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The authors report the case of a patient suffering from central sleep apnea (CSA) who underwent neurosurgery for ventriculo-peritoneal derivation under general anesthesia. Given the risk of postoperative hypoventilation in CSA, intraoperative anesthesia was induced using remifentanyl, an opiate with a plasma half-life of less than 5 minutes. Propofol (2 mg/kg) and remifentanyl at a dose of 0.5 microgram/kg was used during induction. The patient was curarised with vecuronium bromide, intubated and ventilated with a mixture of O2/N2O. During the operation, remifentanyl was administered as a continuous infusion at a starting dose of 0.2 microgram/kg/min, subsequently modified according to changes in arterial pressure and heart rate. At the end of surgery, which lasted approximately 120", decurarisation was carried out using prostigmin, and the infusion of remifentanyl was suspended, together with N2O. Reawakening times were recorded. Extubation took place 8' and 30" after the suspension of remifentanyl. Postoperative monitoring of SpO2 continued for 1 h and blood-gas analysis was satisfactory. No hypoventilation episodes were reported throughout the postoperative period and the patient was discharged from hospital after 7 days. The authors consider that remifentanyl should be the drug of choice to guarantee intraoperative analgesia in patients suffering from CSA requiring general anesthesia.

The role of neurosurgical therapy in tuberous sclerosis is still controversial; generally, a surgical procedure is performed only to treat an increase in intracranial pressure secondary to an obstructive hydrocephalus caused by a neoplasm in the region of the foramen of Monro. The role of surgical treatment in the control of epileptic fits is much more limited because of multifocal EEG epileptogenic foci due to multiple cortical lesions. Recently some authors, however, have suggested that the surgical treatment may be useful in selected patients. In the present report 9 children affected by tuberous sclerosis who were operated on in the period 1982-1992, because of increased intracranial pressure are described. The neuroradiological examination showed tumors in the region of the foramen of Monro in all the patients, with secondary obstruction in the CSF shunt circulation. Operative procedures included CSF shunts and/or giant cell astrocytoma removal. The follow-up period ranged from 1 to 14 years (mean 6 years). According to our experience, tumor excision is the most satisfying therapy, allowing the removal of the cause of the hydrocephalus as well as the possibility of histological diagnosis. A CSF shunt procedure may resolve the symptomatology, but it is often weighted by frequent malfunctioning of the CSF shunt system due to catheter obstruction secondary to abnormally high CSF protein concentration; furthermore, in some patients the insertion of the ventricular catheter may induce intraventricular bleeding when the highly vascularized tumor is accidentally punctured during the procedure of shunt insertion or in cases in which the presence of the ventricular catheter causes chronic trauma on the tumoral surface.

The surgical treatment of hydrocephalus has been greatly improved by the techniques of ventriculo-peritoneal shunting. Several complications may however occur following these operative procedures. Most of the complications are related to the distal end of the shunt device and include obstruction of intraperitoneal catheter, development of inguinal hernia or hydrocele, perforation of viscera. Many observations have been dedicated to these pathological findings, due to their frequency and the relatively easy diagnosis. Intraperitoneal pseudocysts are also a known complication of ventriculo-peritoneal shunts. Owing to their relative rare incidence and the aspecificity of their clinical presentation, this last type of complication has received a minor consideration. In the present report the authors describe two cases of intraperitoneal pseudocysts clinically manifested by the occurrence of postprandial dyspnea and hiccupping, without any apparent sign of CSF shunt device dysfunction.

Two hundred eight patients with non-tumoral congenital hydrocephalus underwent CSF shunting below the age of one month. Ultrasonography was the most frequently utilized tool; hydrocephalus was recognized during pregnancy in 52% of the cases. Hydrocephalus was associated with myelomeningocele in 97 infants; in 38 subjects ventricular dilation was secondary to aqueductal stenosis. Post-hemorrhagic and post-infective hydrocephalus accounted for only 20 and 13 cases respectively. At the follow-up observation, a normal psychomotor development was recorded in 67.3% of the cases. Seventeen patients died. CSF infection was the most common cause of death (41%); in 6 patients the exitus was determined by the natural evolution of congenital associated malformations. Shunt revision did not influence the morbidity and the mortality significantly. On the other hand, CSF infections appeared to influence the prognosis negatively. In our experience, the prognosis of hydrocephalus operated on in the first month of life does not differ from that of hydrocephalus operated on late in life.

