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Aneurysms of the vertebro-basilar junction area have been considered the most difficult to be surgically treated because of their deep location, the proximity of the brain stem and the cranial nerves. However, at present, new endovascular techniques and new transbasal surgical approaches offer valuable management strategies. This paper concerns six consecutive patients whom we managed either endovascularly or surgically during a period of eighteen months. Direct surgical treatment was offered to two young patients with relatively small aneurysms in good neurological condition, whereas the other four patients initially underwent an endovascular attempt at aneurysm obliteration using the Guglielmi detachable coil system. Unfortunately, interventional neuroradiology failed in three cases, and surgery had to be re-considered. Accordingly, a total of five patients underwent surgical clipping through the combination of a transmastoid retrolabyrinthine approach with the suboccipital lateral approach. This combination of approaches provided a good control of both vertebral arteries and basilar artery, and allowed the aneurysm to be correctly clipped in all cases. Good long-term results were achieved in all cases but one. Based on this preliminary experience, we would stress the importance of a multidisciplinary approach with a treatment calibrated for each single case. Furthermore, if surgery is to be performed, the combination of transmastoid-retrolabyrinthine and suboccipital lateral approaches provides a wide exposure of the whole vertebro-basilar junction area and allows good access to the lesion.

The standard treatment of foraminal syringomyelia includes foramen magnum decompression and duraplasty. Improvement or stabilization of the disease are achieved in most of cases. However, at least one third of patients are reported to receive little or no benefit. In this paper we retrospectively reviewed a series of 40 consecutive foramen magnum decompressions in order to identify the possible pre-operative outcome predictors. Based on clinical evolution, neurological impairment and radiological features, a scale of severity was fixed and retrospectively tested. A pre-operative score was obtained for each patient and was correlated with the surgical results. Then a four level grading system was derived. All grade I and grade II patients achieved good results (improvement or stabilization), whereas grade III patients showed intermediate behaviour and grade IV invariably worsened. On this basis, surgical results of foramen magnum decompression might be further improved provided that a careful pre-operative selection is made.

Delayed complications of ethmoid fractures are considered relatively rare. However, meningitis, recurrence of previously ceased cerebrospinal fluid rhinorrhea and delayed onset of cerebrospinal fluid rhinorrhea are possible even years after trauma. We report 10 consecutive patients with delayed complications of ethmoid fractures, whom we treated over the past 11 years. All patients had previously sustained a closed head injury and had remained anosmic. Variously after trauma (ranging from 2 months to 31 years), these patients were re-admitted because of meningitis (6 cases), recurrence of previously ceased cerebrospinal fluid rhinorrhea (3 cases), and delayed onset of cerebrospinal fluid rhinorrhea (1 case). In all cases the delayed complications were associated with relatively large defects of the ethmoid bone. These bone lesions were now evident even in those patients whose radiological assessments had been normal after trauma. All patients underwent a successful surgical repair and remained well during the follow-up. We discuss the possibility that delayed complications of ethmoid fractures are due to a mechanism like that of "growing fractures" in children.

Two cases of an unusual complication of synthetic duraplasty are reported. In both cases, patients had been operated on because of meningiomas and dural defects had been repaired with Silastic. Some years later they developed severe graft-related haematomas and were ultimately successfully treated only by the removal of the synthetic grafts. On the basis of this and other clinical experiences, biological dural grafts seem to be preferable to synthetic ones.

The rCBF was evaluated using I-123 HIPDM and single photon emission computed tomography (SPECT) on 14 patients undergoing extracranial-intracranial (EC-IC) bypass surgery because of internal carotid artery (ICA) occlusion. Before surgery, all patients showed cortical areas of hypoperfusion over the affected cerebral hemisphere. Shortly after EC-IC bypass a rCBF increase was observed in six patients. However, at the 6 and 12 month follow-ups, with angiographic control of bypass patency, rCBF studies did not show any significant rCBF change. Long-term noninvasive tomographic monitoring of perfusion changes occurring after EC-IC bypass surgery failed to show a long-lasting improvement in perfusion.

The aim of this paper is to summarize the most significant results of our experience with ventricular fluid pressure (VFP) monitoring in acute head injury.

