Long-term safety and efficacy of autologous platelet lysate drops for treatment of ocular GvHD

Current ocular GvHD (oGvHD) treatments are suboptimal. We investigated the safety and efficacy of long-term continuous treatment with autologous platelet lysate (PL) drops in patients with oGvHD Dry Eye Syndrome (DES) score 2-3 refractory to topical conventional therapy. Ophthalmic evaluation was performed at 6 month intervals. Symptoms were assessed using the Glaucoma Symptom Scale (GSS). Patients were defined 'responders' when showing a reduction at least one grade on National Institutes of Health Eye Score from baseline at the 6 month visit. Thirty-one patients were included, and 16 (51%) completed 36 months of follow-up (range 6.5-72.7). At 6 months all patients were classified as responders: median GSS symptom score decreased from 70 to 41 (33 at 36 months), median GSS function score reduced from 68 to 46 (33 at 36 months) (all P<0.001). Median Tear Break Up Time improved from 3 to 6 s after 6 months and was maintained over time. All signs improved at 6 and 36 months (clinical and statistical significance). No severe adverse events occurred. Long-term treatment with PL drops is secure and effective for oGvHD and can be an efficient therapy option from initial stages of oGvHD to prevent permanent ocular impairment and improving quality of life.

Ocular impairment of toxoplasmosis

The purpose of this review is to update the latest information about ocular toxoplasmosis. The infection can be congenital or acquired, but also depends about the immune condition of the patient and can affect the eye. Ocular symptoms are variable according to the age of the subject. Retinochoroiditis is the most common manifestation of toxoplasmic infection. Toxoplasmic retinochoroiditis typically affects the posterior pole, and the lesions can be solitary or multiple. Active lesions present as grey-white focus of retinal necrosis with adjacent choroiditis, vasculitis, hemorrhage and vitreitis. Anterior uveitis is a common finding. Atypical presentations include punctate outer retinitis, neuroretinitis and papillitis. Depending on the patient's age and the localization of the lesion, ocular symptoms vary usually presenting with reduced visual acuity or without symptoms. The laboratory diagnosis of toxoplasmosis is based on detection of antibodies and T. gondii DNA using polymerase chain reaction (PCR) which fulfillis clinical findings. Toxoplasmosis therapy includes antimicrobial drugs and corticosteroids. There are several regimens with different drug combinations including, among others, pyrimethamine, sulfadiazine, clindamycin, and trimethoprim-sulfamethoxazol.

Endoscopic approach for the treatment of relapses in cystic craniopharyngiomas

INTRODUCTION

Craniopharyngiomas are tumours of the central nervous system of dysontogenetic origin. They are most commonly localized in the sellar region and appear to originate from an embryogenetic defect of the Rathke cleft. It is universally accepted that radical surgery should be performed as first surgery because surgery after relapses usually causes more difficulty due to tighter adhesion to surrounding structures. It is essential when relapses occur to evaluate which technique to use for treatment. For this reason, any new approach is welcomed in order to have as many alternatives as possible.

MATERIAL AND METHODS

In this paper we present the treatment, with a minimum follow-up of 4 years, of 5 paediatric patients affected by cystic craniopharyngiomas who went through first traditional surgery in other institutions and suffered relapses in various anatomical structures. One had a second successful endoscopic attempt at total gross resection. In 3 cases we endoscopically implanted a stent in the cystic cavity draining the cystic liquid out from the cystic cavity of the craniopharyngioma to the sphenoid sinus in order to form an accessory sinus. In 1 case a multiphase treatment has been undertaken.

RESULTS

All patients treated using a transsphenoidal endoscopic approach are still living, without relapses and no postoperative complications. In particular, there where no episodes of vasospasm (a common complication reported in the literature when the "motor oil" comes into contact with the subarachnoid space) or infections. The patient treated using the multiphase approach recovered but suffered a recurrence 2 years later due to hypothalamic infiltration.

DISCUSSION AND CONCLUSIONS

Craniopharyngioma relapse needs different treatments. Many alternative approaches have been reported but none of them is the first choice alternative. We believe endoscopic stent placement in the cystic cavity is an alternative method for the treatment of cystic relapses.

True 3D reconstruction for planning of surgery on malformed skulls

OBJECTIVES

Since the difficulty associated with surgical planning of craniosynostosis is mostly due to the inadequate possibilities for simulation of surgery, a new technique for constructing a precise reproduction of a patient's malformed skull has been developed.

MATERIALS AND METHODS

CT scans of ten malformed skulls on a scale of 1:1 and with 1-mm slices have been used to reconstruct the skulls in a special resin using a special lathe used in the automobile construction industry for formula one engines. This lathe works in the opposite way to other lathes: by apposition of material instead of subtraction.

