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Objective To analyze the risk factors of worst outcome associated with moderate head injury. Methods Data on patients with moderate head injury were collected prospectively in 11 Italian neurosurgical units over a period of 18 months. Patients older than 18 years with blunt head injury and at least one Glasgow Coma Scale (GCS) score between 9 and 13 were enrolled. The outcome was determined at 6 months using the Glasgow Outcome Scale. Results We analyzed 315 patients. Initial computed tomographic scans showed a diffuse injury type I or II in 63%, a mass lesion in 35%, and traumatic subarachnoid hemorrhage in 42% of the patients. The risk of progression toward a mass lesion was 23% when the admission computed tomographic scan showed diffuse injury type I or II. An emergency craniotomy was performed in 22% of the patients, delayed surgery was performed in 14%, and both were performed in 25%. A favorable outcome was obtained in 74% of the patients. When the GCS score was 9 or 10, the predictor of worst outcome was a motor GCS score of 4 or lower (odds ratio [OR], 8.08; 95% confidence interval [CI], 1.22-67.35; P = 0.008), but when the GCS score was 11 to 13, the factors associated with worst outcome were neuroworsening (OR, 3.43; 95% CI, 1.45-8.17; P = 0.002), seizures (OR, 7.94; 95% CI, 1.18-64.48; P = 0.02), and medical complications (OR, 4.24; 95% CI, 1.74-10.33; P = 0.0006). Conclusion There is a high percentage of surgery and worsening on computed tomographic scans in patients with moderate head injury. Neuroworsening, seizures, and medical complications as outcome predictors were more strongly associated with a GCS score of 11 to 13, whereas a low motor GCS score was more outcome-related in patients with GCS scores of 9 and 10.

We report 24 patients with a traumatic acute subdural haematoma of the posterior fossa managed between 1997 and 1999 at 8 Italian neurosurgical centres.Each centre provided data about patients' clinico-radiological findings, management, and outcomes, which were retrospectively reviewed.A poor result occurred in 14 patients (58.3%). Ten patients (41.7%) had favourable results. Patients were divided into two groups according to their admission Glasgow Coma Scale (GCS) scores. In Group 1 (12/24 cases; GCS score,or =8), the outcome was favourable in 75% of cases. In Group 2 (12/12 cases; GCS score,8), the outcome was poor in 91.6% of cases. Nineteen patients underwent posterior fossa surgery. Factors correlating to outcome were GCS score, status of the basal cisterns and the fourth ventricle, and the presence of supratentorial hydrocephalus. Multivariate analysis showed significant independent prognostic effect only for GCS score (P0.05).acute posterior fossa subdural haematomas can be divided into two distinct groups: those patients admitted in a comatose state and those with a moderate/mild head injury on admission. Comatose patients present usually with signs of posterior fossa mass effect and have a high percentage of bad outcomes. On the contrary, patients admitted with a GCS of 8 or higher are expected to recover. In these patients the thickness of the haematoma (1 cm) seems to be a guide to indicate surgical evacuation of the haematoma.

OBJECTIVE We report 81 patients with a traumatic intracerebellar hemorrhagic contusion or hematoma managed between 1996 and 1998 at 13 Italian neurosurgical centers. METHODS Each center provided data about patients' clinicoradiological findings, management, and outcomes, which were retrospectively reviewed. RESULTS A poor result occurred in 36 patients (44.4%). Forty-five patients (55.6%) had favorable results. For the purpose of data analysis, patients were divided into two groups according to their admission Glasgow Coma Scale (GCS) scores. In Group 1 (39/81 cases; GCS score, ≥8), the outcome was favorable in 95% of cases. In Group 2 (42/81 cases; GCS score, CONCLUSION This study describes clinicoradiological findings and prognostic factors regarding traumatic cerebellar injury. A general consensus emerged from this analysis that a conservative approach can be considered a viable, safe treatment option for noncomatose patients with intracerebellar clots measuring less than or equal to 3 cm, except when associated with other extradural or subdural posterior fossa focal lesions. Also, a general consensus was reached that surgery should be recommended for all patients with clots larger than 3 cm. The pathogenesis, biomechanics, and optimal management criteria of these rare lesions are still unclear, and larger observational studies are necessary.

