Neuroendoscopic Management of Intraventricular Hemorrhage

Background and Purpose— We reviewed our 7-year experience in neuroendoscopic management of severe intraventricular hemorrhage (IVH) to evaluate its safety, efficiency, and efficacy.

Methods— Thirteen patients with spontaneous primary or secondary tetraventricular IVH underwent neuroendoscopy. In all procedures, we used a flexible instrument. CT scans obtained before and after surgery were compared for Graeb score and ventriculocranial ratio. Glasgow Outcome Scale was assessed at 12 months.

Results— In all patients, the procedure resulted in a substantial removal of ventricular blood. Graeb score was reduced by 65%, and ventriculocranial ratio was reduced by 30% ( P <0.002). The procedure was carried out safely even in the presence of a vascular malformation, and no rebleeding or delayed hydrocephalus was observed in any case. Mortality at 12 months was 30.7%. Favorable outcome (Glasgow Outcome Scale, 3 to 5) was observed in 61.5% of cases.

Conclusions— Neuroendoscopic management of severe IVH in this cohort of patients was safe, efficiently reduced the amount of ventricular blood and ventricular dilatation, and effectively produced an outcome profile that compares very favorably with other more conventional treatments.

Choroid plexus and aquaporin-1: a novel explanation of cerebrospinal fluid production

Aquaporins are selective water channel proteins that play a central role in the homeostasis of human body water. The choroid plexus (CP) is considered to be the main cerebrospinal fluid (CSF)-producing structure. In this study, six specimens of normal human CP obtained during surgery were analyzed by immunohistochemistry techniques for aquaporin-1 (AQP1) expression and distribution. Intense, uniformly distributed AQP1 immunostaining was observable in the apical but not the basolateral side of cuboid cells of the CP. Moreover, this polarized expression of AQP1 was weakly detectable in the endothelial cells of choroid microvessels and, with a different pattern, in the cells lining the tubules shaped into crypts. Selective AQP1 expression on the surface of the normal human CP might explain the role of CSF production by this complex structure.

Autologous hemodonation in the corrective surgery of craniostenosis

Homologous transfusions are mandatory in most surgical procedures for correcting craniofacial malformations in infancy. A program of preoperative and intraoperative auto-hemodonation was developed and carried out in eleven infants. Although homologous transfusion could have been avoided in only 7 patients, we think that further experiences and minor corrections of our program may improve these results.

Assessing brain function in post-traumatic coma by means of bit-mapped SEPs, BAEPs, CT, SPET and clinical scores. Prognostic implications

Sixty-eight severely head injured comatose patients were studied. Bit-colour-mapped SEPs to median nerve stimulation, BAEPs, CT and SPET regional values and ICP were assessed in relation to clinical information in evaluating cerebral function. All these variables were related to a 1-year outcome. Statistical tests confirmed the higher predictive reliability of both neurophysiological and perfusive (SPET) functional parameters compared to CT structural findings. Generally, SEPs appeared to be more reliable in predicting outcome than BAEPs. Modifications of frontal components could occur independently of post-central ones, being closely related to underlying cerebral lesions. The parameter showing the greatest correlation with outcome in the first recording session was the P25 latency, whereas this prognostic role was mainly assumed by the amplitude value of the frontal N30-P45 complex in a second recording session carried out during the third week following head trauma.

Long-term effects of octreotide on markers of bone metabolism in acromegaly: evidence of increased serum parathormone concentrations