RESULTS

The anatomical detail of the phantom is of a very high degree. The surgical planning it allows has proved highly consistent with reality in all cases in which it has been used in the planning before the operation.

DISCUSSION AND CONCLUSIONS

This technique has made it possible to plan the surgical treatment of all patients with craniosynostosis in a highly satisfactory way. It has reduced operating times, in addition to which it provides information on materials needed, avoiding waste, and is also an excellent teaching method for residents.

Evolution of childhood central diabetes insipidus into panhypopituitarism with a large hypothalamic mass: is 'lymphocytic infundibuloneurohypophysitis' in children a different entity?

We report on a 15-year-old girl who had presented with acute onset central diabetes insipidus at the age of 8 years; this was followed by growth failure due to acquired growth hormone deficiency. Initial magnetic resonance imaging showed a uniformly enlarged pituitary stalk and absence of posterior pituitary hyperintensity. Frequent patient examination and magnetic resonance imaging gave unchanged results until after 5 years a large hypothalamic mass and panhypopituitarism were found. Dynamic magnetic resonance imaging documented hypothalamic-pituitary vasculopathy. Histopathological examination revealed perivascular inflammatory lymphoplasmic infiltrates with no granulomatosis or necrosis and negative staining for S-100 protein, suggesting autoimmune inflammatory disease (lymphocytic infundibuloneurohypophysitis?). The response to glucocorticoid pulses (30 mg/kg per day for 3 days i.v.) was favorable. the hypothalamic mass being halved and partial anterior pituitary function recovery maintained for 2 years after the start of treatment. We suggest that long-term surveillance is needed for isolated and chronic thickening of the pituitary stalk and that dynamic magnetic resonance imaging can contribute to the demonstration of hypothalamic-pituitary vascular impairment associated with local vasculitis.

Basal ganglia precursors found in aggregates following embryonic transplantation adopt a striatal phenotype in heterotopic locations

Transplantation of immature CNS-derived cells into the developing brain is a powerful approach to investigate the factors that regulate neuronal position and phenotype. CNS progenitor cells dissociated from the embryonic striatum and implanted into the brain of embryos of the same species generate cells that reaggregate to form easily recognizable structures that we previously called clusters and cells that disperse and integrate as single cells into the host brain. We sought to determine if the neurons in the clusters differentiate according to their final location or acquire a striatal phenotype in heterotopic positions. We transplanted dissociated cells from the E14 rat medial and lateral ganglionic eminences, either combined or in isolation, into the E16 embryonic rat brain. At all time points, we found clusters of BrdU- and DiI-labelled donor cells located in the forebrain and hindbrain, without any apparent preference for striatum. Immunocytochemical analyses revealed that cells in the clusters expressed DARPP-32 and ARPP-21, two antigens typically co-expressed in striatal medium-sized spiny neurons. In agreement with observations previously noted by several groups, isolated cells integrated into heterologous host areas do not express basal ganglia phenotypes. These data imply that immature striatal neuronal progenitors exert a community effect on each other that is permissive and/or instructive for development of a striatal phenotype in heterotopic locations.

[Neuropsychic development in children born with spina bifida]

The authors present the outcome of 42 patients operated at birth for closure of the spinal malformation. The age of patients at first observation ranged from 3 months to 21 years (mean 8.3 years); 7 patients (16.7%) had a close spina bifida, 35 (83.3%) had an open spina bifida and 30 (85.7%) of them developed hydrocephalus. The protocol included neurological evaluation, determination of development quotient using the Griffith's scale and intelligence quotient using the Wise-R scale. Adolescents underwent also the Blacky pictures test and Offer's interview. Verticalization and tutorial deambulation were achieved in 95.2% of patients; 76% of patients had a I.Q. > 90. The emotional situation was unsatisfactory in the majority of patients due to reduced autonomy and limited self-consideration.

CNS-85 trial: a cooperative pediatric CNS tumor study--results of treatment of medulloblastoma patients

Between 1985 and 1989, 38 children with newly diagnosed medulloblastoma entered our therapeutic protocol. After surgery and postoperative staging assessments, patients were assigned to risk groups. Eleven with "standard-risk" (SR) tumors were treated with radiation therapy alone, while 27 with "high-risk" (HR) tumors received radiation therapy plus adjuvant chemotherapy with vincristine, methotrexate, VM-26, and 1-(2-chloroethyl)-3-cyclohexyl-1-nitrosourea (CCNU). After a minimum follow-up of 5 years (range 5-9 years) 21/38 children had developed a recurrence or progression of their disease and 19/38 patients had died. Five-year event-free survival rates and 5-year total survival rates for all 38 patients were 47.4% and 50% respectively. The event-free survival rates at 5 years for SR and HR patients separately were 27.3% and 55.6%, respectively. The corresponding 5-year total survival rates were 27.3% and 59.3%. The differences were not statistically significant. Univariate analysis showed age at diagnosis to be the most important prognostic factor. Infants aged 5 years or less had a significantly shorter event-free survival time than older patients (P = 0.00897). Similar effects were found when total survival time was considered. There were significant differences in outcome in patients receiving different doses of radiation, suggesting a dose-response relationship. A Cox stepwise multivariate analysis showed age at diagnosis as the only independent prognostic factor. Variables relating to treatment entered the model, suggesting that chemotherapy could play an important role in determining outcome.

