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Occlusion of the intracranial internal carotid artery (ICA) by a pituitary adenoma with resulting cerebral ischemia is a very rare but devastating occurrence. The authors present a case in which a condition of symptomatic ICA occlusion due to a giant pituitary adenoma was successfully treated using a preliminary extraintracranial bypass as a "bridge" to the tumor removal. A 52-year-old patient presented with a minor stroke followed by pressure-dependent transient ischemic attacks consistent with a condition of hypoperfusion. MR imaging and a digital subtraction angiography revealed a pituitary adenoma occluding the ICA on the right side. He underwent a superficial temporal artery to middle cerebral artery (STA-MCA) bypass with the aim of revascularizing the ischemic hemisphere and reducing the risk of perioperative stroke or stroke evolution. The patient was subsequently operated on to remove the adenoma through a transsphenoidal approach. The postoperative course was uneventful and the patient has suffered no further ischemic events. When there are no emergency indications to decompress the optical pathways but the patient is at risk of impending stroke because of ICA occlusion, a two-step strategy consisting of a bypass and subsequent removal of the pituitary adenoma may be a valuable option.

Background: Anterior spinal surgery has a predominant role in the treatment of traumatic lesions of the subaxial cervical spine. Plating is considered indispensable to achieve stability but may cause dysphagia, dysphonia, and adjacent-level ossification. Zero-P (Synthes GmbH, Oberdorf, Switzerland), an anchored interdisc spacer, can be used without an associated plate. The present study aimed to test if this new implant would be associated with a low rate of dysphagia and other short-term complications compared with the standard for anterior spinal fusion surgery and would be able to achieve a solid fusion and maintain correct metamere alignment., Material and Methods: This is a preliminary presentation of a clinical case series of patients with subaxial cervical injuries who underwent anterior interbody fusion. From July 2009 until September 2011, 12 patients were treated with a Zero-P cage. The data for analysis included operating time compared with the standard for spinal fusion surgery with a cage plus plate construct, intraoperative blood loss, clinical and radiographic results, and complications., Results: In the postoperative period no patient had neurologic worsening. One patient experienced transient dysphonia and moderate dysphagia. All the patients were followed up for a minimum of 6 months (mean: 13 months; range: 6-27 months). Stability and fusion were obtained in all patients together with correct metamere alignment., Conclusion: We presented the preliminary results of a clinical case series. Our results support the initiation of prospective randomized trials with more patients and longer follow-up., (Georg Thieme Verlag KG Stuttgart · New York.)

Streptococcus pyogenes is a rare but aggressive cause of meningitis, which often evolves in a poor outcome with fatal consequences. Although lumbar puncture and CT scan of the brain are the gold standard of diagnosis of cerebral infections, they can have some limitations. We report and describe the clinical history and neuroimaging of a 36-year-old woman admitted to the emergency department of our hospital three days after the onset of earache and otorrhoea. When the patient developed an emergent refractory status epilepticus, the CT scan of the brain showed an unusual pneumocephalus. However, the MRI study of the brain revealed a pachymeningitis with partial thrombosis of the right transverse sinus and subdural empyema due to a S. pyogenes otitis media. Prompt diagnosis and the specific findings of the MRI allowed rapid correct treatment and thus led to a good outcome for the patient.

This report describes two elderly patients with large disc fragments extruded into lumbar radicular recesses not treatable by any conventional conservative, minimally invasive or surgical approach. Direct access to the disc fragments was obtained crossing the articular zygapophyseal cavity instead of the interlaminar space and spinal canal, using a small needle through which a laser fibre was inserted to deliver energy for tissue ablation. The procedures obtained regression of both symptoms and the bulk of the fragments at early and late clinical and MR follow-ups.

