 months).

CONCLUSION

It appears that the outcome in these patients depends on the gravity of preoperative deficits, whereas the survival is influenced by the type of treatment.

Comparison of DNA-protein interactions in intact nuclei from avian liver and erythrocytes: a cross-linking study

DNA-protein cross-linkages were formed in intact nuclei of chicken erythrocytes and liver cells by the action of cis-diammine dichloroplatinum (II). Most cross-linked proteins were components of the nuclear matrix, and their heterogeneity reflected the different complexity of liver and erythrocytes matrices, respectively. Some basic proteins, including histones, were also cross-linked, particularly in erythrocyte nuclei. South-Western blotting revealed that a variety of proteins isolated from the cross-linked liver nuclei recognized DNA specifically. In this group of proteins two relatively abundant, acidic, species of 38 and 66 kDa, respectively, might represent novel DNA-binding proteins from the nuclear matrix. In the case of erythrocytes, only the basic proteins showed a DNA-recognition capacity, and among them there were some unidentified species, absent from liver. Lamin B2 was cross-linked but was unable to recognize DNA, and the same was true for other abundant, cross-linked proteins from both types of nuclei. This led to the hypothesis that for some DNA-nuclear matrix interactions the aggregation typical of matrix proteins is essential for the specificity of DNA recognition. Hybridization analysis of the DNA isolated from the cross-linked complexes showed that SARs (scaffold attachment regions) and telomeric sequences were well represented in the cross-linked fragments, that the cross-linked DNA of liver was partially different from that of erythrocytes and that two defined SAR sequences were found to be present only in the cross-linked DNA. These results are in agreement with the present views on DNA-nuclear matrix interactions, which are usually studied on isolated nuclear matrices or purified proteins. Instead, our results provide experimental evidence obtained directly from intact nuclei.

Occult dysraphism in adulthood. A series of 24 cases

The results of a retrospective study of 24 adult patients with occult dysraphism are described. There were 15 males and 9 females, with an average age of 31.1 years. Specific circumstances precipitated symptomatic onset in 67% of patients. Pain, often referred to the anorectal region, was the most common presenting symptom. Bladder and bowel dysfunction were also common findings. The most common tethering lesions were intradural lipoma and a short thickened filum terminale. Myelography revealed the diagnosis of tethered conus in most cases, but the addition of CT and MRI images provided valuable structural details. The surgical outcome was gratifying in relation to pain and sensory-motor deficits but disappointing in the resolution of sphincter disorders. Our conclusion is that symptoms and/or signs of TCS with onset in adult life are not invariably irreversible.

Birthday of peripheral nervous system surgery: the contribution of Gabriele Ferrara (1543-1627)

SURGERY OF THE peripheral nerves has only recently achieved brilliant results thanks to technological advances in the development of neurosurgical instrumentation. In past centuries, few surgeons made relevant contributions to this topic and improvement was slow and difficult. Avicenna, Guglielmo da Saliceto, and Guido Lanfranchi reported some attempts to suture nerves directly, but Gabriele Ferrara was the first to give a lucid and succinct description of suturing of the stumps of a transected nerve. He described applying gentle traction on the retracted stumps, suturing using a special needle with an eye, after immersion in a decoction of red wine, rosemary, and roses (alcoholic disinfection?), and, finally, insulating the sutured segment with a mixture of oils. We are celebrating the 400th anniversary of the first edition of his fundamental work (1596-1996), and we truly esteem this surgeon, a pioneer of peripheral nerve surgery wo primarily contributed to its progress.

Vasospasm following tumor removal: report of 5 cases

Cerebral vasospasm is a clinical/angiographical condition frequently observed after a subarachnoid hemorrhage due to the rupture of an intracranial aneurysm. Twenty cases of vasospasm observed after the removal of cerebral tumors have been reported in the literature; we here report on a further five. The time of onset of symptomatic vasospasm was 3-7 days after surgery; three of the patients died of an ischemic event induced by the vasospasm and two survive. Although no angiographic confirmation was obtained in our cases, serial transcranial Doppler (TCD) flow velocities were always high. It is suggested that the TCD-revealed accumulation of blood in the basal cisterns observed in all cases may have been responsible for this unusual condition, and it is therefore important to consider vasospasm as a probable etiological cause of clinical deterioration in patients undergoing the surgical removal of a cerebral tumor. For this reason, whenever any neurological deterioration occurs in such patients, it is advisable to perform TCD in order to verify the presence of any vasospasm and promptly commence suitable treatment.