Effects of vitamin D and retinoic acid on human glioblastoma cell lines

The biological significance of vitamin D receptors expressed by glioblastoma and other glial tumours is still unclear. In an effort to clarify this issue we studied the effects of increasing concentrations of 25-dihydroxyvitamin D3 and its metabolite 1 alpha,25-dihydroxyvitamin D3 on two human glioblastoma cell lines. Both substances were capable of inducing a significant (> 50%) reduction in growth of the two glioblastoma cell lines at dosages over 5 microM. When the HU 70 cell line was treated by increasing dilutions of 25-dihydroxyvitamin D3 combined with 1 microM all trans-retinoic acid, significant inhibition was apparent even after addition of 25-dihydroxyvitamin D3 in the nanomolar range. Reduction of growth index was mainly due to induced cell death. Our results provide in vitro evidence that vitamin D metabolites alone or in combination with retinoids may be potentially useful agents in the differentiation therapy of human malignant gliomas.

In vivo enhanced antitumor activity of carmustine [N,N'-bis(2-chloroethyl)-N-nitrosourea] by simvastatin

The effects of a combination of simvastatin, a cholesterol-lowering agent, and carmustine (BCNU; N,N'-bis(2-chloroethyl)-N-nitrosourea) on experimental C6 glioma were studied in vitro and in vivo. In vitro simvastatin and BCNU alone inhibited cell proliferation in a dose-dependent fashion. A subliminal concentration of simvastatin (0.1 microM) markedly and synergistically increased the BCNU toxicity to C6 glioma cells. The cytofluorimetric analysis of DNA from simvastatin-treated C6 glioma cells showed, besides the already described arrest in G1, an arrest/retardation in G2-M. Mitotic index from C6 cells incubated with simvastatin (10 microM) decreased by about 90%, indicating a specific C6 arrest/retardation in G2. The drug effects could be completely reversed by simvastatin withdrawal or mevalonate addition to the cultured cells. The combination of simvastatin and BCNU resulted predominantly from the profound retardation of cells in the G2-M compartment of the cell cycle. In vivo simvastatin (administered daily mixed with food) and BCNU (single i.p. injection), when given separately, caused a dose-dependent inhibition of labeling index in C6 glioma homografts (ID50, 61 mg/kg/day and 8.7 mg/kg, respectively). The combination of the lowest doses tested (simvastatin, 25 mg/kg/day and BCNU 0.3 mg/kg) resulted in a significant growth delay (compared to either drug alone) in C6 glioma (P < 0.05). There was no significant increase in toxicity as assessed by myelosuppression (WBC counts and bone marrow labeling index) and body weight. The results provide in vivo support for the combined use of simvastatin, a cholesterol-lowering agent, and BCNU in brain tumor treatment.

A short term analysis of the behaviour of conditionally immortalized neuronal progenitors and primary neuroepithelial cells implanted into the fetal rat brain

Conditionally immortalized (temperature-sensitive) striatal-derived neuronal progenitor cell lines and primary neuroepithelial cells were transplanted into the CNS of gestational day 15-16 rat fetuses using an 'in utero' surgical procedure. Each fetus received 2.5-3 x 10(4) donor cells previously labelled in vitro by incubation with 5-bromo-2'-deoxyuridine (BrdU). At 5 days following transplantation, 69% of the fetuses were still alive. Engrafted cells were detected by BrdU immunohistochemistry, and the appearance of the engrafted cells and the time course of Nestin and PCNA expression were measured at 6, 24, 64 h and 5 days after transplantation. The evolution of Large T-Antigen immunoreactivity in engrafted temperature-sensitive (ts) cells was also evaluated at the above time intervals. The results indicate that the majority of the implanted cells were aggregated into clusters 24 h after transplantation. These clusters were not visible at 6 h, when most of the cells were isolated. The clusters were located in both the ventricles and parenchyma. These findings were common to both ts cells and striatal primary neuroepithelial cells. At 64 h and 5 days, isolated cells associated with the germinal layer and scattered throughout the parenchyma were also found. In the clusters, Nestin expression decreased proportionally with time following transplantation. Furthermore, Large T-Antigen immunoreactivity disappeared from ts cells between 6 and 24 h after transplantation. Finally, measurements of the temporal evolution of PCNA expression within the clusters indicate a progressive reduction in the mitotic activity of the transplanted cells. The results demonstrate that striatal primary neuroepithelial cells and conditionally immortalized neuronal progenitors can survive, migrate and/or compartimentalize into clusters whilst changing their antigenic properties and ability to proliferate.

