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Neurosurgery is considered a technically demanding specialty; nonetheless, it also requires non-technical skills (NTSs) to reach mastery.

We propose this combined balloon occlusion and surgical technique to treat selected patients with large-giant aneurysms not suitable for a pure endovascular or surgical approach.After an occlusion test a non detachable balloon catheter is positioned deflated proximally to the neck of the aneurysm under general anesthesia. The patient is then moved to the neurosurgical room. During the intervention the balloon is inflated and deflated when necessary to allow better surgical control of the aneurysmal sac. With this approach we achieve complete aneurysm occlusion and shorten the surgery time. Since January 2003 we have treated 13 giant aneurysms (ten paraclinoid and three vertebrobasilar) without significant complications related to balloon assistance and a good outcome in all patients.

A rare embryonal brain tumor has been diagnosed in a 4-year-old boy. The mass, located at the pons and mesencephalon, has been histologically classified as an embryonal tumor containing abundant neuropil and true rosettes.A rare embryonal brain tumor has been diagnosed in a 4-year-old boy. The mass, located at the pons and mesencephalon, has been histologically classified as an embryonal tumor containing abundant neuropil and true rosettes.

Human brain astrocytomas range from the indolent low-grade to the highly infiltrating and aggressive high-grade form, also known as glioblastoma multiforme. The extensive heterogeneity of astrocytic tumors complicates their pathological classification. In this study, we compared the protein pattern of low-grade fibrillary astrocytomas to that of glioblastoma multiforme by 2D electrophoresis. The level of most proteins remains unchanged between the different grade tumors and only few differences are reproducibly observable. Fifteen differentially expressed proteins, as well as seventy conserved spots, were identified by mass spectrometry. Western and immnunohistochemical analysis confirmed the differential expression of the identified proteins. These data provide an initial reference map for brain gliomas. Among the proteins more highly expressed in glioblastoma multiforme, we found peroxiredoxin 1 and 6, the transcription factor BTF3, and α-B-crystallin, whereas protein disulfide isomerase A3, the catalytic subunit of the cAMP-dependent protein kinase, and the glial fibrillary acidic protein are increased in low-grade astrocytomas. Our findings contribute to deepening our knowledge of the factors that characterize this class of tumors and, at the same time, can be applied toward the development of novel molecular biomakers potentially useful for an accurate classification of the grade of astrocytomas. Keywords: astrocytomas • gliomas • proteomics • 2D-gel electrophoresis • mass spectrometry

The surgical technique used for cerebral aneurysms is still considered a delicate procedure but surgeons' skill yields excellent results in the majority of regular aneurysms. Moreover, the endovascular treatment with detachable coils has become a routine procedure and at present the discussion about the best indication for treating the aneurysms is lively. We present our series of 361 aneurysms treated in six years with 267 surgical procedures and 94 endovascular treatments. The indication for endovascular treatment in our Department is usually put for aneurysms of the basilar trunk, basilar bifurcation, infraclionid tract of the Internal Carotid artery, in patients with higher H&H grade (3–4) and in older patients with poor general condition. The global mortality of endovascular cases was 21% while in the surgical series the global mortality was 15%. We must consider that 60% of endovascular cases were in grade 3–4 of Hunt&Hess while in the surgical series only 40% were in the same situation. Only 2.7% of the cases (10 patients) were a really difficult problem for each separate technique. In these cases a combination of surgical and endovascular procedure was adopted and in only five cases was it possible to treat the aneurysms properly.In our opinion, a combined approach can be useful only in some selected cases but we should take into account the fact that nowadays surgery has reached the upper limits of its technique while, on the contrary, the endovascular technology is still in progress.

La ventricolocisternostomia (VCS) può essere risolutiva in alcuni casi di idrocefalo con pervietà dell'acquedotto di Silvio, probabilmente grazie alla rapida trasmissione dell'onda pulsatile negli spazi subaracnoidei. Vengono descritti 17 casi di idrocefalo normoteso con prevalente dilatazione triventricolare dell'anziano, trattati con VCS. Sette pazienti sono migliorati, sette sono rimasti invariati e tre sono peggiorati, per cui è stato applicato uno shunt ventricoloperitoneale. Il miglioramento clinico nel 45% dei casi è un dato incoraggiante, che permette di proporre l'intervento endoscopico in casi selezionati.