Homovanillic acid (HVA) and 5-hydroxyindolacetic acid (5-HIAA) in ventricular CSF were determined in 19 patients (12 female 7 male) with brain tumours. No relationship was found between ventricular fluid pressure (VFP) and levels of HVA and 5-HIAA. A relationship was observed between ventricular CSF, HVA concentrations and tumour induced alterations in CSF dynamics. HVA concentrations were very high in patients whose tumours involved the third ventricle, the aqueduct, or the fourth ventricle, producing marked alterations in CSF flow. HVA concentrations significantly lower than in controls were observed in cases where tumours involved the lateral ventricles. Concentrations of acid metabolites in patients with little or no alteration in CSF dynamics corresponded with those in patients with other neurosurgical disorders.

10 patients suffering from intracranial aneurysm causing subarachnoid hemorrhage (SAH) have been treated during the acute pre-and postoperatory phase with omega-aminocaproic acid. The blood and the cerebrospinal fluid of the treated patients have been analyzed in order to study fibrin(ogen) degradation products (FDP) and fibrinolytic activity (FA). The results so obtained show only an alteration of local fibrinolytic processes either inside or around the aneurysmatic clot: there were no alterations of the systemic FA. Furthermore, monitoring of FDP and FA was a very useful tool in those patients who took advantage of the treatment with omega-aminocaproic acid which protected them from rebleeding.

The aims of this paper are (1) to report post-operative angiographic results obtained in a series of 40 patients treated by an extra-intracranial arterial bypass (EIAB) procedure, and (2) to describe the patterns of postoperative regional brain perfusion (rBP), as investigated in a limited series of patients, by a new method.

Angiographie Studies: Sixty postoperative angiographies of 40 consecutive patients treated by EC-IC bypass were reviewed. Major results can be expressed as follows. Total patency rate (early and late controls) in approx. 95% of cases, with patency increasing on subsequent studies. Enlargement of donor artery in 50%. Intracranial steal reduction in 10%. Enlargement of pre-existing collaterals in 6%.

In order to further evaluate the role of intracranial pressure (ICP) monitoring in brain injured, comatose patients, in terms of both prognostic significance and usefulness for treatment, our total series of monitored patients has been reviewed.

Continuous electroencephalographic (EEG) monitoring was done during 143 consecutive carotid endarterectomies in 130 patients to detect intolerance to cross-clamping. An intraluminal shunt was inserted when EEG changes appeared (in the first 100 procedures) or when EEG changes appeared and a long clamping time was supposed (in the last 43 cases). 121 patients had no EEG changes at clamping time and only 1 had a postoperative deficit due to embolization, which occurred before clamping and was revealed by a decrease of voltage on tracing. 15 patients showed early (within 4 min after clamping) changes and in 11 patients shunting led to the reversal of EEG anomalies in all cases but 2. The state of these 2 patients was worse after surgery, in one because of embolic problems, in the other (shunted 30 min after clamping) probably for hemodynamic reasons. 4 patients with early EEG changes, not shunted because of the short clamping time, had no neurological deficit. 7 patients, 2 of which were shunted, showed late (after 4 min) EEG changes. Only 1 nonshunted patient in this group awoke with a minor, transitory neurological complication. Moreover, EEG changes have been correlated with the preoperative clinical condition and with the presence, on angiography, of contralateral carotid lesions. Also, EEG findings have been correlated with the computed tomography data (in 71 cases) and with the values of interior carotid artery (ICA) back pressure (in 58 cases). No possibility to predict the tolerance to clamping appeared from these correlations. However, a relatively higher risk of intolerance to clamping in patients with contralateral ICA occlusion was noted.(ABSTRACT TRUNCATED AT 250 WORDS)

Indications for superficial-temporal-artery—middle-cerebral-artery (STA-MCA) anastomosis are becoming more and more clear. Some centers performing this type of surgery are now presenting encouraging clinical followup results in a large number of patients treated. This supports the opinion that this procedure is going to become a common neurosurgical operation in the near future.

Alphaxalone — alphadolone (Althesin) causes a marked reduction of intracranial pressure (ICP, cerebral blood flow and metabolism (1,2). Thiopentone has a similar effect and has been successfully used against severe intracranial hypertension (HICP) in man (3).