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Balt (Montmorency, France) recently manufactured the Leo+Baby dedicated intracranial stent for arteries with a calibre between 1.5 and 3.10 mm. We describe a patient with a partially thrombosed giant sacciform aneurysm of the anterior communicating artery treated without success by surgery and coil embolization subsequently occluded by placement of a Leo+Baby stent (Balt, Montmorency, France). A 56-year-old man presented with a giant aneurysm in the anterior communicating artery region. Following successive surgical intervention and embolization procedures the patient was referred to us with a revascularized aneurysm measuring 15×9×8 cm. To stabilize the endovascular occlusion a combined treatment was scheduled with coil embolization and stent deployment after dual antiplatelet therapy started five days before the interventional procedure. Treatment was undertaken two weeks later under general anaesthesia and total heparinization. A microcatheter was inserted into the aneurysmal sac and four metal coils were released for a total of 61cm obtaining almost complete occlusion of the aneurysm from the circulation. A Leo+Baby stent (2.5×18 mm) was subsequently deployed across the aneurysm neck. At follow-up angiography two months later the aneurysm appeared substantially excluded from the arterial circulation except for a small portion in the neck. Six months later, four months after suspending antiplatelet therapy, follow-up angiography disclosed the complete exclusion of the aneurysm from the circulation. Deployment of the new ministent through the same microcatheter used to release the coils made the interventional procedure simpler and faster.

We describe the MR features which appeared after resection of a medulloblastoma in the posterior fossa in a boy who developed postoperative cerebellar mutism. The anatomical and physiopathological factors responsible for this disorder are discussed.

This study aimed to define the indications, technique and results of presurgical embolization of intracranial extra-axial tumours using Glubran 2® a new acrylic glue with the CE mark, suitable for permanent embolization of the pathological circulation of tumours. Embolization was performed prior to surgery in seven patients with benign tumours and three patients with malignant lesions. All the procedures were technically feasible and achieved partial or complete embolization of the vascularized lesion without periprocedural complications. Glubran 2® proved easy to use with excellent intravascular penetration achieving permanent embolization. The degree of presurgical embolization in terms of surgical field haemostasis was satisfactory in all cases and correlated to the degree of vascular occlusion achieved.

Object We report two cases of bobble-head doll syndrome associated with a large suprasellar arachnoid cyst successfully treated with a minimally invasive endoscopic approach. Methods The clinical history, surgical treatment and results of two children, a 9-year-old boy and a 1-year-old girl, both presenting the clinical features of the bobble-head doll syndrome, are described. As a first procedure, a ventriculo-cystostomy was endoscopically performed in both patients, obtaining either resolution of the symptoms or notable cyst reduction. In the girl, a re-closure of the stoma, with cyst re-expansion, was observed after 18 months. She then underwent a second procedure, a ventriculo-cysto-cisternostomy, with a good result. After 3 years’ follow-up, the neurological condition of both patients remains good with complete resolution of abnormal head movement. Conclusion In our opinion, endoscopic treatment is the procedure of choice for this condition, as it involves few complications and gives good results.

La scelta del trattamento chirurgico delle MAV cerebrali rappresenta oggi uno degli argomenti più dibattuti ed attuali in ambito neurochirurgico, in considerazione dell'avvento di tecniche alternative o complementari che possono dare un contributo essenziale e spesso risolutivo al trattamento di queste lesioni. Sulla base dell'esperienza di 47 casi operati consecutivamente presso l'Ospedale Bellaria negli ultimi anni, si è cercato di vedere quali fossero i criteri che hanno ispirato la scelta chirurgica e di valutare i risultati della stessa per una revisione critica di queste scelte. Da un'analisi completa dei casi le conclusioni possono essere che, se si escludono le situazioni in cui è necessario intervenire in emergenza, in tutti gli altri casi, il criterio della scelta chirurgica adottato si è rivelato nel complesso utile per avere un risultato definitivo buono (asportazione completa della MAV), con rischi contenuti. In particolare si è potuto desumere che l'indicazione chirurgica può essere ancora oggi la scelta preferibile nelle malformazioni di grado I-II-III (secondo Spetzler e Martin), se si escludono casi particolari in sedi cerebrali critiche. Nelle malformazioni di grado IV invece la chirurgia deve essere riservata a situazioni molto particolari, in cui la MAV risulta non trattabile in via alternativa e vi sia stato un evento emorragico di presentazione. In queste circostanze, l'embolizzazione pre-operatoria può essere un contributo molto importante per la soluzione chirurgica.