Choroid plexus carcinoma: report of one case with favourable response to treatment

Choroid plexus carcinoma (CPC) is a rare tumor with usually severe prognosis, whose optimal treatment has not yet been established. The exact role of complete surgical resection, chemotherapy, and radiotherapy has been debated but not clarified. We report one girl with CPC diagnosed at age 3 months and apparently cured with minimal surgical resection, chemotherapy, and delayed irradiation. At the age of 8 years, she is well, with minor psychomotor retardation and growth hormone deficiency as the only sequelae.

Altered membrane lipid composition in a human meningosarcoma

In a sample of meningosarcoma, obtained at the time of surgery, the amount of total gangliosides and phospholipids was examined, together with the cholesterol content and the distribution of different ganglioside and phospholipid species. The phosphatidylinositol, phosphatidylinositol-4-phosphate, phosphatidylinositol-4, 5-bisphosphate and phosphatidylcholine fatty acid composition was also analyzed. The ganglioside pattern in the meningosarcoma was different from the previously reported pattern in meningiomas of different histological origin, showing a higher concentration of GD3, indicating that the so-called b pathway of ganglioside biosynthesis was the preferred one in this type of tumor; moreover the percentage content of polysialylated gangliosides was very low. Cholesterol and phospholipid content was lower than in meningiomas; the phosphatidylcholine increase and the sphingomyelin decrease would indicate a lower membrane microviscosity, a characteristic of tumor cells. Phosphoinositide and phosphatidylcholine fatty acid analysis revealed a considerable amount of docosahexaenoic acid. This abnormal presence of this fatty acid could lead to the production, after receptor stimulation, of a diacylglycerol containing docosahexaenoic acid, which, in turn, could be responsible for an altered activation pattern of protein kinase C, in this way promoting carcinogenesis.

Brain tumours in infants. Preferred treatment options

Since the advent of CT scan and MRI, the diagnosis of neonatal infantile brain tumours and related diseases is more easily accomplished; their rarity is reflected in the small number of cases reported. Astrocytomas and teratomas are the most common oncotypes in infants and particularly in neonates. Surgical mortality rates are not high and have decreased because of the advances of diagnosis and improvements in treatment. However, the survival rates are disappointing. Follow-up shows little improvement in last 2 decades. Adjuvant therapy is still a problem; radiotherapy gives a small percentage of favourable later neuropsychological results. Postoperative chemotherapy added to maximal surgical resection and delayed irradiation may prolong survival with only minimal short term neurotoxicity in very young children with malignant tumours. Different protocols of chemotherapy are suggested but still not definitely accepted. Radical surgery seems to have a higher chance of success in neonates than infants and remains the less aggressive means; in low grade gliomas after total removal it may be preferable to perform a second operation if the tumour recurs and withhold irradiation and chemotherapy until after 3 years of age.

Medullomyoblastoma: report of two cases

Two cases of medullomyoblastoma in children are described. The muscular component showed different features in the two cases and were associated with neuronal differentiation. Morphological, immunohistochemical, and electron microscopical findings are presented. The origin of the muscular component is discussed in relation to the findings in other cases of the literature. Both differentiation from primitive neuroepithelial cells and derivation from ectomesenchyme are considered.

Correlation between magnetic resonance imaging of posterior pituitary and neurohypophyseal function in children with diabetes insipidus

The posterior pituitary lobe and stalk were studied by magnetic resonance imaging in 20 children with diabetes insipidus of different origins: primary familial autosomal dominant (n = 2) or idiopathic (n = 2), and secondary to craniopharyngioma (n = 6, resected in 5), to Langerhans cell histiocytosis (n = 5), to excessive water intake (dipsogenic; n = 3), to renal vasopressin insensitivity (n = 1), and to osmoreceptor dysfunction (n = 1). Of the four children with primary diabetes insipidus, the posterior bright signal was recognizable in two with the familial autosomal dominant form and one with the idiopathic form; in the latter, the pituitary stalk was thin, while it was normal in the first two patients; no posterior hyperintense signal with enlarged and gadolinium-enhanced pituitary stalk was observed in the fourth. The posterior hyperintense signal was absent without evidence of ectopic posterior pituitary tissue regeneration in five children with surgically removed craniopharyngioma and was doubtful in the child with unresected craniopharyngioma; the stalk was unrecognizable in all patients. In the five children with Langherans cell histiocytosis, the posterior bright signal was absent, while the stalk was normal in two and unexpectedly enlarged in three (uniformly in two and mainly at the level of median eminence and hypothalamus in one). All five patients with dipsogenic or nephrogenic diabetes insipidus or osmoreceptor dysfunction had normal images of posterior pituitary lobe and stalk. Normal posterior pituitary bright signal and stalk were found in all 25 healthy control children. Plasma vasopressin was undetectable in all patients except in nephrogenic one, in the child with osmoreceptor dysfunction, and in two of three dipsogenic children, the third mimicking partial neurogenic diabetes insipidus.(ABSTRACT TRUNCATED AT 400 WORDS)

