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Purpose: Anterior decompression of the craniovertebral junction is reserved to patients with irreducible ventral bulbo-medullary lesions and rapidly deteriorating neurological functions. Classically performed through the transoral approach, the exposure of this region can be now achieved by a minimally invasive endonasal endoscopic approach (EEA)., Methods: Four patients with irreducible, anterior bulbo-medullary compression due to rheumatoid pannus and basilar invagination were enrolled. The imaged-guided EEA was used to resect the odontoid process, trying to preserve the C1 anterior arch., Results: Neurological improvement and adequate bulbo-medullary decompression were obtained in all patients. In two cases, anterior C1 ring was preserved. These patients did not required a posterior fusion., Conclusions: Compared with the standard transoral technique, the EEA provides the same good exposure but with potentially less complications. The preservation of the anterior C1 arch can contribute to avoid cranial settling and posterior fusion with its related risk of subaxial instability.

Although the spine is frequently involved in metastatic Ewing's sarcoma, primary involvement of the spine, beside sacrum, is much less frequent, especially in adult patients. Because of the low incidence of these tumors, there are currently no clinical guidelines outlining their management and a multitude of therapeutic strategies have been employed with varying success. The definitive management of Ewing's sarcoma of the spine, as in other locations, could include the combination of three main modalities: aggressive surgery, radiotherapy, and combined chemotherapy. Whenever possible, en bloc spondylectomy or extralesional resection is preferable, providing a better oncological result with a longer survival and a better preservation of the spine biomechanics. This is the lesson we learned about the case, we present here, of nonmetastatic lumbar localization by Ewing's sarcoma in as adult patient.

Background: Various methods of fixation have been described for custom made hydroxyapatite cranial implants. Their poor malleability limits most of the common used fixation techniques because of the high risk of cranioplasty's fracturing or higher exposure to infections. We present our experience with a new fixation technique, based on an appositely premodified hydroxyapatite implants., Methods: In a 2-year time period, 12 patients underwent cranioplasty by a modified custom made porous hydroxyapatite implant. Once the three-dimensional computer model of the prostheses was performed, three semicircular extensions placed at strategic positions were drawn and the final prosthesis was realized. At surgery, holes fitting the extensions were drilled into the skull borders and the implant was easily embedded inside the defect. Small titanium meshes overlying the extensions were fixed by screws to the surrounding bone., Results: A minimal increase of operative times was recorded, with drilling and fixation requiring additional 30 and 15 minutes, respectively. Optimal contact between cranioplasty and skull borders was always observed at control computed tomography (CT) scans. Permanent rigid fixation was obtained in all cases, with good functional and aesthetic results at follow-up., Conclusions: Modifications of hydroxyapatite implants are obtained without additional costs. The minimal increase of operative times is largely counterbalanced by optimal fixation results. Finally, the bone drilling and the immediate proximity of bone to prosthesis might enhance the potential for osteogenesis and osteointegration.

The co-occurrence of a vestibular schwannoma and a low-grade glioma is rare, and even rarer is the association with an oligodendroglioma. Although various authors have addressed the problem of treating patients with incidentally discovered indolent low-grade gliomas, an established protocol does not exist to date. The common approach is to reserve surgery until there is radiological evidence of tumor growth or high-grade transformation. However, because incidental low-grade glioma may represent the first stage of unavoidable pathological progression towards high-grade glioma, early and radical surgical resection should be advocated in order to increase the chance of a "cure" and prolonged survival. This case report supports this view, and suggests reflection on a possible change from a conservative philosophy to preventative surgical treatment.

Paravertebral titanium rod migration represents an unusual and potentially fatal complication of vertebral stabilization surgical procedures. This condition, which requires a prompt and rapid diagnosis, is often mistaken for other more common diseases, or scotomized. We present a case of a 69 years old female affected by a non-Hodgkin lymphoma with evidence of migration of both rods five years after the posterior stabilization procedure for a pathological L3 fracture. Unusual clinical onset was represented by a left S1 radiculopathy without other symptoms. For several months, the symptoms were attributed to a possible radicular infiltration by the lymphoma. We conclude that paravertebral rod migration could happen not only within the spinal canal, but could also rarely damage blood vessels or parenchymal organs. This is generally a long-term complication, probably due to an insufficient fixation. Strict long-term follow-up monitoring is mandatory since this unusual complication can mimic other more common pathological conditions.

