Paravertebral high cervical chordoma. A case report

Spinal chordomas are more often located on the midline and are associated with marked destruction of the vertebral bodies. We report a rare case of large cervical (C2-C3) right lateral paravertebral chordoma extending into the spinal canal through a very enlarged intervertebral foramen. The tumor was initially diagnosed as a mucous adenocarcinoma on a percutaneous needle biopsy. However, the neuroradiological features, including the well-defined tumor margins, the regular and sclerosing lytic bone changes with regular enlargement of the intervertebral C2-C3 foramen, were in favor of a more slowly growing lesion, such as schwannoma or neurofibroma. At surgery a well-demarcated capsulated tumor involving the nerve root was partially resected. Histology was in favor of a low-grade chordoma (Ki-67/MIB-1<1%). Postoperative proton beam therapy was also performed. The differential neuroradiological diagnosis is discussed.

Early clinical and neuroradiological worsening after radiotherapy and concomitant temozolomide in patients with glioblastoma: tumour progression or radionecrosis?

OBJECTIVES

This study investigates the diagnosis and management of patients with resected brain glioblastomas who presented early clinical and neuroradiological worsening after the completion of the Stupp protocol. Its aim is to discuss the occurrence of early radionecrosis.

METHODS

Fifty patients with brain glioblastoma treated by surgical resection and Stupp protocol were reviewed; 15 among them (30%) had early clinical and neuroradiological worsening at the 6-month follow-up. The MR spectroscopy and surgical findings of these patients are reviewed.

RESULTS

MR spectroscopy was in favour of tumour recurrence in 14 among 15 patients and showed radionecrosis in one. Among 10 patients who were reoperated on, 7 had histologically verified tumour recurrence or regrowth, whereas in 3 histopathology showed necrosis without evidence of tumour. The 7 patients with tumour progression had prevalence of focal neuroradiological signs (6/7) and a survival of 7.5-12 months (median survival 10 months). The 4 patients with early radionecrosis (including one patient who was not reoperated on) had clinical worsening with mental deterioration, confusion and ataxia, and MR spectroscopy positive for tumour recurrence in 3. Three were alive 24-30 months after the end of the radiotherapy, whereas one died at 40 months.

CONCLUSION

Early radionecrosis after the Stupp protocol is not a rare event due to the radiosensitization effect of temozolomide. This phenomenon may predict a durable response to radiotherapy. MR spectroscopy may simulate tumour recurrence. A correct diagnosis is necessary to avoid useless reoperations and incorrect withdrawal of temozolomide.

Prognostic and survival-related factors in patients with well-differentiated oligodendrogliomas

Oligodendrogliomas are brain tumors with unpredictable biological and clinical behavior. Prognostic factors related to survival are still controversial. The present study reviews 50 patients with well-differentiated (WHO grade II) oligodendrogliomas, located in the cerebral hemispheres and operated upon between 1980 and 1998. Prognostic factors studied include patient's age and sex, tumor location and extent, preoperative KPS, and extent of the surgical resection. The Ki-67 and the proliferative cell nuclear antigen (PCNA) levels were studied in all patients and some growth factors (GFs), including vascular endothelial growth factor (VEGF), epidermal growth factor (EGF), platelet-derived growth factor (PDGF) and tenascine were examined in 20 patients. The long-term outcome and survival are not significantly correlated with the patient's age and sex, tumor location and extent, preoperative KPS and procedure for resection. Patients with lower Ki-67 and PCNA showed a significantly longer survival time (p < 0.001 and p < 0.019, respectively). Between 45 and 70 % of the tumors stained positive for one or more growth factors. Interestingly, cases with late recurrences (more than 4 years after surgery) and longer survival are significantly associated to negative GF expression or slight positivity, as compared with the variable and more often moderate immunoreactivity of cases with early anaplastic recurrences and shorter survival time. The presented data suggest that low proliferation indices and negative GF expression are associated with longer survival in well-differentiated oligodendrogliomas.

Microsurgical Repair of the Facial Nerve

OBJECTIVE

To report a series of 18 patients who underwent microsurgical repair of the facial nerve using different techniques and to discuss the indications and results of facial reinnervation procedures.

METHODS

Eighteen patients with post-surgical facial palsy underwent facial reinnervation using different techniques.'These included classic hypoglossal-facial anastomosis in 13 cases, one-stage hemihypoglossal-intratemporal facial nerve anastomosis and translabyrinthine removal of residual intra-canalar acoustic schwannoma in 3, hemihypoglossal-facial nerve anastomosis in one, and neurotization of facial muscles through a nerve graft in one.

RESULTS

The facial muscle function improved in all patients, up to grade III in 7 cases (39 %), grade IV in 9 (50 %) and grade V in 2 (11 %). The tongue atrophy was minimal in 70.5 %, moderate in 17.5 % and severe in 12 %. The outcome was better in younger patients (less than 40 years of age) and in those with a lesser grade of preoperative facial impairment.

CONCLUSIONS

The classic hypoglossal-facial anastomosis is the technique of choice in most cases. The use of the intratemporal facial nerve is indicated when removal of an intra-canalar residual schwannoma must also be performed. The neurotization of the facial muscles through a nerve graft may be used when there is no distal trunk of the facial nerve available for the anastomosis.

Cabergoline-induced CSF rhinorrhea in patients with macroprolactinoma. Report of three cases

induces the macroprolactinoma shrinkage. Endoscopic transsphenoidal surgery offers a safe, minimally invasive and efficient management of this complication, which allows to regularly perform the following steps of the therapeutical strategy against the prolactinoma.