Surgical treatment of craniosynostosis

The authors report their experience with the cranial recontouring techniques in the treatment of craniosynostoses. The results obtained treating sixteen children suggest that these techniques can be tolerated well by patients, with very limited postoperative complications. It is underlined that the precocity of the surgical treatment is an indispensable prerequisite in order to obtain satisfactory clinical and cosmetic results.

Shunt in high-risk newborns

Twenty-four high-risk newborns with a low birth weight developed progressive hydrocephalus and underwent ventriculoperitoneal shunting (at the time of shunting they weighed 1,100-1,900 g, mean 1,541 g). The changes in hydrocephalus after shunting were determined by ultrasound examinations; preoperative examination was by CT. Of the factors evaluated for their relationship to shunt complication, we considered in particular babies with a CSF protein level of over 1.5 g/l (7 cases). These cases were treated with external drainage and later with ventriculoperitoneal shunting. Shunt infections occurred in 20.9%, in contrast with a low incidence of shunt blockage (8.3%), probably owing to previous external shunting in children with high CSF protein. There were 2 deaths (8.3%). All children underwent careful follow-up during the 1st year and serial checkups subsequently for 5 years.

Arachnoid cysts: diagnosis and treatment

Twenty supratentorial and 10 infratentorial arachnoid cysts are reported. The patients were from 0 to 15 years of age. The commonest presenting symptoms in children were cranial enlargement, epileptic seizures, and psychomotor retardation. Neuroradiological evaluation included CT, metrizamide CT, cisternography, and angiography. Echography was performed in 5 newborns. Therapeutic criteria according to the clinical and neuroradiological findings are reviewed. Cystoperitoneal shunting in combination with ventriculoperitoneal shunting for associated hydrocephalus is considered the treatment of choice.

[Intracranial aneurysms and subarachnoid hemorrhage in children and adolescents]

42 cases concerning symptomatic intracranial circulation aneurysms and spontaneous SAH have been observed by the authors during the period 1965-1984; 37 of them were treated from 1970 on. This group represents 2.6% in the number of patients treated for SAH during the above mentioned period in the series of Pavia and Verona Neurosurgery. In 7 cases angiography did not evidence any malformation responsible for the hemorrhage. These cases have been defined as "sine materia" SAH. In 33 cases was documented the presence of an intracranial aneurysm as responsible for the hemorrhage. In the 2 remaining cases was found an aneurysm that even if unbroken had manifested itself. In 4 cases aneurysms were mycotic ones. The most frequent sites of aneurysms have been the carotid artery bifurcation and the middle cerebral artery 24% each one followed by the anterior communicating artery 21%. 5 patients were younger than 4 years and each one had peculiar clinical features. The 37 remaining patients were older than 9 years and have been subdivided in 2 groups: 16 patients from 9 to 15 years old in who the most common site of the aneurysm was the carotid artery bifurcation and the middle cerebral artery (31%) and the frequency of intracerebral hematoma was 50%; 21 patients from 16 to 20 years old in who the most common site of the aneurysm was the anterior communicating artery (33%) and the presence of an intracerebral hematoma was markedly inferior (14%). 23 of the 35 patients having an aneurysm underwent a surgical procedure for its exclusion. Operative mortality rate was nearly 5% and morbidity rate was nearly 12%. 5 patients who were in agony when admitted were not operated; 5 patients had a conservative therapy and in 2 of them an angiography performed at distance from the hemorrhage revealed the disappearance of the aneurysm. Clinical disturbances bound to ischemic phenomenons by cerebral vasospasm were observed in only 3 patients--all of them older than 17--in who a CT scan had showed a conspicuous cisternal blood suffusion. In 13% of cases appeared hydrocephalus and only in 3 cases was necessary to perform a shunt. The global results of therapy have been significantly better than in adults having 74% of good results and 19% of deaths. This prognostic improvement is probably due both to the well known recovery from neurological failure in young patients and to the very low incidence of ischemic manifestations from vasospasm in this range of age.

