Carotid-cavernous sinus fistulas (CCF) are abnormal communications between the carotid artery and the cavernous sinus. Most spontaneous CCFs are low-flow fistulas, supplied by branches of the omolateral internal carotid artery or the external carotid artery. A 64-year-old man, with increasing diplopia, mild exophthalmos on the left side, blurred left vision and omolateral red eye, was admitted to our institution. The patient underwent a bilateral cerebral angiography that showed a left CCF fed by meningo-hypophyseal branches of the right internal carotid artery and draining from the cavernous sinus into a parahippocampal vein. A transarterial embolization of the carotid-cavernous fistula was performed, with complete obliteration of the fistula. Although anecdotal reports exist, there is a scarcity of well-documented cases of exclusively contralateral flow in the carotid-cavernous fistula. Most of the reported cases referred to contralateral flow into the carotid-cavernous fistula by the external carotid artery branches. To the best of our knowledge, there are no previous cases of a spontaneous CCF supplied by contralateral meningo-hypophyseal branches. A discussion of treatment options and a literature review are also performed.

Hemangioblastomas of the filum terminale are particularly rare tumors. The authors present the case of a 62-year-old woman with a 6 month history of low-back-pain, who underwent surgery for the removal of an hemangioblastoma affecting the cauda at L2-L3 level. This highly vascularized tumour is tightly adherent to the filum terminale and hence is a very challenging pathology to remove. Histologically it consisted in vascular structures interposed to a network of capillary-like vessels, surrounded by stromal cells. MRI, angiography with pre-surgical embolization, and radical surgery represent the focal points in the diagnosis and treatment of these tumours. The most relevant literature has been carefully reviewed.

Spinal primitive neuroectodermal tumors (PNET) are very rare tumors, and intramedullary localization is even less common. Indeed, amongst the 23 cases of the spinal PNET described in the literature, only eight cases had an intramedullary localization. Following the WHO 2000 classification, PNETs have been considered embryonal tumors composed of undifferentiated neuroepithelial cells with a capacity of differentiation into different cellular lines, such as astrocytic, ependymal, melanotic and muscular. They have been considered to arise from a neoplastic transformation of primitive neuroepithelial cells, thereby making their presence possible in any part of the central nervous system. The optimal treatment for these malignant tumors is not yet clear, although, over the years, radiotherapy has been considered the best treatment for spinal PNETs. The described case is that of a 38-year-old man with a primary intra-extramedullary PNET, treated by laminectomy, open biopsy and chemotherapy. The patient, 18 months after the onset of his symptomatology, died without cerebral tumor involvement.

The association between partial seizures and cardiac asystole has rarely been reported in the literature. This potentially life-threatening symptom has been observed principally in left-sided epilepsies, in particular during seizures originating in temporal lobe. We describe a case with ictal bradycardia followed by cardiac asystole during right frontal lobe seizures. Video-EEG monitoring recorded two partial seizures with electro-clinical findings suggestive of a right frontal lobe origin, associated with ictal bradycardia followed by prolonged asystole. The brain MRI showed a lesion located in the cingulate gyrus of the right frontal lobe. The patient required a subsequent placement of a pacemaker. In conclusion, cardiac asystole may be a potentially life-threatening symptom during seizures of frontal lobe origin. The right fronto-mesial structures may play a role in autonomic regulation of cardiovascular responses.

Brain metastasis from prostate carcinoma occurs very rarely. We describe 13 patients with single brain metastasis from prostatic cancer. Total removal of the lesions was performed in ten patients. Three patients underwent stereotactic biopsy. All patients were treated with postoperative whole brain radiotherapy (WBRT). Eight patients died for systemic disease after a mean time of 9.2 months with a diagnosis of metastasis. Five patients are still alive at 20, 14, 11, 7 and 6 months, respectively. Even if brain metastasis from prostate cancer is often a terminal event with death occurring within few months from diagnosis, we suggest the same protocol (surgery and/or radiosurgery plus postoperative WBRT) usually adopted to treat brain metastasis from other primitive tumours. A non specific neurological symptomatology and a possible normal dosage of serum specific antigen may contribute to a delay in diagnosis. However, considering the rarity of brain metastasis from prostate carcinoma, standard brain MRI follow-up in men with prostatic cancer does not seem to be necessary yet.

STUDY DESIGN:Spinal subarachnoid hematomas are unusual and difficult to diagnose and the outcome of treatment is influenced by the lesions that frequently accompany them.OBJECTIVES:To clarify the neuroradiological diagnostic aspects of spinal subarachnoid hematoma as well as the results of treatment.BACKGROUND:Only recently has subarachnoid hematoma been clearly distinguished from more common subarachnoid hemorrhage and its characteristics have still not been dealt with in detail.METHODS:A total of 69 cases (3 personal case, 66 published cases) were revised in terms of etiology, diagnostic imaging and the results of both surgical and conservative treatment.RESULTS:The most common causes of spinal subarachnoid hematoma are coagulopathies (either pharmacologically-induced or resulting from systemic diseases) (40.5%), lumbar puncture for diagnostic or anesthesiological purposes (44.9%) and traumatic injuries (15.9%): these factors may be present singly or variously combined. They may be spontaneous (17.3%) or, in rare cases, associated with aortic coarctation or degenerative vascular diseases. Overall mortality is 25.7%. In the 50 cases in whom long-term follow-up was possible, the outcome of treatment, which is almost exclusively always surgical, was good in 93.5% of 31 patients in whom neurological status on admission was satisfactory and in 15.8% of 19 cases with severe neurological deficits.CONCLUSIONS:MRI and CT are not usually diagnostic because they are not able to differentiate between a subarachnoid lesion and a subdural one. However, diagnosis may be possible when these investigations detect the CSF or the contrast medium surrounding the hematoma. Although the risks of producing spinal subarachnoid hematoma as a result of LP are remote, this is, in fact, the primary cause in patients with coagulopathies. The results of treatment depend on the patient's initial neurological condition, the severity of any concomitant pathologies, the position of the hematoma and the eventual association of a subdural hematoma.