The effects of octreotide on biochemical markers of bone turnover were evaluated in patients with active acromegaly. Serum GH, IGF-I and serum and urinary markers of bone metabolism were measured before and after 4 months of treatment in 27 patients (short-term treatment) and after 12 and 24 months of treatment in 15 patients (long-term treatment). In the short-term, octreotide significantly decreased the levels of serum GH, IGF-I, calcium, osteocalcin, carboxyterminal propeptide of type I collagen and alkaline phosphatase plus urinary excretion of calcium. Short-term treatment significantly increased serum parathormone levels (before treatment 30.1 +/- 9.57 and at 4 months 46.1 +/- 24.98 ng/L, p < 0.001) and urinary excretion of phosphate; urinary excretion of hydroxyproline was unchanged. The same results were observed during long-term treatment, except that there was no significant difference of serum calcium and alkaline phosphatase levels before and after treatment. Parathormone concentrations were still higher at 24 months compared with those prior to treatment (before treatment 31.9 +/- 9.74 and at 24 months 44.9 +/- 21.18 ng/L, p < 0.05). The changes of most bone markers during octreotide therapy can be explained by the decrease of serum GH and IGF-I concentrations. On the other hand, the rise of parathormone concentrations suggests that octreotide has ulterior and long-standing actions on calcium homeostasis: intestinal malabsorption of calcium due to the octreotide could contribute to this secondary hyperparathyroidism. The clinical consequences of these alterations of bone metabolism need to be further clarified.

Endoscopic treatment of colloid cysts of the third ventricle: 9 consecutive cases

The purpose of this study is to evaluate the efficacy of the endoscopic technique for the treatment of the colloid cysts of the third ventricle. Between August 1995 and October 1997 a series of nine patients with colloid cyst of the third ventricle (6 males and 3 females) were treated with this method. The technique, consisting of cyst fenestration, aspiration of the colloid, and coagulation of the internal layer of the wall, was always effective in restoring CSF circulation. Operating time was 54-120 min (median 67 min). We recorded only one post-operative septic complication but no signs of direct surgical morbidity. Post-operation hospital stay was 2-30 days (median 5 days). Follow up was 14-40 months (mean 27 months). We did not observe any clinical or radiological recurrence. Endoscopic treatment of colloid cysts of the third ventricle is a safe and effective alternative to the well-established approaches of microsurgical removal and stereotactic aspiration. Only a very long follow-up will answer the question of the long-term effectiveness of this method.

Monosialoganglioside in subarachnoid hemorrhage

We studied 119 patients with disturbance of consciousness following subarachnoid hemorrhage, due mostly to verified aneurysm rupture, admitted to five Italian neurosurgical departments over 18 months. Level of consciousness as assessed by score on the Glasgow coma Scale ranged from 8 to 14 before the beginning of treatment; level of consciousness was assessed again 7, 14, and 21 days later. Patients were randomly allocated to treatment with monosialoganglioside or placebo according to a double-blind experimental design. The two treatment groups were homogeneous at entry with regard to the main clinical parameters. Both groups improved, but the rate and degree of improvement were greater in the monosialoganglioside-treated group. The difference was significant on days 14 (p = 0.04) and 21 (p = 0.02). Our results seem to confirm the hypothesis that monosialoganglioside reduces brain edema and provides nonspecific neuronal membrane protection.

Aqueductal stenosis following mumps virus infection. Case report

A case of aqueductal stenosis following mumps infection is reported, to the authors' knowledge the 12th case in the literature. The pathogenetic events are discussed and the literature reviewed.

Reappearance of brain-stem auditory evoked potentials after surgical treatment of a brain-stem hemorrhage: contributions to the question of wave generation

We report on a patient suffering a spontaneous hemorrhage primarily located in the right brain-stem; surgical correction of this led to a substantial improvement in clinical deficits. Brain-stem auditory evoked potentials (BAEPs) were recorded on postoperative days 18, 30, 55 and 205. Waves II through V were initially undetectable on stimulation of the damaged side, whereas the absence of peak V was the only abnormality seen on left-side stimulation. With the regression of the right lower mid-pontine deficits, the right waves gradually reappeared and normalized progressively. On the last recording, only a left wave V abnormality persisted. At that time, the patient had a moderate left hemisyndrome due to a circumscribed right upper pontine-midbrain lesion. Therefore, it can be suggested that the first 4 waves of BAEPs mainly originate in the ipsilateral pons, and the Vth in the contralateral higher regions.