Two forms of verbal fluency test, phonological (FF) and semantic (FS) sets, have been administered to four groups of demented patients: 11 with Alzheimer-type dementia (DAT), 13 with multi-infarct dementia (MID), 8 with Parkinson-Dementia (P-D) and 11 with adult chronic hydrocephalus (ICA). Patients were matched for age, educational level and neuropsychological impairment pattern. Further, ten neurologically healty subjects were selected as control group. Control subjects result to be different from all other groups in both FF and FS; moreover, FF test results to be more impaired in ICA than in DAT. Furthermore, FF is more impaired than FS in P-D and ICA patients. On the basis of our results, verbal fluency tests might represent an useful instrument to differentiate demented subjects from non-demented ones and within demented groups to characterize the different neuropsychological pattern of the cortical and subcortical type of cognitive deterioration.

Apart from headaches due to expanding lesions or vascular abnormalities which require a direct neurosurgical approach, some cases of untractable, acute or chronic headaches may need some neurosurgical management. Among these, "low pressure hydrocephalus" is responsible for a number of cases that can be relieved by ventriculo-atrial or ventriculo-peritoneal shunts: "dural headaches" including some atypic migraines and "cluster headaches" can be cured by sectioning of the afferent meningeal rootlet of the trigeminal nerve in its retrogasserian portion. Some occipital types of headache, "venous headache" or "strain headache", may benefit of a cross section of the occipital dura mater. The Authors have also used in selected cases of untractable headache, their technique of intermittent electrical stimulation of the nucleus ventralis posterolateralis by means of an implanted stimulator.

The authors have examined the statistics of extracardiac malformations in infants with congenital heart disease, aged between birth and 12 months. Cases have been registered and studied within a period ranging from 1969 to 1979 at A. Meyer Hospital of Florence (Pediatric Institute of the University, Divisions of Medical Pediatrics and of Pediatric Surgery). Extracardiac abnormalities occur in 23,05% of infants seen during the first year of life for significant cardiac disease. Sometimes the extracardiac malformations are multiple and 66,3% of the affected infants have some established syndrome, especially chromosomal. The most frequent associated cardiac malformations are: ventricular septal defect (29,3%), complex heart disease (18,5%), non cyanotic heart disease with increased pulmonary blood flow (16,3%) and endocardial cushion defect (10,8%).

We have studied 15 occipital, 3 frontal and one parietal cases of encephaloceles from the point of view of the etiopathogenetic, clinic and especially diagnostic problem. The diagnosis of M.E. is based on: 1) the x-ray demonstration of the bone-gap by particular projections and by tomography; 2) in the frontal M.E. the presence of face deformity, with hipertelorism and widening of nose bridge and the finding of ectopic tissue in the nose or in the oral cavity in presence of palatoschisis. Cerebral angiography and pneumoencephalography, made by tomography, are useful to show the herniated brain, hydrocephalus and other associated anomalies. Finally we think computerized tomography (C.T.) is very important for the diagnosis, since it shows the herniation, the bone-gap and the kind of herniated tissue.

The AA. underline the evolution of the neuropsychiatrical approach to the shunt-dependent child and the need of constant and long lasting clinic monitoring to prevent or reduce possible deficit. Moreover they wish in this case a multicentric collaboration outlineing the notable importance. They tell, then, as a explication, their personal experience of follow-up about 49 cases.

The finding is described of a Gram-negative bacterium in cerebrospinal fluid of a patient suffering from internal hydrocephalus and taken in the hospital of Udine with symptoms of meningitis. The isolated bacterium belongs to the genus Bacteroides. The cases of meningitis are indicated in which the bacteriological examination of the cerebrospinal fluid for anaerobes is recommended.