We used light and electron microscopic immunocytochemical techniques to analyze the distribution, cellular and synaptic localization of EAAT2, the main glutamate transporter, in normal human neocortex. EAAT2a-immunoreactivity (ir) was in all layers and consisted of small neuropilar puncta and rare cells. In white matter EAAT2a+ cells were numerous. Electron microscopic studies showed that in gray matter ∼77% of immunoreactive elements were astrocytic processes, ∼14% axon terminals, ∼2.8% dendrites, whereas ∼5% were unidentifiable. In white matter, ∼81% were astrocytic processes, ∼17% were myelinated axons, and ∼2.0% were unidentified. EAAT2a-ir was never in microglial cells and oligodendrocytes. Pre-embedding electron microscopy showed that ∼67% of EAAT2a expressed at (or in the vicinity of) asymmetric synapses was in astrocytes, ∼17% in axon terminals, while ∼13% was both in astrocytes and in axons. Post-embedding electron microscopy studies showed that in astrocytic processes contacting asymmetric synapses and in axon terminals, gold particle density was ∼25.1 and ∼2.8 particles/μm(2), respectively, and was concentrated in a membrane region extending for ∼300 nm from the active zone edge. Besides representing the first detailed description of EAAT2a in human cerebral cortex, these findings may contribute to understanding its role in the pathophysiology of neuropsychiatric diseases.

Early postoperative seizures are defined as those that appear within the first week after surgery and are a well-known and feared complication in patients with supratentorial brain tumors. Few studies have investigated the value of pharmacological prophylaxis in the prevention of postoperative seizures in these patients and their outcome has not been consistent. Furthermore, the efficacy of the new generation of antiepileptic agents in the prophylaxis of perioperative seizures has not been assessed so far. We analyzed the data related to 150 patients harboring supratentorial brain gliomas with the aim to assess the efficacy of oxcarbazepine in preventing the occurrence or the recurrence of early postoperative seizures and its tolerability when it is rapidly titrated. Only four patients (2.7%) experienced seizures within the first week after surgery. Patients did not report disturbances during the titration phase. Regarding adverse events in the first week, six patients (4%) showed minor skin rash. Persistent symptomatic hyponatremia never occurred. Our data showed that oxcarbazepine can be a good alternative to traditional antiepileptic agents in the prevention of perioperative seizures being efficacy, ease of use (rapid titration in 3 days, not requiring close plasma concentration monitoring) and good tolerability (no major side effects during titration and during the first postoperative week) the key factors. Moreover, oxcarbazepine can be a valid choice when long-term therapy is required because of the low interaction with other drugs and the low hematological side effects.

Introduction: Vagus nerve stimulation (VNS) is an effective alternative treatment for patients with partial refractory epilepsy. Nevertheless, information regarding VNS in children is still limited., Materials and Methods: The clinical efficacy, safety and neuropsychological effects of VNS in 34 children (mean age 11.5 years) with drug-resistant epilepsy were studied. Mean follow-up was 30.8 months. Nine patients have been diagnosed with Lennox-Gastaut Syndrome, nine patients were affected by severe partial epilepsy with bisynchronous EEG and drop attacks, and 16 patients suffered from partial epilepsy without bisynchronous EEG and fall seizures. Forms were designed for prospective data collection on each patient's history, seizures, implants, device settings, quality of life (QOL), neuropsychological assessment and adverse events. Surgical technique was performed both by standard two incisions and single neck incision., Results: Mean reduction in total seizures was 39% at 3 months, 38% at 6 months, 49% at 12 months, 61% at 24 months and 71% at 36 months. Significant better results were obtained in partial epilepsy, with and without drop attacks, than in Lennox-Gastaut syndrome--three patients being seizure-free. No operative morbidity was reported. Side-effects were minor and transient--the most common were voice alteration and coughing during stimulation. In two patients, electrode breakage occurred 3 years after surgical procedure; in both cases, a new device was implanted after removing the vagal electrode coils and generator., Conclusion: VNS can be considered an appropriate strategy as an add-on treatment in children affected by drug-resistant partial epilepsy and ineligible for resective epilepsy surgery.

