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The GDC endovascular approach represent an effective alternative to surgery for treatment of intracranial aneurysms. Anyway no data are available about the impact of endovascular embolization with GDC on overall outcome of patients with subarachnoid hemorrhage. We analyse retrospectively a series of 234 patients admitted for ruptured intracranial aneurysm. Results were then compared with results of three surgical series from the literature. The 95,7% of patients underwent aneurysm treatment; 56,4% of patients were classified as good recovery, 12,8% presented moderate disability, 10,3% were severely disabled, 3% were in persistent vegetative state and 17,5% were dead. Patients older than 60 years accounted for 37% of all cases and good outcome in this group accounted for 54,7%. Good results were obtained in 90,1%, 61,7% and 22,8% of patients with Hunt-Hess grade I–II, III and IV–V respectively. Finally good outcome was observed in 82,8% of patients with aneurysms of the posterior circulation. Introduction of GDC embolization in clinical practice contributed to the extension of indication for aneurysm treatment leading to a reduction of overall mortality. GDC utilisation does not affect the overall percentage of patients with good outcome reflecting an increase of severely disabled patients. Endovascular treatment seems an effective theraputic choice in selected grade I–II patients. Results in grade III patients suggest that surgery may be advantageous because of washing and decompression of the basal cisterns while results in grade IV and V patients are unsatisfactory. GDC embolization clearly improves the prognosis of patients with posterior circulation aneurysms and probably is an advantageous theraputic choice in elderly patients.

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 aim of this study is to review the clinical outcome of patients treated for spinal dural arteriovenous malformations and investigate the presence of pretreatment indicators of outcome after short- and midterm follow-up. The authors retrospectively reviewed the records of 65 consecutive patients treated either surgically or endovascularly in 3 neurosurgery departments between 1989 and 2009. After treatment, 80% of patients reported improvement of at least 1 symptom. Motor symptoms improved more than sensory disorders, pain, or sphincter impairment. Spinal dural arteriovenous fistulas at the thoracic level, and in particular at the lower level, responded better than those in other spinal areas. Spinal dural arteriovenous fistula is a rare pathology with a malignant course that should be treated aggressively. This study appears to confirm that neurological status before treatment, anatomical location of the fistula, and symptoms at presentation are all factors that can predict outcome. Early diagnosis of spinal dural arteriovenous malformations in the lower thoracic area in patients with an Aminoff scale score < 3 was associated with the most favorable outcome.

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.

OBJECTIVE: The outcome of treatment for a spinal dural arteriovenous fistula is unpredictable. In this study, we reviewed the outcome of patients treated for this condition, in relation to pretreatment indicators. METHODS: We reviewed the records of 37 consecutive patients treated either surgically or endovascularly in our department between 1989 and 2002. RESULTS: At follow-up, 78% of the patients reported improvement. Those with motor symptoms had the best outcome: improvement was achieved in more than 60% of the patients, amounting to 1 or 2 points on the Aminoff scale. Sensory disorders improved in 43% of cases, pain in 61%, and sphincter impairment in only 37%. Patients with a fistula in the lower thoracic region did better than those with fistulae in other locations. CONCLUSION: The clinical state before treatment is certainly relevant in predicting outcome. Age and duration of the symptoms before treatment have no direct relation to the chances of improvement with treatment, particularly when motor improvement is considered. The modality of onset of symptoms and location of the fistula play significant roles, also: a fistula in the lower thoracic segment was associated with more severe symptoms but tended to improve more (83%, P = 0.04) after treatment. Midthoracic and lumbar fistulae showed a lower incidence of improvement (

✓ Intracranial dural arteriovenous fistulas (AVFs) have been recognized as acquired lesions that can behave aggressively depending on the pattern of venous drainage. Based on the type of venous drainage, they can be classified as fistulas drained only by venous sinuses, those drained by venous sinuses with retrograde flow in arterialized leptomeningeal veins, and fistulas drained solely by arterialized leptomeningeal veins. Serious symptoms, including hemorrhage and focal deficit, are related to the presence of arterialized leptomeningeal veins. In this paper, the authors report a consecutive series treated between 1988 and 1993 of 20 cases of intracranial dural AVFs with “pure leptomeningeal drainage.” All patients underwent surgical interruption of the leptomeningeal draining veins. Based on the arterial supply, nine patients were managed by direct surgery, whereas 11 patients were prepared for surgery by means of preoperative arterial embolization. Radioanatomical cure of the fistula and good neurological recovery were achieved in 18 cases. Complete obliteration of the fistula was documented angiographically in two cases, but fatal hemorrhage occurred, probably due to partial thrombosis of the venous drainage. Based on this experience, the authors believe that surgical interruption of the draining veins is the best treatment option for intracranial dural AVFs. However, surgical results may be affected by the extension of postoperative thrombosis, which in turn may be related to the degree of preoperative venous engorgement.

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.

The authors report a case of leptomeningeal spinal metastasis of chiasmatic juvenile pilocytic astrocytoma. A 7-year-old boy underwent surgery and radiation therapy for a chiasmatic pilocytic astrocytoma. Three years later he experienced a syndrome of medullary compression. A lumbosacral intradural extra-axial tumor was discovered and subtotally excised. Pathologic examination revealed a metastasis of the chiasmatic tumor without any evidence of malignant transformation. Only five cases of leptomeningeal spinal dissemination of pilocytic astrocytoma have been previously reported. The authors review and discuss the clinical and pathologic features of these cases.

We report two rare cases of progressive myelopathy caused by intracranial dural arteriovenous fistulae with venous drainage into the spinal medullary veins. Both patients were referred to us with a history of progressively worsening quadriparesis. A posterior fossa dural arteriovenous fistula with spinal venous drainage was discovered by angiography in both cases. Treatment consisted of direct clipping of the venous drainage in one patient and of transarterial embolization and excision of the involved dural sinus in the other patient. Such procedures provided a radioanatomical cure and marked neurological recovery in both patients. Only 10 cases of progressive myelopathy caused by an intracranial dural arteriovenous fistula have been previously reported. Dysfunction of the cervical cord by venous engorgement is thought to be the most probable cause of the neurological symptoms in such cases.