Glial fibrillary acidic protein and vimentin in the experimental glial reaction of the rat brain

Glial reaction has been studied in the rat by the immunohistochemical demonstration of glial fibrillary acidic protein (GFAP) and vimentin (VIM) in two experimental conditions. The first was represented by a necrotic cerebral lesion obtained by laser irradiation and the second by the development of experimental tumors induced by transplacental ethylnitrosourea. Reactive astrocytes develop not only in the proximity of the lesion but also distant from it. The intensity of the glial response seems to depend upon the normal distribution of astrocytes and the perilesional edema. GFAP decorates all the reactive astrocytes, whereas VIM is positive only in those at the edges of the lesion. The significance of the different responses in the two models and between the two intermediate filaments is discussed.

Selected ion monitoring technique for the evaluation of sterols in cerebrospinal fluid: a new approach to desmosterol test for central nervous system tumors

The desmosterol test for the diagnosis of central nervous system (CNS) tumors is proposed in a simplified form. The procedure is based upon the analysis of sterol profile in cerebrospinal fluid (CSF) by selected ion monitoring (SIM) technique. Applied to 55 patients with tumoral and non tumoral CNS disease, the new test detects average levels of CSF desmosterol in tumor bearing patients that are tenfold higher than in the absence of CNS neoplasia. On an individual basis, a concentration of CSF desmosterol equal to or higher than the mean plus twice the standard deviation for the reference group of patients with no CNS tumor, is considered a positive result. Based on this criterion, a correct diagnosis was made in 73% of cases vs 77% of the former test, which required a 5-day treatment period with a desmosterol-reductase inhibitor in order to increase CSF desmosterol concentration. With this revised procedure CSF desmosterol can be detected in smaller volumes of CSF without any drug pretreatment, thus making the test more suitable for clinical application.

Late post-traumatic headache in pediatric age

In this study we evaluate the incidence and clinical characteristics of headache which arise 12-18 months after a cranial trauma in a pediatric age group of subjects. We contacted 217 individuals who had been hospitalized for head injury to return for check-up; of the 138 who responded, there were 86 males and 52 females (mean 9.2 years). The responders were given a complete physical and neurological examination and, in the presence of at least one parent, asked to fill out a headache questionnaire. Twenty-nine per cent suffered from headache, and in 6.5% the headache was migrainous in nature. The 138 patients were split up into three sub-classes in accordance with the nature of the trauma and two sub-classes in accordance with the presence or absence of fractures. The results were then compared with those obtained from a control population (246 patients with a mean age of 8.8 years). An increased headache frequency was found in those patients with average to severe trauma. We conclude that cranial trauma is not likely to be followed by headache unless accompanied by loss of consciousness and/or focal neurological signs.

Growing skull fractures of childhood. Case report and review of 132 cases

Authors report a case of growing skull fracture, unusual complication of linear skull fracture in infancy and childhood. A review of 132 cases reported in literature is done with an analysis of general characteristics of this lesion. The most common localization is parietal (50%); clinical presentation is represented by development of seizures (54 cases), focal neurological deficit (57 cases) or loss of consciousness (50 cases). In 50% of cases interval time between head injury and first symptom varies between 1 day and 1 year. After the first year of age the 34.4% of patients develop seizures and 59% present loss of consciousness. Among patients from 1 day to 6 months of age, 46% develop seizures, 38% focal neurological deficit and 21% loss of consciousness. Asymptomatic presentation is more common in fronto-parietal or fronto-parieto-occipital localizations. In parieto-occipital and occipital localization (30 cases), 13 patients (43.3%) have seizures, 36.7% a focal neurological deficit and 60% loss of consciousness. In parieto-temporal localization there is a higher probability of seizures (62.5%) and loss of consciousness (62.5%). The long-term follow-up and the functional recovery in patients which undergo surgery is linked to the clinical presentation and early diagnosis.

Rectal extrusion of the catheter and air ventriculography following bowel perforation in ventriculo-peritoneal shunt

Ventriculo-peritoneal shunt is frequently carried out in infantile hydrocephalus. The peritoneal shunt has a lower morbidity than ventriculo-atrial shunts and severe complications are uncommon. Abdominal complications include intestinal perforation, shunt migration, inguinal hernia, cerebrospinal fluid pseudocysts and hollow viscus perforation. A few cases of catheter extrusion from the rectum, vagina, umbilicus and urethra have been described. We report a new case of intestinal perforation with rectal extrusion of the catheter associated with a ventriculogram.