Negli ultimi anni la risonanza magnetica funzionale dell'encefalo (fMRI) si è proposta con successo nello studio dell'attività encefalica durante lo svolgimento di determinate funzioni. Si è inoltre delineato per essa un ruolo paricolarmente interessante nell'ambito della pianificazione preoperatoria di pazienti destinati ad un intervento chirurgico in sedi encefaliche critiche, ovvero ad alto rischio di invalidtà postoperatoria.Il presente lavoro mira alla realizzazione di mappe di attivazione motoria in pazienti con lesioni occupanti spazio nell'encefalo mediante un tomografo a 1,5 T di non recentissima tecnologia; successivamente si è voluto valutare l'informatività di tali mappe, sia dal punto di vista neurochirurgico sia dal punto di vista neurofisiologico.Sono stati presi in esame 5 pazienti, tutti portatori di una lesione occupante spazio in prossimità della corteccia perirolandica e tutti destinati ad un intervento chirurgico in stereotassi per l'asportazione di tale lesione. I pazienti venivano sottoposti in un'unica seduta allo studio funzionale e morfologico dell'encefalo con il casco stereotassico in sede.Lo studio di fMRI si è svolto su uno o massimo due piani assiali orientati ortogonalmente al decorso della scissura di Rolando. Esso prevedeva come prova di attivazione il movimento della mano controlaterale all'emisfero con la lesione da asportare.In un paziente la funzione motoria è stata studiata anche intraoperatoriamente mediante la stimolazione elettrica della corteccia cerebrale.In 4 pazienti si è avuta una netta rappresentazione della corteccia sensitivo-motoria di tale emisfero. In 3 di essi si è vista inoltre un'attivazione dell'emisfero opposto, ipsilaterale alla mano in movimento. Altre zone di attivazione visualizzate nei nostri studi sono state messe in relazione con l'area motoria supplementare (3 pazienti) e l'area premotoria (2 pazienti).Nel paziente in cui si è proceduto intraoperatoriamente con la stimolazione elettrica della corteccia cerebrale è stata riscontrata una buona concordanza tra lo studio elettrofisiologico e l'indagine di fMRI.Analizzando i risultati da noi conseguiti possiamo concludere che anche un tomografo a 1,5 T di tipo convenzionale si presta ad un'indagine di fMRI in pazienti con lesioni encefaliche. Le mappe di attivazione realizzate su uno o due piani assiali sono in grado di fornire delle informazioni sui rapporti tra la lesione da asportare e la corteccia sensitivo-motoria, in particolare l'area della mano. Ciò ha notevoli implicazioni dal punto di vista neurochirurgico, considerando quanto sia importante la salvaguardia dell'integrità funzionale del soggetto che si sottopone ad un intervento neurochirurgico in una sede critica come la corteccia perirolandica.

Summary Since 1990 112 patients have undergone Stereotactic resection of intra-axial tumoural lesions with volumetric reconstruction, using the Kelly-Goerss system. Stereotactic integration of CT, angiographic and particularly MRI information, together with three-dimensional information of the lesion, provide an innovative evaluation of the most appropriate surgical approach, even for each single patient. The main limitation of this surgical method is in cases where the infiltrating part of the tumour is pre-eminent, while it can allow “macroscopically complete resection” of well circumscribed lesions, almost independently of their location and volume. Some technical aspects of Stereotactic resection of brain tumours are discussed in the light of our experience.

Cerebral lesions may alter the capability of bilingual subjects to separate their languages and use each language in appropriate contexts. Patients who show pathological mixing intermingle different languages within a single utterance. By contrast, patients affected by pathological switching alternate their languages across different utterances (a self contained segment of speech that stands on its own and conveys its own independent meaning). Cases of pathological mixing have been reported after lesions to the left temporoparietal lobe. By contrast, information on the neural loci involved in pathological switching is scarce. In this paper a description is given for the first time of a patient with a lesion to the left anterior cingulate and to the frontal lobe--also marginally involving the right anterior cingulate area--who presented with pathological switching between languages in the absence of any other linguistic impairment. Thus, unlike pathological mixing that typically occurs in bilingual aphasia, pathological switching may be independent of language mechanisms.