Viene valutato il flusso ematico cerebrale mediante indagine Xenon-TAC in 11 traumi cranio-cerebrali gravi (GCS all'ingresso uguale od inferiore a 8) con quadro TAC morfologico di lesione diffusa secondo la classificazione di Marshall. La quantificazione della perfusione ematica cerebrale, confrontata con i valori attesi di norma permette, fin dalla fase acuta del trauma attendibile giudizio prognostico che si è dimostrato statisticamente significativo sia per il sottogruppo di pazienti con favorevole evoluzione clinica che per quelli con sfavorevole evoluzione valutata al follow-up di 3 e 6 mesi, rispetto ai valori stimati su un campione di pazienti sani. In particolare l'analisi statistica (eseguita con il “Chi Test”) ha dimostrato significatività di valori flussimetrici sia a livello dei nuclei della base che in sede corticale mentre minor significatività è stata rilevata per i valori di flusso valutati a livello dell sostanza bianca e globalmente in sede emisferica.

A rare case of persistent intractable hiccup as presenting symptom of cavernous angioma in the medulla oblongata is reported. Pathophysiologic hypotheses about the triggering mechanism of hiccup are discussed, with special reference to the causes affecting the central nervous system. A review of the literature concerning medullary lesions presenting with persistent hiccup is also reported. Finally we have included some brief considerations about cavernous angiomas and the patterns of their clinical presentation, focusing on those located in the medulla oblongata.

Although pharmacological GH stimulation tests are still considered the gold standard for GH deficiency (GHD) diagnosis, they are burdened by poor specificity. The majority of children diagnosed as having GHD show normal GH responses when re-tested at the end of growth, thus questioning the initial diagnosis. We evaluated the concordance between IGF-I levels and GH responses to provocative tests.We analyzed 105 GHRH plus arginine tests, 79 arginine tests, and 124 clonidine tests performed in 192 short children. IGF-I levels ≤-2SD score (SDS) were considered suggestive for high likelihood of GHD. The percentage of positive and negative results for each test was determined and compared with IGF-I levels, clinical follow-up and response to therapy.In children with IGF-I-2SDS the arginine test showed a concordance rate of 6.9%, the clonidine test of 28.6%, and GHRH plus arginine test of 70%. In children with IGF-I≤-2SDS the concordance was 96.1%, 85.7%, and 46.4%, respectively. The overall concordance was 66.7% for GHRH plus arginine, 42.7% for clonidine, and 27.8% for arginine tests.Our results suggest that GHRH plus arginine test provides the best concordance with the assessment of IGF-I levels thus suggesting that the combination of the two procedures may significantly reduce the need of a second provocative test.

This is a report of 33 consecutive cases of petroclival meningioma treated surgically at our institution over the last 10 years; there were 21 women and 12 men between the ages of 27 and 68 (mean age, 52). All patients were assessed by computed tomographic scans including coronal sections and bone algorithm studies; in most cases, digital subtraction angiography and magnetic resonance imaging were also done. The largest tumor diameter was between 2 and 3.5 cm in 14 cases, 3.5 to 6 cm in 15 cases, and over 6 cm in 4 cases. Dural attachment predominantly involved the clivus and apical petrous bone on one side only; in 14 cases, however, the tumor grew over the clivus midline or crossed the tentorial notch. Cranial nerve deficit was extant in all cases and was commensurate with tumor size. Cerebellar signs and somatic motor deficits were present in 60 and 30% of cases, respectively. The surgical approaches used were the retromastoid-retrosigmoid in 23 cases, subtemporal in 5 cases, and combined retromastoid subtemporal presigmoid in the remaining 5. Total removal was achieved in 26 cases (79%); incomplete removal occurred in 7 cases (21%). The extent of tumor removal and operative morbidity were not significantly related to tumor size. Brain stem indentation, arterial and cranial nerve encasement, and epidural invasion were the main factors that prevented total tumor removal and influenced operative morbidity. There was no intraoperative mortality, but three patients (9%) died perioperatively. In the postoperative period, most patients went through momentary neurological deterioration, chiefly due to new cranial nerve deficits. The average follow-up was 4.3 years in 27 patients; of these 17 were unchanged and 10 were improved. Before surgery, only 13 patients were self-sufficient; at long-term follow-up, another 6 had achieved independence. Our experience suggests that, even though real petroclival meningiomas still represent a formidable surgical challenge, such tumors can in most cases be removed completely with low attendant mortality and acceptable morbidity.