Outcome following acute supratentorial subdural hematoma in pediatric age

The authors report their experience in surgical treatment of 39 cases of acute subdural hematoma, followed by intensive therapy and physiokinesitherapy. The causes of head injuries, types of fractures, localization of the hematomas, concomitant lesions, diagnostic and therapeutic clinical features are discussed. The most common neurological evaluation scales for rating the state of comas are used for comparing the cases of head injury in adults (Glasgow Coma Scale) and in children (Children's Coma Scale). The Authors also report clinical follow-up, morbidity, and general mortality rate. Moreover, they emphasize the frequency and clinical importance of cases with unapparent symptomatology and demonstrate that extrinsic eye movement is a very important factor for prognostic evaluation.

[Surgery of brain tumors in childhood]

The Author analyze incidence, localizations and the great variety of hystopathological specimen of brain tumors in infancy and childhood. Clinical and surgical problems expecially derive from growth and development of infant. Medulloblastoma is the most common tumor of posterior fossa. Between supratentorial tumors gliomas and intraventricular neoplasms are the most commonly found at the operation; more rare tumors of the skull and cranial basis. The importance of pre-operative ventricular shunt in case of posterior fossa tumors and the cases of high- dimensioned supratentorial tumors with little symptoms are discussed.

[Chemotherapy of malignant brain tumors in childhood]

The best conventional care for medulloblastoma and malignant ependymoma in children consists of surgery and radiotherapy. The preliminary observations of some authors suggested that chemotherapy could be useful in treating these tumors. The two major experiences in this field are those from SIOP and CCSG -RTOG trials which used chemotherapy as adjuvant to surgery and radiotherapy. In such studies chemotherapy appears to be effective mostly in high-risk patients. A study performed by Italian Child's Neurooncology Group ( ICNG ) confirms the preceding results.

[Markers of brain tumors]

Biological markers of tumors are compounds or enzymatic activities measurable in body fluids. Their presence or concentration must be linked to tumoral growth. The markers of the central nervous system tumors are detected in CSF. Alpha-feto-protein, carcinoembryonic antigen, human chorionic gonadotropin, adenohypophyseal peptide hormones, enzymes, etc., have found some application in the early diagnosis of leptomeningeal metastasis. Other applications involve the early detection and recurrency of primary brain tumors, as well as the evaluation of efficacy of their therapy. The tests based on the CSF content of desmosterol and polyamines have been studied extensively. Their rationale is discussed and specificity, sensitivity, efficiency and predictive value are considered. Experimental results concerning a new possible biochemical marker, based on CSF concentration of cyclic adenosine monophosphate, are reported.

Extradural spinal lipomas. Report of two cases and review of the literature

The authors present two cases of extradural spinal lipomas causing spinal cord compression, not associated with spinal dysraphism. Sixty-nine cases of such tumours have been reported in the literature. It is important to distinguish between two histological types of these neoplasms: angiolipoma and true lipoma. They have a different distribution in relation to age and site of occurrence. The outcome can be quite variable considering the greater surgical problems that true lipomas can cause.

Diagnosis and treatment of post-traumatic hydrocephalus

From August 1972 to December 1980, 36 patients were operated on at the Neurosurgical Clinic of the University of Pavia for post-traumatic hydrocephalus. The materials and methods for making a correct diagnosis of post-traumatic hydrocephalus and for follow-up assessment are discussed. Of our patients who were surgically treated 45% improved, 22% remained unchanged, 22% died and we have no follow-up data on the remaining 11%. Comparisons are made with data from the literature regarding the immediate and long-term results.

Dense dermoids in craniocervical region

Computed tomography of dermoids and epidermoids usually demonstrates areas of variable hypodensity, located most frequently in the sellar region and in the cerebellopontine angle. This report presents two cases of hyperdense dermoids of the craniocervical region which are compared with six other cases described in the literature.

Cyclic nucleotides in experimental and human brain tumors

It is well known that the system of cyclic nucleotides plays an important role in cell differentiation and proliferation. Cyclic AMP is capable of stimulating cell growth, and cyclic GMP is thought to control cell division and growth. The authors measured adenylcyclase activity (AC) and cGMP content in the tumor latency period and in early neoplastic proliferations in rats with brain tumors induced by transplacental ethylnitrosourea (ENU). AC activity, which is high during the first days of life, decreases until it reaches, at the 60th day, levels lower than those in control animals. Cyclic GMP, on the contrary, increases during the first month in treated animals and remains consistently higher than controls up to the 45th day. In fully developed experimental brain tumors (mixed gliomas, isomorphic and polymorphic oligodendrogliomas) the percentage of reduction in AC activity is significantly higher. AC activity was measured also in human tumoral tissue. In malignant tumors it is markedly lower than in benign tumors. In the same patients cAMP in the cerebrospinal fluid was measured with results similar to those obtained in tissues. These findings confirm that the system of cyclic nucleotides is implicated in all the developmental phases of brain tumors and therefore may reveal how research can clarify the first transformations of tumoral cells.