L'approccio endovascolare alle malformazioni artero-venose (MAV) con vari agenti embolizzanti è una opzione terapeutica ormai collaudata da alcuni decenni. Esso consente la completa chiusura della malformazione in circa un quarto dei casi, quando si considerino cumulativamente le varie casistiche presenti in letteratura, con una significativa variabilità di tale dato da autore ad autore.La colla acrilica va considerata un mezzo embolizzante valido, definitivo, ma di uso difficile e con significativi rischi per il paziente.Un altro aspetto negativo è che non è stata dotata dalla ditta produttrice del marchio CE per l'uso endovascolare, che viene addirittura vietato nelle indicazioni all'uso.Da alcuni anni è stato presentato un nuovo materiale embolizzante, l'Onyx (Onyx System MicroTherapeutics, Inc., MTI), che ha la caratteristica teorica di essere un materiale “schiumoso” progressivamente occludente piuttosto che bruscamente “incollante”. L'Onix è dotato di marchio CE per uso endovascolare.Riportiamo i risultati ottenuti nei primi sette pazienti.L'Onyx sembra essere un materiale più maneggevole, più sicuro e, soprattutto, più prevedibile e riproducibile nella sua dinamica rispetto al cianoacrilato. Restano da verificare la sua stabilità nel tempo e, secondo alcuni, la possibile tossicità del DMSO.

Il contributo dell'endoscopia nella patologia dell'angolo ponto-cerebellare inizia negli anni settanta.Negli anni successivi vi è stato un miglioramento tecnico e tecnologico delle procedure endoscopiche che ha consentito una diffusione dell'applicazione della tecnica, come assistenza alla microchirurgia.Noi riportiamo la nostra esperienza nelle assistenza endoscopica alla microchirurgia dei conflitti neurovascolari.Si tratta di 23 casi: 19 nevralgie trigeminali e 4 emispasmi del facciale.L'assistenza endoscopica permette una ottimizzazione della procedura microchirurgica.

Gli Autori presentano casi esemplificativi della loro esperienza nell'impiego della chirurgia endoscopica transnasosfenoidale in diverse patologie: fistole liquorali, lesioni sellari cistiche non adenomatose, neoplasie etmoido-sfeno-clivali e neoplasie invadenti il seno cavernoso. I risultati preliminari sono incoraggianti, ma, sino alla loro conferma su più ampie casistiche e più protratti follow-up, è necessaria, soprattutto in campo oncologico, estrema prudenza limitandone l'uso a quanti, informati, lo richiedano e da parte di chirurghi che, in caso di risultato insoddisfacente, sappiano commutare l'intervento endoscopico in uno più tradizionale, ma di provata efficacia.

MRI showed impingement of the vertebral artery on the left lateral medulla in two patients with arterial hypertension, exaggerated startle reflexes (hyperekplexia), and progressive spastic paresis. One patient underwent microvascular decompression with normalization of arterial hypertension, disappearance of hyperekplexia, and improvement of spastic paresis. The combination of arterial hypertension, hyperekplexia, and progressive spastic paresis should arouse suspicion of neurovascular compression of the lateral medulla.

Summary:  In a proportion of small acoustic neuroma patients, monitoring with magnetic resonance imaging shows no volumetric increase of tumour size over the years. The object of the study was to identify some indications for the clinical choice between immediate surgery (with the related risks) and watchful waiting.  We performed a retrospective study of 47 non-surgically-treated patients affected by acoustic neuroma and monitored by gadolinium-enhanced MRI between January 1990 and February 1999. Six clinical variables (tumour size, sex, age, initial symptoms, ABR pattern and duration of the symptoms) were examined by univariate analysis. Chi-square test and variance analysis were performed to evaluate the statistical significance.  In 30/47 (63.8%) cases, no growth was observed during the entire period of follow-up. In the remaining 17/47 (36.2%) patients, a volumetric increase was detected, most often within the first year of observation. The clinical factors examined did not significantly correlate with growth.  Despite the relatively short period of observation, we believe that immediate surgery does not need to be considered mandatory for small acoustic neuromas, even in young patients. However the irregular behaviour of the tumour underlines the importance of monitoring with MRI at least once a year.