Surgical treatment of ventricular dilatation following severe head trauma (GCS8) remains controversial due to the difficulty to distinguish brain atrophy-related ventriculomegaly from active, symptomatic ventricular dilatation. Consequently, the reported incidence of post-traumatic hydrocephalus in literature varies greatly from 0.7-29%. The presence of ventricular dilatation following severe head trauma should be considered and demands investigation, based also on satisfactory results obtained with cerebrospinal fluid (CSP) shunting,Ninety-eight patients with post-traumatic hydrocephalus undergoing CSF shunting were selected for this study among 4,044 patients with severe head trauma treated from 1972 to 1999 at the Department of Neurosurgery at the City Hospital of Verona. Patients included 82 (84%) males and 16 (16%) women, ranging from one month to 83 years (mean age; 39 years). In 24 (24%) cases, the brain trauma lesion was single, while in 74 (76%) cases the patient suffered multiple cranio-cerebral lesions. The total number of lesions was 230 including 214 (93%) supratentorial and 16 (7%) posterior cranial fossa (PCF) lesions. Seventy-nine operations were performed on 59 (60%) patients. The onset of hydrocephalus was immediate after trauma in 14 (14%) cases, whereas a delayed onset was observed within 30 days in 44 (45%) cases, between one-four months in 30 (31%) cases and between four-six months in 10 (10%) cases. Of the 98 patients in this study, 15 were treated with an external CSF shunt and 83 underwent internal CSF shunting.Long-term results of the 15 patients with external shunts demonstrated good recovery in 13% while 87% of cases resulted in death. In the 83 cases of internal shunts, despite severe preoperative conditions (75% in coma or persistent coma), the results were as follows: good recovery in 37 (45%) patients, partial disability in nine (11%), persistent coma in 29 (35%) and death in seven (8%) cases.Post-traumatic hydrocephalus is a complication that must always be considered in cases of severe head trauma (GCS8) in young patients presenting added neurological deficits, ceased clinical improvement (ceased improvement after initial improvement), increased hypertonia, surgical flap tension or CSF accumulation. The results of this study suggest the necessity to treat post-traumatic ventricular dilatation with aggressive surgery and CSF shunting, based on favorable outcome seen even in coma and persistent coma patients.

A case of a patient with an accidentally discovered scalp mass is presented. Radiological investigation documented an osteolytic intradiploic lesion of the cranial vault. The lesion was surgically removed and histological examination revealed a meningioma. The literature concerning these uncommon tumours of the skull is reviewed, and the differential diagnosis is discussed.

OBJECTIVE: Currently, the surgical approach to olfactory meningiomas can vary depending on the size and expansion of the tumor, although surgical treatment still relies on the anterior bilateral craniotomy. Since 1989, we have use the pterional approach as a standard procedure in the treatment of 37 consecutive cases. We present our results in an attempt to contribute an alternative and valid surgical strategy for the treatment of these tumors. METHODS: Between 1989 and 1996, a series of 37 consecutive patients underwent microsurgical tumor resection using the unilateral pterional approach; all patients except one underwent operations on the right side. In 23 patients (62%), the tumor diameter measured approximately 6 cm, and the size was less than 4 cm in only 5 patients. The clinical presentation included mental dysfunction in 27 patients and visual impairment in 16 patients. The advantages of this approach are the early recognition of the posterior cerebrovascular complex, followed by a safe, rapid, and complete devascularization of the tumor and later by a favorable dissection of the capsular area from the frontal vascular branches and parenchyma. RESULTS: Total removal was achieved in all cases. There was one death unrelated to surgery. All patients presenting with mental dysfunction or with preoperative visual deficits recovered or improved. Postoperative magnetic resonance imaging confirmed complete tumor removal and demonstrated the brain parenchyma to be preserved and intact, primarily on the side opposite from the craniotomy. CONCLUSION: Our experience with the pterional approach suggests a greater role for this procedure in the treatment of olfactory groove meningiomas.

Brain-stem auditory evoked responses (BAERs) and Blink Reflex (BR) were evaluated in 7 patients with brain-stem cavernous angiomas (CA). The average size of the lesions, measured by the maximum diameter as shown by magnetic resonance imaging (MRI), was 18 mm. Five lesions were located in the pons, 1 in the ponto-mesencephalic junction and 1 in the midbrain; 5 lied on the left side, 2 on the right. We compared the accuracy and sensitivity of the BAERs and BR methods with that of physical examination and of MRI. Both BAERs and BR seem sensitive tools in revealing brain-stem dysfunction. Of the two, BAERs are more specific for side and location (especially for lesions situated in the lower pons) and correlate with ear impairment, even if some lesions are silent since they do not involve the acoustic pathways. BR disclosed abnormalities of duration prevalently, but no typical patterns regarding location and clinical signs.