Glycosaminoglycans in human cerebral tumors. Part II. Histochemical findings and correlations

The occurrence and the distribution of GAGs have been studied histochemically in 224 human cerebral tumors by means of Alcian blue techniques. In the normal peritumoral gray matter the alcianophilia is stronger than in the white matter and demonstrated the presence of HA and CS. In the glioma group the alcianophilia, due to HA and CS, is mainly related to the presence of infiltrated cortex. In the other tumors, GAGs are histochemically disclosed in relation to collagen, reticulin, mesodermic areas, etc. The vessels of every tumor show a positive staining for HA, CS and HS. The histochemical findings are consistent with the biochemical ones as reported in Part I, even though the significance of GAGs in cerebral tumors remains unknown.

Chemotherapy for medulloblastoma in children. Current status and future prospects

Surgery and radiotherapy are the most common modalities in the treatment of medulloblastoma in children. Our previous experience and that of others suggest that chemotherapy is useful in prolonging the survival of these patients. Since August 1979, the Italian Child’s Neurooncology Group (ICNG) has adopted a controlled and randomized protocol which calls for two types of treatment: (1) surgery + radiotherapy + CCNU, vincristine; (2) surgery + radiotherapy + CCNU, vincristine, procarbazine. An analysis of this trial is presented.

Saccular aneurysm of infancy and early childhood: report of a case

A case of intracranial saccular aneurysm with intracerebral haematoma occurring in early childhood and presenting with sudden loss of consciousness and right hemiparesis is reported. The aneurysm was located in the opercular portion of the left middle cerebral artery. Surgery, besides removing the intracerebral haematoma, involved clipping and complete removal of the aneurysmal sac. The child made an uneventful recovery, and he is completely safe after 40 months. Microscopic examination of the lesion shows disruption of the normal sequence of the original layers, with widespread inflammatory cells.

CT scan and craniostenosis

The authors propose the use of CT scan in the diagnosis of patients with suspected craniostenosis. The technique offers a valid preoperative screening, uncovering associated malformations, and in addition, is particularly useful in following assessment. It can therefore, reduce surgical indications and limit conventional neuro-radiologic investigations.

Experimental brain tumors by transplacental ENU. Multifactorial study of the latency period

Experimental cerebral tumors have been induced by transplacental ENU. The morphologic study of the brains of treated rats revealed that cellular hyperplasias appear at the 30th day of extrauterine life in the paraventricular white matter, i.e., before the already known "early neoplastic proliferations". Cytofluorimetric investigations failed to demonstrate differences between treated and control rats during the 1st month. On the contrary, adenylate cyclase activity is very high in that period. The duration of the latency period is discussed.

Cerebral tumours induced by ENU; changes of adenylate cyclase activity in the tumour latency time

Tumours of the nervous system have been induced by transplacental ENU. Until the fourth month of life the tumoural lesions appear as mixed glial proliferations or oligodendroglial foci. From the fourth month on they develop as glial micro- and macrotumours or as isomorphic and polymorphic oligodendrogliomas. The adenylate cyclase activity studied during these two distinct phases of tumour development was markedly reduced in brain tumours, independent of their cellular origin, compared with the level in the normal brain. On the other hand, the activity of the enzyme responsible for the synthesis of cyclic AMP is significantly increased during the first period of tumour development when early neoplastic proliferations are present.

Cerebral tumors induced by transplacental ENU: study of the different tumoral stages, particularly of early proliferations

Experimental cerebral tumors have been induced by transplacental ENU. A systematic diachronic study of the brains has been performed starting from the 15th day of extrauterine life. The tumoral lesions firstly appear as "early stage proliferations" or oligodendroglial foci and develop as glial micro- and macrotumors or as isomorphic and polymorphic oligodendrogliomas respectively. Neurinomas appear later than glial tumors. The duration of the different lesions is sketched out. The usefulness of the model for chemotherapy studies is discussed.

Chemotherapy of human nervous system tumors: influence on cerebrospinal fluid sterols

The cerebrospinal fluid levels of cholesterol, desmosterol, and the ratio 100 D:C taken from a study of 59 patients are reported. The patients, who had tumors of the nervous system, underwent neurosurgery, radiotherapy, and chemotherapy with 1,3-bis(2-chloroethyl)-1-nitrosourea or 1-(2-chlororethyl)-3-cyclohexyl-1-nitrosourea. The relationships among the levels of these three parameters and the clinical and neuroradiologic evolution are discussed.

Chemotherapy studies of various nitrosoureas: prevention of development of ethylnitrosourea-induced tumors in the nervous system

Of four nitrosoureas administered to F344 rats that were offspring of mothers treated with ethylnitrosourea during pregnancy, 1-(2-chloroethyl)-3-cyclohexyl-1-nitrosourea and its methyl derivative were particularly effective in blocking tumor development.