20 patients who had undergone microvascular decompression for the treatment of “idiopathic” trigeminal neuralgia (9 cases), hemifacial spasm, (7 cases), glossopharyngeal neuralgia (3 cases) and paroxysmal vertigo and tinnitus (1 case) were followed up for 25 months on average. Permanent relief of symptoms was observed in 19 (95%), with sparing of cranial nerve function. Analysis of the clinical data shows that the patients described in the present series did not differ from those considered to suffer from “idiopathic” cranial nerve dysfunction syndromes.

Intracranial microvascular decompression was performed in 21 out of 24 patients with hyperactive dysfunction of cranial nerves: 8 cases of hemifacial spasm, 12 of trigeminal neuralgia, 3 of glossopharyngeal neuralgia and 1 case of paroxysmal vertigo and tinnitus. In 21 cases an abnormal vascular loop was found to impinge on the root entry zone of the nerve in the brainstem. Dissection of this loop with decompression of the nerve resulted in long-lasting relief of symptoms in all but two patients who presented early recurrence; in one of these a second procedure was eventually successful. In two patients with trigeminal neuralgia a benign tumor of the cerebellopontine angle that had escaped preoperative diagnosis was present. Finally, in one case no compressive lesions were found. From the data of the literature and from our present experience microvascular decompression can be considered a safe as well as an effective procedure, affording a high success rate in conditions often or usually resistant to medical treatment and erroneously considered “idiopathic”.

Summary Intact aneurysms of the carotid siphon at the point of take-off of the posterior communicating artery may exhibit orbital pain, whether associated with oculomotor palsy or not as a warning symptom prior to rupture. In order to explain this symptom the hypothesis of a sensory pathway within the third cranial nerve, which is liable to compression by the enlarging aneurysm sac, has been investigated.

Objective This study assessed the role of endoscope-controlled microneurosurgery (ECM) in the treatment of intracranial cerebrospinal fluid (CSF) cysts. Methods Twelve patients affected by symptomatic arachnoid cysts (11 in the sylvian fissure and 1 in the cerebellopontine angle) underwent ECM, in which the endoscope is used to view the operating field while microsurgical instruments can be passed alongside the endoscope for surgical maneuvers. All the cysts were superficially located and could be reached directly through a burr hole on their surface, so that the endoscope was inserted into the cyst without passing through the brain parenchyma. We used a rigid endoscope, performing a wide fenestration of the cyst in the basal cisterns (cystocisternostomy). The excellent endoscopic vision facilitated the surgical procedure with safe maneuvers through a minimally invasive approach. In 11 patients, we observed the resolution of symptoms. A radiological reduction in the cyst was observed in 7 cases. No mortality or major complications were observed. Conclusions Endoscope-controlled microsurgery is a valid minimally invasive procedure for treating superficially located intracranial arachnoid cysts.

Development of a squamous cell carcinoma in an epidermoid cyst is rare. A case is presented in which such malignant change arose in the capsule remnants of an intracranial epidermoid removed 31 years previously. The limited literature dealing with this late sequela is summarized.

Background As yet, no population-based prospective studies have been conducted to investigate the incidence and clinical outcome of glioblastoma (GBM) or the diffusion and impact of the current standard therapeutic approach in newly diagnosed patients younger than aged 70 years. Methods Data on all new cases of primary brain tumors observed from January 1, 2009, to December 31, 2010, in adults residing within the Emilia-Romagna region were recorded in a prospective registry in the Project of Emilia Romagna on Neuro-Oncology (PERNO). Based on the data from this registry, a prospective evaluation was made of the treatment efficacy and outcome in GBM patients. Results Two hundred sixty-seven GBM patients (median age, 64 y; range, 29–84 y) were enrolled. The median overall survival (OS) was 10.7 months (95% CI, 9.2–12.4). The 139 patients ≤aged 70 years who were given standard temozolomide treatment concomitant with and adjuvant to radiotherapy had a median OS of 16.4 months (95% CI, 14.0–18.5). With multivariate analysis, OS correlated significantly with KPS (HR = 0.458; 95% CI, 0.248–0.847; P = .0127), MGMT methylation status (HR = 0.612; 95% CI, 0.388–0.966; P = .0350), and treatment received in a high versus low-volume center (HR = 0.56; 95% CI, 0.328–0.986; P = .0446). Conclusions The median OS following standard temozolomide treatment concurrent with and adjuvant to radiotherapy given to (72.8% of) patients aged ≤70 years is consistent with findings reported from randomized phase III trials. The volume and expertise of the treatment center should be further investigated as a prognostic factor.