This is a report of 33 consecutive cases of petroclival meningioma treated surgically at our institution over the last 10 years; there were 21 women and 12 men between the ages of 27 and 68 (mean age, 52). All patients were assessed by computed tomographic scans including coronal sections and bone algorithm studies; in most cases, digital subtraction angiography and magnetic resonance imaging were also done. The largest tumor diameter was between 2 and 3.5 cm in 14 cases, 3.5 to 6 cm in 15 cases, and over 6 cm in 4 cases. Dural attachment predominantly involved the clivus and apical petrous bone on one side only; in 14 cases, however, the tumor grew over the clivus midline or crossed the tentorial notch. Cranial nerve deficit was extant in all cases and was commensurate with tumor size. Cerebellar signs and somatic motor deficits were present in 60 and 30% of cases, respectively. The surgical approaches used were the retromastoid-retrosigmoid in 23 cases, subtemporal in 5 cases, and combined retromastoid subtemporal presigmoid in the remaining 5. Total removal was achieved in 26 cases (79%); incomplete removal occurred in 7 cases (21%). The extent of tumor removal and operative morbidity were not significantly related to tumor size. Brain stem indentation, arterial and cranial nerve encasement, and epidural invasion were the main factors that prevented total tumor removal and influenced operative morbidity. There was no intraoperative mortality, but three patients (9%) died perioperatively. In the postoperative period, most patients went through momentary neurological deterioration, chiefly due to new cranial nerve deficits. The average follow-up was 4.3 years in 27 patients; of these 17 were unchanged and 10 were improved. Before surgery, only 13 patients were self-sufficient; at long-term follow-up, another 6 had achieved independence. Our experience suggests that, even though real petroclival meningiomas still represent a formidable surgical challenge, such tumors can in most cases be removed completely with low attendant mortality and acceptable morbidity.

Updating a previous report, the authors offer a review of 45 patients between age 2 and 63 treated by direct surgical excision for brainstem tumours of various description. Since 1986 all candidate patients were examined by NMR imaging in addition to CT scanning, sometimes with the further addition of digital-subtraction vertebral angiography. By Epstein and McLeary's criteria, 24 of the tumours were focal, 12 were cervicomedullary and 9 were diffuse. The most frequent histological diagnosis was glioma (36 cases between low-grade astrocytoma, anaplastic astrocytoma and glioblastoma); the balance was provided by cavernoma (6 cases), haemangioblastoma (2 cases), and lipoma (2 cases). Gross total resection was achieved in 28 patients, namely all those with ependymoma or vascular tumours and 14 of 17 with low-grade astrocytoma. Resection was subtotal in 16 cases and confined to a generous biopsy in one. There was no operative mortality, but 2 deaths occurred in the early postoperative period. At discharge, neurological status was unchanged or improved in 35 cases. At 3-month follow-up examination, 12 patients were improved, 27 were unchanged and 3 were worsened. By January 1990 (6 to 72 months postoperatively) 27 of the first 40 patients treated were alive: 13 had resumed normal life, 6 were self-sufficient and 8 were disabled. The authors conclude that present-day microsurgical resection of intra-axial brainstem tumours is associated with low mortality and morbidity and affords favourable results for which they credit high-quality NMR imaging, efficient microsurgery, adequate anesthesia, and competent postoperative intensive care.

Between 1987–1990 a series of 43 consecutive patients with inoperable brain tumors, either recurrent malignant gliomas (26 cases) or intracranial metastases (17 cases) have been treated with oral methylprednisolone megadose in our department, for a total amount of 35 evaluable (1 completed cycle) cases: 22 recurrent gliomas and 13 metastases. Eligibility criteria included a Karnofsky score over 40, age over 18, no further indications for surgery or radiation therapy. Pre-treatment grading was based upon a neurological, radiological (CT scan) and performance score. Oral methylprednisolone megadose schedule ( 1 cycle: 300 mg/sq.m. p.o./alt. days q 10–12 wks) was immediately withdrawn if non-tolerated or suspended after 1 cycle if ineffective. Each single cycle was routinely followed by a day-hospital re-grading with laboratory controls. Even though a long-term follow-up is still under evaluation, preliminary results indicate an improved quality of life, with no steroid-dependency and a dramatic decrease in gastro-enteric side-effects.