The diagnosis of CSF fistulas with rhinorrhea by isotope cisternography

The experience with the use of RIHSA cisternography in cases of spontaneous or posttraumatic CSF rhinorrhea is reported. The utility of this method for identifying the fistulous tract so that the neurosurgeon can, as far as he is able, carry out a direct and not solely exploratory operation is pointed out.

Cerebral cavernous angiomas in the first year of life

Two rare cases of cerebral cavernous angiomas in two infants, 9 and 6 months old, respectively, are reported and the other 11 cases in the literature concerning patients in the first year of life are reviewed. Cavernous angiomas of the brain occur rarely in the first year of life and present with seizures and head enlargement. On computed tomographic scan they typically appear as large, hyperdense, unenhanced masses, with large cysts and must be differentiated from tumors more common in infants, such as teratomas, ependymomas, and mixed tumors. Total removal is often possible, even with large lesions, because of the small amount of bleeding and the well-defined limits of the mass.

Paralysis of the deep branch of the radial nerve due of an entrapment neuropathy

The clinical and neurophysiological findings in two cases of spontaneous paralysis of the deep branch of the radial nerve are reported. The patients are sisters and the dominant hand was affected in both. One patient was submitted to surgical exploration, and 'entrapment neuropathy' was found to be the cause. After neurolysis the patient gained complete recovery. The usefulness of the EMG illustrated and stressed.

A simplified endoscopic third ventriculostomy under local anesthesia

The aim of this study is the analysis of our experience with awake endoscopic third ventriculostomy (ETVS) in hydrocephalic patients. From September 1994 to December 2001, 24 neuroendoscopic procedures were performed under local anesthesia. Local infiltration was administered using a bupivacaine and lidocaine mixture. Analgesics were titrated to the effect. A free-hand technique with a flexible endoscope was adopted in 24 patients with primitive and secondary (neoplastic) hydrocephalus. ETVS was performed successfully in all cases. No procedure needed to be discontinued due to seizures, bleeding or agitation. Dural incision/coagulation and Fogarty dilatation proved to be the most painful maneuvers requiring, sometimes, supplemental analgesic administration. No intraoperative complications were observed; however, two asymptomatic trajectory hematomas were incidentally discovered two and three days after the operation, respectively. Awake ETVS is a valuable alternative procedure that can be adopted in adult cooperative patients, provided that the procedure is done in an essential and fast way with the free-hand technique, by means of a flexible endoscope, and with the assistance of an anesthesiologist.

The CSF myelin basic protein in pediatric hydrocephalus

Concentrations of myelin basic protein (MBP) in ventricular and lumbar cerebrospinal fluid (CSF) of 20 pediatric hydrocephalic patients were reviewed. Raised values were found to be particularly significant in children aged more than 1 year. Control measurements after shunt placement showed an important drop in the MBP concentration, which could therefore be considered a marker for correct functioning of the shunt. The dosage of MBP could play a role in assessing the activity of an hydrocephalic process. Preliminary data gained from monitoring of MBP in the lumbar CSF in posthemorrhagic neonatal hydrocephalus could yield further criteria for indication of a shunt operation.

Immunobiology of paediatric intracranial tumours. A preliminary report

Preliminary findings in the evaluation of the immune response of children with primary neoplasms of the CNS, mainly medulloblastomas, are reported and discussed. A broad scheme for the monitoring of B- and T-cell-dependent immunity and of delayed hypersensitivity reactions in this type of patient is presented. The most important immunobiological findings are discussed. Special attention is given to the striking failure of the T-cell-dependent pool (currently identified by "active" RFC and blastigenesis tests) and to the remarkable decrease of hypersensitivity reactions (depressed skin-test response), both of which seem to be related to the degree of malignancy of the tumour. A very peculiar feature, i.e., the appearance of cells with natural cytotoxic activity, is dealt with in some detail. Our present knowledge concerning the immunobiology of primary CNS neoplasms is still very incomplete, but seems to suggest a possible role for immunotherapy in paediatric neurosurgery.