Endoscopic endonasal transsphenoidal surgery in recurrent and residual pituitary adenomas: technical note

Despite a good cure rate after surgery, the recurrence rate in pituitary adenomas is globally high. The decision making in such cases can be problematic for the nature of the lesion, for the anatomic structures involved, for the different pharmacological, surgical, radiotherapeutic and radiosurgical options nowadays available. In the perspective of an improvement and refinement of the surgical procedure an endoscopic endonasal transsphenoidal approach to the pituitary was recently adopted in the Neurosurgical Department of the University of Naples. Its minimal invasiveness and its wider and direct anatomic control of the operative field has allowed a faster, greater and safer potential of tumour excision, with respect of the sphenoid, sellar and parasellar structures. The authors have examined the advantages provided by this technique in 12 patients with recurrent pituitary adenomas and in 2 craniopharyngiomas already treated via a transnasal transsphenoidal approach (TTA), where the anatomy of surgical field had been distorted by the first operation or the radiation therapy. They conclude that the endoscopic transsphenoidal re-operation might be considered the procedure of choice in case of recurrences and its easiness in such conditions could favour its larger use, before other more aggressive therapeutic solutions.

Percutaneous retrogasserian glycerol rhizolysis for treatment of trigeminal neuralgia. Technique and results in 191 patients

Percutaneous retrogasserian glycerol rhizolysis (PRGR) became a diffuse and valuable method for treatment of trigeminal neuralgia, following its introduction by Hakanson in 1981. Its main advantages are: a) mild postoperative facial sensory loss, b) simplification of the technique, c) reduction of costs. Our results in a series of 191 patients treated between September 1983 and September 1990 are reported. The procedure was performed according to Hakanson's method with minor modifications. In 11 cases (5.7%) we failed to pierce the foramen ovale; the procedure was successfully repeated a week or two later. In 17 cases it was impossible to obtain CSF from the needle. Complete relief of pain was achieved in 177 patients (92.7%), in 124 (64.9%) immediately, in 53 (27.8%) within 6 days; the operation was unsuccessful in 14 (7.3%). Postoperative sensory evaluation showed: no sensory loss in 33 cases (17.3%); hypalgesia in 8 (4.2%); mild hypesthesia in 88 cases (46.1%), confined to the affected divisions in 45 (23.6%), exceeding it in 43 (22.5%); moderate hypesthesia in 62 cases (32.4%), restricted to the target divisions in 36 (18.8%), exceeding them in 26 (13.6%). No case of anesthesia occurred. Complications of PRGR were: circum-oral ipsilateral herpetic eruption (herpes simplex type), spontaneously and completely regressing: 63 cases (33%); minor dysesthesia, seldom reported as painful: 33 cases (17.3%); impairment of corneal reflex: 19 cases (9.9%), the first branch being the target of the treatment in 11; regressive masticatory weakness; 11 patients (5.7%); aseptic meningitis, promptly regressed: 2 cases (1.0%). Follow-up ranges from 1 to 7 years (Sept. 1983-Sept. 1990). A recurrence was observed in 44 cases (23%): in 15 patients (7.8%) a partial relapse occurred, well controlled by drug therapy and not requiring further surgical treatment; in 29 cases (15.2%) a new percutaneous procedure was required. The mean time of recurrence was 30.5 months. The recurrence rate in the patients of our series at the end of the follow-up period was 23%. Glycerol produces a weak neurolytic lesion, that generates minor post-operative facial deafferentation; it is the best technique, in our opinion, for treatment of tic douloreux.

[The role of the blood viscosity and hematocrit value in acute stroke. Experimental considerations]

The link between blood viscosity, Ht and the onset of stroke is highlighted and reports in the literature are examined. On this basic, the paper proposes an experimental model of cerebral ischaemia in the rabbit as providing a better insight into this aspect which may be highly significant, particularly in the prevention of strokes.

Subarachnoid hemorrhage and "normal pressure hydrocephalus": fatal complication of percutaneous microcompression of the gasserian ganglion. Case report

A 62-year-old man underwent percutaneous balloon catheter compression of the gasserian ganglion for typical trigeminal neuralgia. After this, a subarachnoid hemorrhage was discovered and normal pressure hydrocephalus developed, which required shunting. Although the neurological function recovered, the patient died 8 months later because of supervening hepatic insufficiency, probably caused by protracted antibiotic therapy. Such a fatal complication, the first one associated with the technique of percutaneous trigeminal compression, was perhaps predisposed by preexistent cerebral atrophy with enlargement of the subarachnoid spaces; the unforeseen piercing of the dilated trigeminal cistern probably permitted the intracranial subarachnoid diffusion of an otherwise trivial hemorrhage. The safety of the procedure may be greatly reduced in such instances.

Percutaneous retrogasserian glycerol rhizolysis. Observations and results about 50 cases

Fifty patients complaining of trigeminal neuralgia have been treated by Percutaneous Retrogasserian Glycerol Rhizotomy (PRGR) from September 1983 to December 1985. In 94% of cases the procedure was successful in relieving pain with minor facial sensory loss, in 29 cases confined to the affected divisions, in 13 cases extending in an adjacent division. A herpes eruption occurred in 39 patients. A partial relapse (not requiring re-operation) verified in 12 patients. Even it firm conclusions cannot be reached as to the efficacy of this therapy, till when longer duration follow-up studies will not available, it seems to offer a manageable and very efficient way of treating trigeminal pain, constituting a valid alternative to other percutaneous techniques of trigeminal rhizolysis.