Updating a previous report, the authors offer a review of 45 patients between age 2 and 63 treated by direct surgical excision for brainstem tumours of various description. Since 1986 all candidate patients were examined by NMR imaging in addition to CT scanning, sometimes with the further addition of digital-subtraction vertebral angiography. By Epstein and McLeary’s criteria, 24 of the tumours were focal, 12 were cervicomedullary and 9 were diffuse. The most frequent histological diagnosis was glioma (36 cases between low-grade astrocytoma, anaplastic astrocytoma and glioblastoma); the balance was provided by cavernoma (6 cases), haemangioblastoma (2 cases), and lipoma (2 cases). Gross total resection was achieved in 28 patients, namely all those with ependymoma or vascular tumours and 14 of 17 with low-grade astrocytoma. Resection was subtotal in 16 cases and confined to a generous biopsy in one. There was no operative mortality, but 2 deaths occurred in the early postoperative period. At discharge, neurological status was unchanged or improved in 35 cases. At 3-month followup examination, 12 patients were improved, 27 were unchanged and 3 were worsened. By January 1990 (6 to 72 months postoperatively) 27 of the first 40 patients treated were alive: 13 had resumed normal life, 6 were self-sufficient and 8 were disable. The authors conclude that present-day microsurgical resection of intra-axial brainstem tumours is associated with low mortality and morbidity and affords favourable results-for which they credit high-quality NMR imaging, efficient microsurgery, adequate anesthesia, and competent postoperative intensive care.

Activated cellular oncogenes have frequently been reported in primitive neuroectodermal tumors. As regards malignant gliomas, either primary tumors or cell lines, gene amplifications, rearrangements, overexpressions of a spectrum of oncogenes have been described.

This study reports the preliminary results obtained in a series of 107 patients with histologically proven malignant gliomas (86 glioblastomas and 21 anaplastic astrocytomas) operated upon between 1986 and 1989, with an aggressive attitude aimed to achieve extensive and possible "radical" excision of the tumor. Gross total removal was achieved in 62% of cases, while in the remaining the postoperative contrast enhanced CT scan showed more than 10-15% of residual tumor mass. There was no operative and postoperative mortality. The one-year survival rate was 60% in patients with total removal and 24% in those with partial resection. Furthermore the Karnofsky rating at discharge was improved in the former group while was unchanged in the latter. Although preliminary, these data seem to confirm the primary positive role of radical surgery in the combined management of malignant gliomas.

1572 Background: The efficacy of temozolomide (TMZ) is strictly related to the possibility to reach and maintain high and prolonged cellular drug concentrations in the target tissue. Evidence exists demonstrating that the achievement of this goal and the subsequent activity of TMZ are categorically schedule dependent. Aim of the present randomized phase II study is to verify whether a treatment schedule with TMZ appropriately modified induces better response rates along with a decrease of mielotoxicity as compared to the conventional one. Methods: Twenty patients (5 F/15 M), median age of 53 years (range 35–74), median Karnofsky PS 90 (range 70–100), with GBM in progression after surgery and adjuvant RT have been treated as follows: Schedule A - TMZ for 5 days in a 28-day cycle, at the dose of 150 mg/m2/d at the first cycle and of 200 mg/m2/d thereafter, up to a total of 8 cycles. Schedule B - TMZ for 7 days alternating with 7 days of rest up to a total of 12 cycles: the starting dose of TMZ at the first cycle was 50 mg/m2/d with progressive serial dose escalations of 25 mg/m2/d in the subsequent ones until the achievement of the dose of 150 mg/m2/d at the 5th cycle, and then keeping this regimen until the 12th cycle. Results: They are summarized in the table : Severe thrombocytopenia and stomatitis have been observed only in patients treated with Schedule A. Conclusions: These preliminary results, which deserve to be confirmed in a larger sample size, indicate that the treatment with TMZ on alternate week basis is strongly interesting and promising. In spite of the modality and the small number of patients included in this study, which doesn’t allow a direct comparison between two different treatments, it should be noted that schedule B achieved a 2-year OS and PFS rate of 40% and 20% respectively, compared to 10% and 0% of schedule A. [Table: see text] No significant financial relationships to disclose.