Multidisciplinary treatment of medulloblastoma: a 5-year experience with the SIOP trial

A 5-year experience of the multidisciplinary treatment of pediatric medulloblastoma with the SIOP (International Society of Pediatric Oncology) trial is presented. 33 eligible patients finally reduced to a total of 30 evaluative cases were treated with major surgical resection, extensive irradiation, and combined chemotherapy (vincristine + CCNU). The overall survival rate without recurrence was encouraging, and the actuarial survival rate is satisfactory. At follow-up controls, most of the patients showed a good performance status and a promising neurological stage. However, the problem concerning quality of life remains unsolved: morbidity and sequelae following high-dose radiotherapy and concomitant antiblastic treatment were noticeable.

Cyclic nucleotides in medulloblastomas: correlative study of tumoral and cerebrospinal fluid levels

The tumoral and cerebrospinal fluid (CSF) levels of cyclic nucleotides and of the main adrenergic metabolites (homovanillic acid and 5-hydroxyindoleacaetic acid) were investigated in a group of children with posterior fossa medulloblastomas. A longitudinal evaluation of CSF change of cyclic adenosine monophosphate (cAMP), cyclic guanosine monophosphate (cGMP), and adrenergic metabolites before and after surgical removal of the tumor mass is presented. Some preliminary patterns concerning correlative levels in the neoplastic tissue are discussed. The relevant increase of cGMP in medulloblastoma specimens and in CSF samples operation and the rapid decrease in the CSF after surgical removal of the tumor seem to suggest a possible role of cyclic nucleotides in the neoplastic growth of these tumors. (Neurosurgery, 7: 359-362, 1980).

Active singling out of shunt independence

The availability of telemetric devices for intracranial pressure (ICP) measurements in line with a multipurpose valve (MPV) was shown to be the ideal condition for safe investigation of the problem of shunt independence in 21 patients. After percutaneous closure of the shunt, all but 4 patients developed some degree of intracranial hypertension. The time lapse between blockade of the MPV and appearance of the morphology, in the tracing, that suggests ICP is different for each patient and could reflect individual conditions such as the residual pathways of CSF, ventricular size and compliance of the system.

Immunobiology of primary CNS tumors in infancy and childhood. B- and T-cell dependent immunity and cytotoxicity and cell kinetic evaluation

The authors report their experience on the immunological monitoring of children with posterior fossa medulloblastomas. The most important findings concerning humoral and cell-mediated immunity in this kind of patient are discussed. Among the main immunobiological pictures, the authors stress the remarkable failure of the T-cell dependent immune response, generally correlated to the degree of malignancy of the tumor, and the characteristic appearance of cells with natural cytotoxic activity, whose precise outlining is, at present, in progress. The B-cell dependent pool, mostly investigated through immunofluorescence studies, turned out to be very close to normal.

CSF levels of cyclic nucleotides in primary intracranial neoplasms: a preliminary report

Recent evidence indicates that cyclic nucleotides are of importance for general and neurosurgical oncology, especially with respect to the contact-inhibition mechanisms and tumour cell growth. This preliminary report deals with the CSF levels of c-AMP and c-GMP in primary neoplasms in children and to problems related to the blood-brain barrier. Some cases of medulloblastoma were studied as well as a few cases of brain stem glioma and cystic astrocytoma. The importance of some rather unusual findings seems undebatable, i.e., the marked increase in c-GMP values usually observed in medulloblastoma and the decrease of c-AMP, that is fairly common in all malignant neoplasms. The main changes in the c-AMP/c-GMP ratio are also discussed.

Stereotactic location and delimitation of brain tumors in children

Our preliminary experience with a method of localizing and delimiting brain tumors is reported. The borders of the neoplasm facing important functional areas are mapped with stereotactically injected non-spreading dyes. This procedure precedes craniotomy and provides the surgeon with safer landmarks when he resects deep-seated lesions.