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Background Ventriculoatrial shunts were one of the most common treatments of hydrocephalus in pediatric and adult patients up to about 40 years ago. Thereafter, due to the widespread recognition of the severe cardiac and renal complications associated with ventriculoatrial shunts, they are almost exclusively implanted when other techniques fail. However, late infection or atrial thrombi of previously implanted shunts require removal of the atrial catheter several decades after implantation. Techniques derived from management of central venous access catheters can avoid cardiothoracic surgery in such instances. Methods We retrospectively investigated all the patients requiring removal of a VA shunt for complications treated in the last 5 years in our institution. Results We identified two patients that were implanted 28 and 40 years earlier. Both developed endocarditis with a large atrial thrombus and were successfully treated endovascularly. The successful percutaneous removal was achieved by applying, for the first time in this setting, the endoluminal dilation technique as proposed by Hong. After ventriculoatrial shunt removal and its substitution with an external drainage, both patients where successfully weaned from the need for a shunt and their infection resolved. Conclusion Patients carrying a ventriculoatrial shunt are now rarely seen and awareness of long-term ventriculoatrial shunt complications is decreasing. However, these complications must be recognized and treated by shunt removal. Endovascular techniques are appropriate even in the presence of overt endocarditis, atrial thrombi, and tight adherence to the endocardial wall. Moreover, weaning from shunt dependence is possible even decades after shunting.

Biopsies of clival lesions are usually performed, under general anaesthesia, through an anterior endoscopic approach or, alternatively, through a trans-nasal or trans-oral stereotactic approach. A 57-year-old man with a symptomatic osteolytical lesion of the clivus, who refused general anaesthesia, underwent a sterotactically guided biopsy of the lesion by an antero-lateral approach through the temporal and sphenoid bones. Biopsy was successfully performed and the resulting diagnosis was myeloma. The patient was comfortable during and after surgery and there were no complications. The present stereotactic antero-lateral approach to the biopsy of the upper clivus can be considered an useful adjunct to the current trans-oral and transnasal approaches that often require general anaesthesia.

1 alpha, 25-dihydroxyvitamin D3 was previously shown to induce cell death in brain tumour cell lines when added to the medium at micromolar concentration. In this paper we show that Cholecalciferol, a poor ligand of the vitamin D receptor, also induces cell death of HU197 human glioblastoma cell line and early passages cultures derived from a recurrent human glioblastoma. This finding suggests that the effects of vitamin D metabolites on brain tumour cells are at least partially independent from the activation of the classic nuclear receptor pathway. Vitamin D metabolites have been shown to activate the sphingomyelin pathway inducing an increase in cellular ceramide concentration. We determined the levels of sphingomyelin ceramide and ganglioside GD3 in Hu197 cells after treatment with cholecalciferol. A significant increase in ceramide concentration and a proportional decrease in sphingomyelin was already present after 6 hours of cholecalciferol treatment when no morphological changes were visible in the cultures. Treatment with ceramides (N-acetylsphingosine or natural ceramide from bovine brain) of the same cells also induces cell death. Similarly, treatment of the same cells with bacterial Sphingomyelinase also results in cell death. The demonstration of an increase in intracellular ceramide after cholecalciferol treatment and the ability of ceramide to induce cell death suggest that the sphingomyelin pathway may be implicated in the effect of vitamin D metabolites on human glioblastoma cells. Inhibition of ceramide biosynthesis by fumonisin B1 treatment did not alter the dose response curve of HU197 cells to cholecalciferol. Insensitivity to fumonisin B1 together with a decrease in sphingomyelin content after cholecalciferol treatment indicate that activation of sphingomyelinase should be responsible for the increase in intracellular ceramide concentration.

Epidemiological studies indicate a link between low-dose irradiation (10,000 mGy) to the head and the local occurrence of tumors after decades of delay. Comparable radiation doses can be reached during neuro-endovascular procedures (NEP), but the incidence of similar exposures has not been completely delineated. We compared the levels of radiation to the head measured during NEP to those reported for patients developing radiation-induced cancers.In our prospective study we determined the cumulative maximum entrance skin doses (MESD) and the incidence of epilation in 107 consecutive patients submitted to NEP between 2003 and 2007. We also extensively searched the literature and compared our results with the data we found.The cumulative MESD due to NEP was above 3,000 mGy (range 3,101-5,421 mGy) in 18 patients. In 22 we observed partial epilation within 10 weeks from the initial NEP. Sixty cases of epilation after NEP have been previously reported in the literature. The average of the reported MESD was 4,241 mGy (range 2,000-6,640 mGy).Physical dosimetry and the incidence of partial epilation indicate that about one fifth of the patients submitted to NEP received radiation doses comparable to those linked to the occurrence of tumors. The potential risks of developing tumors after a long delay, when compared to the immediate benefits of endovascular treatment of aneurysm and arteriovenous malformations (AVM) of the brain, do not counterindicate NEP, but increased awareness of the risk should help physicians and patients to make a fully informed decision when other treatments are available.

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.