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Background: Twenty-six patients underwent application of a new posterior plating system (CIDEF SYSTEM) for the alignment and the stabilization of C3-C7 cervical unstable fractures from January 1992 to December 1993., Methods: The osteosynthesis apparatus employs posterior articular screw fixation and plate application. Indications for surgery were the presence of neurological damage and cervical column instability. Operative techniques included decompressive and exploratory laminectomy in 20 cases and an articular resection in six cases of posterior superior articular fractures. A one-stage operation with an anterior approach, designed to remove anterior compression from herniated discs, or bone fragments, was also performed in four cases. Three cervical motion segments were immobilized in 15 of the treated cases; four in nine; and five in two. All patients were studied pre- and postoperatively with plain radiographs and computed tomography. Pre- and postoperative examinations demonstrated no alteration in neurological status., Results: At a mean follow-up period of 47 months, no evidence was found of infection, rejection of the materials used, or mechanical failure of the plates and screws; all patients with incomplete lesion showed improvement in neurological function. Four patients tetraplegic at admission expired from systemic complications (one from pulmonary embolism; one from Disseminated Intravascular Coagulopathy; one for sepsis; and one from myocardial infarction). All patients were immobilized for at least 4 months with a Philadelphia collar. No injury to the neural or vascular structures contiguous to the cervical spine has occurred., Conclusions: The authors' experience suggests that the new system offers ease and versatility of application, restoration of vertebral alignment, enhanced spinal stability and is useful in the treatment of urgent and rather complex traumatic lesions of the lower cervical spine.

Three hundred and twenty-seven patients with intracranial aneurysm were managed at the Neurosurgical Division of Emergency Department of the Cardarelli Hospital of Naples. Of the 327 patient, 231 (70.6%), (I group), were operated on after 72 hours and 96 patients (29.4%), (II group), were operated on within 72 hours of subaracnoid hemorrhage. The patients operated on within 72 hours of hemorrhage (II group) were divided in two subgroups: 29 patients operated on within 72 hours formed the IIa group ("ultraearly" surgery) and 67 patients operated on between 24-72 hours formed the IIb group. Poor clinical grades (IV and V Hunt and Hess grades) were excluded from this study. Glasgow outcome scale (GOS), simplified in three grades was used to evaluate the results (GOS 1 good recovery; GOS 2 moderate or severe disability, and GOS 3 dead). The outcome was evaluated at the dimission and at 6 months. The best results seem to be for the patients in group IIb (24-72 hours), but if we consider that 31.2% of the patients operated on within 24 hours (IIa group) were in grade III of Hunt and Hess classification, also for these patients the surgical results seem to be good. The clinical presentation, treatment and outcome are discussed in this report.

Methods: Twenty-four cases of unstable thoraco-lumbar fractures with significant canalar stenosis were operated in the Emergency Neurosurgical Unit of the Cardarelli Hospital from November 1989 to October 1991. The surgical technique was the combined transpedicular (TPA) and transarticular (TAA) postero-lateral approach, posterior osteosynthesis and arthrodesis. The average follow-up was 20 months., Results: No evidence of implant breakage or pseudoarthrosis was detected., Conclusions: The authors affirm recalibration of the posterior wall by direct impaction, epidural hemostasis, removal of extruded disc fragments and dural repair are the advantages offered by this technique without compromise the contsrist stability. This approach represents an alternative to single posterior and combined anterior-posterior approaches in the management of the thoraco-lumbar fractures with severe canal stenosis.

Between 1990 and 1992 six cases of subdural empyema were surgically treated at the Neurosurgical Division of Emergency Department of Cardarelli Hospital in Naples. Three cases were associated with paranasal sinusitis and three cases with otitis media. Headache and fever were the presenting symptoms in all cases; in only two cases they were associated with seizures and altered mental status. CT scans showed convexity low density collections in five cases and multilocalized pus collection in one; concurrent paranasal or mastoid infections were visualized as well. The organisms responsible for the subdural empyema were Peptococcus in four cases, Streptococcus and anaerobius in the other two cases. In five cases surgical treatment consists in pus drainage by selective burr hole and placement of a subdural small silicon tube for local antibiotic therapy. In one case with a loculated diffuse empyema, craniotomy was performed in order to provide a better access to all the localizations. In all cases drainage of the wound and intravenous antibiotic therapy were used. Paranasal sinus drainage or mastoidectomy performed by the otolaryngologist when a localized collection of pus was present, grave a quicker regression of symptoms. A full recover of the original neurological status was achieved in all cases; a 20 months mean followup confirms the results.

CO2 cerebrovascular reactivity has been recorded in 12 healthy volunteers and 10 patients with unilateral > 70% extracranial internal carotid artery (ICA) stenosis, using non invasive techniques. The relative changes of middle cerebral artery blood flow velocity (VMCA) and velocity waveform pulsatility (PIMCA) after that hypocapnia was induced by spontaneous hyperventilation were recorded. 35.5% average VMCA reduction and 63% PIMCA increment of basal values was produced in healthy subjects after hyperventilation. The percentage variation of CO2 Reactivity Index (RI), expressed in terms of VMCA (V-RI) and PIMCA (PI-RI), per mmHg change in pCO2, presents a good right-left side correlation (r = 0.82 and r = 0.83 respectively) in healthy subjects, while a dissociation between V-RI and PI-RI was found in our patients. A significant reduction of PI-RI was also recorded in the group of patients on the side of ICA stenosis. From our data CO2 reactivity index recorded in terms of PI seems to allow a better separation between pathology and normality, without the need to assume a close relationship between velocity and blood flow under the condition considered. Furthermore, PI-RI seems to be a valid index in the evaluation of some attribute pertaining to the distal vascular bed.

The pathogenesis of syringomylia is not yet well known and its surgical management still poses problems. Terminal ventriculostomy, as proposed by Gardner et al. (1977), in treating the communicating syringomyelia could be an alternative approach as opposed to the cranio-vertebral decompression or subarachnoid shunt of the syrinx. This operation was performed by the authors in 3 cases. In all of them there was postoperative improvement of the neurological symptoms. In the authors' opinion the main problem is the difficulty in preoperative diagnosis of communicating syringomyelia. This technique is simple and could present an efficient means of diagnosing the communicating syringomyelia, particularly when there are no associated malformations.

A newly developed Transcranial Doppler system (TCD) has been used in a group of subjects without any cerebrovascular disease (CVD) in order to establish the standard criteria for transcranial basal cerebral arteries examination and settle normal velocimetric and hemodynamic parameters. TCD examination in patients suffering from CVD provides useful information for clinical management of such pathological conditions.