Chronic subthalamic nucleus deep brain stimulation (STN-DBS) is an efficacious treatment for idiopathic Parkinson's disease (PD) that cannot be further improved by medical therapy. We present a case of an individual with juvenile parkinsonism caused by homozygous deletion of exon 3 in the parkin gene with disabling long-term side-effects from levodopa who underwent bilateral STN neuromodulation. Parkin-linked parkinsonism may show clinical features different from sporadic PD, yet it shares levodopa responsiveness. Because levodopa responsiveness is a predictor of STN-DBS efficacy, we argued that this kind of surgical approach might be efficacious in hereditary parkin-linked juvenile parkinsonism. We evaluated clinical and functional assessment before and 12 months after surgery. The results showed that the Unified Parkinson Disease Rating Scales Motor score improved by 84% in our patient, the levodopa equivalent daily dose medication (LEDD) was reduced by 66%, and, finally, disabling and severe dyskinesias disappeared., (2004 Movement Disorder Society.)

Aim: High frequency stimulation of the subthalamic nucleus (STN) is gaining recognition as a new symptomatic treatment for Parkinson's disease (PD). The first available long-term observations show the stability of the efficacy of this procedure in time., Methods: Quadripolar leads were implanted bilaterally under stereotactic conditions in the STN of patients with advanced PD. High frequency stimulation was applied for 24 hours a day. Following implant, antiparkinsonian medication was reduced as much as possible and stimulation was gradually increased. The patients were evaluated in the practically defined "off" condition and in the "on" condition using the unified PD rating scale (UPDRS) and the Schwab & England scale. Neuropsychological testing was performed before and after the implant. Thirty-three patients were followed up for at least 3 months and 13 among them until 36 months., Results: The patients had a mean age of 56.8+/-7.1 years and a mean disease duration of 13.8+/-5.5 years; they were followed-up for an average of 25.7+/-13.5 months. At the time of the last available visit, the stimulation amplitude was 2.47+/-0.40 V (the total energy delivered averaged 1.57+/-0.8 microW). The levodopa-equivalent daily dose was reduced by 56.2% (p<0.001). Parkinsonian features were improved in all patients, the greatest changes were seen for tremor, gait, bradykinesia and postural stability, then rigidity and limb akinesia. Compared with the pre-implant conditions, the UPDRS motor score in the "off" condition was improved by 51.6% at the time of the last visit (p<0.001), the UPDRS activities of daily living score was improved by 68.5% (p<0.001), the Schwab & England scale was improved by 196.8% (p<0.001). The neuropsychological data did not show significant changes. Night sleep improved in all patients, due to increased mobility at night. In almost all patients insomnia was resolved. All patients gained weight after surgery with an increase of 11.1% (p<0.001) compared to their pre-implant weight. The most common permanent side effects consisted in hypophonia and dysarthria, transient side effects were increased sexuality and mania, the most common side effects related to stimulation were ballic or choreic dyskinesias. The most common adverse event related to the surgical procedure was transient psychosis; unexplained switching-off of the stimulator was the most common device-related effect., Conclusion: This study extends our recently published 3-years FU series. It confirms again that symptomatic efficacy of STN stimulation is retained during the 2(nd) and 3(rd) years following the implant, without any obvious decay of efficacy or need for increase of energy delivered. Improvement of dyskinesias also persists and the procedure is well tolerated. Side effects and adverse events are sometimes severe, but can be managed in most cases. The improvement of daily living activities outweighs by far the motor benefit, indicating that the use of this procedure significantly improves the patients' lifestyle.

In order to identify the incidence, risk factors and prognostic indicators of postneurosurgical bacterial meningitis, a 9-y retrospective cohort study was performed. The cohort comprised 3580 individuals who underwent neurosurgical operations at the Department of Neurosurgery of Catholic University, Rome, a 1,700-bed university hospital. We observed 52 episodes of postneurosurgical meningitis, with infection rates of 1.4/100 patients, 0.8/100 operations for craniotomies and 2.6/100 operations for internal cerebrospinal fluid (CSF) shunt or ventriculostomy with external drainage. The overall infection rate decreased from 2.5/100 operations in 1989 to 0.9/100 in 1997 (p = 0.03). Logistic regression analysis indicated that duration of ventriculostomy with external drainage [p < 0.01; odds ratio (OR) = 9.67; 95% confidence interval (CI) = 2.44-38.321 and increasing value of the APACHE III score (p <0.01; OR = 8.51; 95% CI = 2.15-33.68) were independent risk factors for development of meningitis. The overall case fatality rate was 8%. Predictors of mortality were low ( < 1.66 mmol/l) CSF glucose concentration (p = 0.001), increasing value of the APACHE IIl score (p = 0.002) and Gram-negative aetiology (p = 0.003).