Purpose: Knowledge of the cumulative balance of sodium (CBS) is important for the diagnosis of salt disorders and water homeostasis and has the potential to predict hypovolemic status in acute neurological patients. However, an extensive application of the use of CBS is still lacking in the intensive care setting, where salt and water homeostasis represents a priority., Methods: Records of consecutive series of acute neurological patients admitted to a neurointensive care unit over a 6-month period were retrospectively reviewed. CBS was calculated at the admission to the Emergency Department. Discrimination between cerebral salt-wasting syndrome (CSWS) and the syndrome of inappropriate antidiuretic hormone secretion (SIADH) was performed on the basis of the classical criteria. Additionally, we used the findings of a negative CBS exceeding 2 mEq/kg for the diagnosis of CSWS. Two independent clinicians who were blinded to the CBS results performed diagnosis of the causes of hyponatremia and estimated the daily volemic status of the patients on the basis of clinical parameters. Logistic regression analysis was used to determine the independent prognostic factors of hypovolemia., Results: Thirty-five patients were studied for a total of 418 days. Four patients (11.4%) fitted the criteria of CSWS and three patients (8.5%) had SIADH. The unavailability of the CBS led to a wrong diagnosis in three of the eight hyponatremic patients (37.5%). The risk of developing hypovolemia in patients with negative CBS was 7.1 times higher (CI 3.86-13.06; p < 0.001). Multivariate analysis revealed that negative cumulative fluid balance, negative CBS >2 mEq/kg, and CVP ≤5 cmH2O were independent prognostic factors for hypovolemia., Conclusions: CBS is likely to be a useful parameter in the diagnosis of CSWS and a surrogate parameter for estimating hypovolemia in acute neurological patients.

Aneurysmal bone cyst is a pseudotumoral lesion. Complete resection prior to selective arterial embolization seems to be the treatment of choice for the more extensive and destructive lesions. In these cases maintaining stability of the cervical spine is critical. This can be very challenging in children and adolescents in whom the axial skeleton is still growing. In this case a young girl presented with a voluminous cervical aneurysmal bone cyst encaging both vertebral arteries and spinal cord. The lesion was treated with aggressive surgical resection, followed by cervical vertebral fusion with instrumentation. After nine months the patient referred no pain and no neurological deficit. MRI scans showed an extensive local recurrence. The family of the young girl refused any other therapy and any other followup. The patients returned to our attention after five years with no pain and neurological deficit. Cervical spine radiographs and MRI scans showed a complete regression of the extensive local recurrence. In the literature, the possibility of spontaneous regression of residual part or local recurrence is reported. The case of this young girl provided the chance to attend a spontaneous regression in an extensive recurrence of aneurismal bone cyst.

Candida osteomyelitis in the current literature is an emerging infection. The factors contributing to its emergence include a growing population of immunosuppressed patients, invasive surgeries, broad-spectrum antibiotics, injection drug users, and alcohol abuse. The diagnosis requires a high degree of suspicion. The insidious progression of infection and the nonspecificity of laboratory and radiologic findings may contribute to a delay in diagnosis. The current case concerns a 27-year-old man with a spinal cord injury who, after undergoing anterior cervical fixation and fusion surgery, developed postoperative systemic bacterial infection and required long-term antibiotic therapy. After six months, a CT scan demonstrated an almost complete anterior dislocation of the implants caused by massive bone destruction and reabsorption in Candida albicans infection. The patient underwent a second intervention consisting firstly of a posterior approach with C4-C7 fixation and fusion, followed by a second anterior approach with a corpectomy of C5 and C6, a tricortical bone grafting from the iliac crest, and C4-C7 plating. The antifungal therapy with fluconazole was effective without surgical debridement of the bone graft, despite the fact that signs of the bone graft being infected were seen from the first cervical CT scans carried out after one month.

The use of inhaled nitric oxide in patients with traumatic brain injury, intracranial hypertension, and acute respiratory distress syndrome (ARDS) has been reported in an intensive care unit setting only in a few case reports. The use of the prone position for patients with traumatic brain injury and lung impairment has been reported only in selected cases. Here we report our experience with the use of both inhaled nitric oxide and the prone position together in the operating room in a patient with head injury and ARDS who underwent column stabilization.