This is a report of clinical manifestation, physical findings, neurophysiological data, magnetic resonance imaging, and results after surgery in a 71-years-old man with cervical abscess. Magnetic resonance imaging after two weeks of empiric antibiotic therapy demonstrated the persistence of an anterior cervical epidural collection and signs of spondylodiscitis at the C5-C6 and C6-C7 levels. Surgery was performed by posterior endoscopy assisted key-hole approach at the C2-C3 level to drain the abscess and to decompress the spinal cord. Postoperative specific medical treatment was then administered. A successful outcome, at 24 months follow-up, was achieved by surgery with complete clinical recovery, resolution of the abscess and healing of the spondylodiscitis. After unsuccessful blind medical therapy the minimally invasive microsurgical technique allowed us to keep the surgical injury of the healthy tissue to a minimum while producing the maximum therapeutic effect.

Seventy-three patients with subcortical or deep-seated brain tumours have been operated on with the aid of intraoperative ultrasonography. Forty-one had metastases and thirty-two primitive neuroepithelial neoplasms. In all cases ultrasonography allowed an easy and precise localization of the tumours. The removal was gross total in 45 cases (61.6 per cent), subtotal in 17 (23.3 per cent) and partial in 11 (15.1 per cent). Preservation or improvement of the Karnofsky Performance Status was obtained in 63 patients (86.3 per cent), with a morbidity and mortality rate of 11 and 2.7 per cent respectively. Our results indicate that ultrasound guided microsurgery represents a handy, reliable and relatively low risk procedure for the treatment of intra-axial brain tumours.

Four meningiomas and six neuroepithelial tumors were assayed for the presence of estrogen receptors (ER), type II estrogen binding sites (EBS) and progesterone receptors (PgR). ER were detected in 7 out of 10 cases with levels ranging between 2.5 and 20.7 fmoles/mg of cytosolic protein. On the contrary, PgR were found in all samples (10 cases) and their levels ranged between 8.8 and 130.6 fmoles/mg of cytosolic protein. All tumor samples expressed appreciable amounts of type II EBS ranging between 452 and 2320 fmoles/mg of protein. Although the precise functional role of type II EBS is still unknown, their presence may reflect an hormonal sensitivity of these tumors.

Between 1980 and 1988, 16 patients (9 females, 7 males) with malignant neuroepithelial tumors of the brain were treated by brachycurietherapy (BCT) and external radiation therapy (ERT) in a phase II nonrandomized study. There were 13 grade III and 3 grade IV tumors according to the WHO classification. Five patients in the grade III group who showed anaplastic foci in a generally grade II background were separately examined. Six patients received only BCT whereas 10 patients were treated by a combination of BCT and ERT, according to the tumor volume. We utilized as radioactive sources 192Ir in 14 cases and 125I in 2. Thirteen patients underwent permanent implant, 3 others received temporary irradiation with removable afterloaded catheters. The target volume was less than 50 cc in 8 cases, between 50 and 100 cc in 7, and larger than 100 cc in 1 patient. The total dose at the periphery of these volume ranged between 70 and 144 Gy. The result were analyzed referring to the following aspects: performance status, survival, side effects, grading. The impact of BCT was analyzed especially in a grade III with anaplastic foci group which showed a median survival of 6 years compared with only 2 years median survival of the pure grade III group.

Progression represents the qualitative tumor evolution during the time. Recently it received great consideration, mainly since the introduction of the neuroradiological imaging (CT and MRI). A series of 224 supratentorial astrocytic tumors of the juvenile and adult age have been analyzed: we found the morphological features of progression in 26% of them. These data introduce, perhaps, the most important information about progression: the "crisis" of the concept that low-grade tumors are stable lesions during the time.

Brachicurietherapy represents a low dose-rate irradiation able to deliver high focal doses within relatively small tumor volumes. Its application to brain tumors utilizing the stereotactic techniques is nowadays considered with growing interest. The Authors analyze, on the basis of their personal experience, the possibilities and the limits offered by this therapeutic procedure in neuro-oncology. The choice of the sources and their modality of application, the definition of the optimal dose/time and dose/volume ratio are the main problems taken into consideration and discussed.