Central nervous system mesenchymal chondrosarcomas are rare malignant tumors that constitute a separate entity from the classical chondrosarcoma and myxoid variant. Clinical behaviour of central nervous system chondrosarcomas is still unknown. We describe two rare examples of intracranial mesenchymal chondrosarcoma with a review of the literature, in an attempt to clarify the clinical characteristics, prognosis and treatment of choice of these unusual tumors. Among the 55 reported cases, 23 had postoperative radiotherapy. Although there is no statistical significance according to the Log-Rank test (p=0.7), the patients treated with radiation therapy seem to have a better chance of survival. Patients who had adjuvant chemotherapy (only 5) showed survival times similar to those patients who had none. Although clinical behaviour of central nervous system chondrosarcomas remains to be defined, data from our series as well as literature show that radical removal is the best therapeutic choice. In addition, patients treated with postoperative radiotherapy seem to show a trend toward increased survival.

Introduction: Clival chordomas represent skull base tumors with epithelial and mesenchymal aspects that show a high propensity for local recurrence and distant metastases through both the systemic and cerebrospinal routes. Even today these tumors maintain a high recurrence rate after surgery, especially in those cases involving the anterior cranial fossa and facial structures. The most effective first-line treatment for clival chordomas is surgery, but some studies demonstrated that a combined multimodality therapy including surgery and chemoradiotherapy may prolong the survival rate of these patients. To date, a trans-sphenoidal approach to treat clival chordomas, as well its technical variants, offers an excellent alternative to standard skull base approaches achieving the avoidance of a prolonged exposure time and brain retraction. The paper reports three cases of midline extradural clival chordomas operated via trans-sphenoidal approach and their clinical outcomes.

Introduction: The literature stresses the advantages of aggressive multimodality treatment for advanced nasopharyngeal carcinoma. A selection of operative approaches depends on the size of the anterior skull base defects and extent of intracranial invasion. This paper reports a case of a 63-year-old female patient diagnosed with nasopharyngeal carcinoma with anterior skull base invasion and right orbital spread.

Pituitary abscess is a serious intrasellar infection representing less than 1% of all pituitary pathologies. A 30-year-old female patient with intermittent headaches, polyuria and amenorrhea was admitted. A bitemporal hemianopsia, a nasal polyposis and a partial pituitary insufficiency were demonstrated. M.R. imaging revealed a pituitary cystic mass lesion with a capsular contrast enhancement after gadolinium. No sphenoidal sinusitis was present. Via endoscopic transsphenoidal surgery, purulent materials were drained by cutting the underlying fibrous pituitary tissue. A polipectomy was also performed. The cultures revealed coagulase-negative staphyloccoccus and microscopical study demonstrated a lynphocytic inflammatory process with hyperplasya. Four months after surgery she presented no neurological deficit and no recurrence of intrasellar mass.

Remote cerebellar hemorrhage represents a severe clinical condition in patients operated on for cranial and spinal pathologies. The present paper reports a case of a cerebellar hemorrhage following a spinal operation performed to remove a large lumbar neurinoma. A 35-year-old male patient with pollachyuria, stranguria and urinary incontinence was admitted. Lumbo-sacral M.R. imaging showed a lumbar mass lesion extending between L5 and S2. An L5-S2 laminectomy was performed, followed by a total resection of the tumour. Four days after surgery, the patient presented an intracranial hypertension syndrome with dysarthria and dislalya. A CT-scan demonstrated a large hemorrhage occuping both cerebellar hemispheres and compressing the IV ventricle. The patient was treated conservatively and a new CT-scan showed a good recovery of the cerebellar lesions.

Cerebral micotic infections are rare in non-immunodepressed patients. Even more exceptional is a sudden blindness onset. The authors report a severe rhino-orbito-cerebral Phycomycosis in a 56 year-old patient, pastry chef by profession and suffering from diabetes mellitus. Cephalea was the first, main, clinical sign. A cerebral M.R. imaging showed a retrochiasmatic hypodcnsity area infiltrating the optic pathways. Via a right pterional craniotomy, the chiasmatic area was explored and a partial removal of the mass was possible. Microscopic studies on the granulomata specimens suggested an infection by Phycomycosis. The patient was treated with Amphotcricina and Itraconazolo but obtained no clinical improvement and died few months following surgery. Literature reports very few cases of optic Phycomycosis. The pathogenetic role played by flour is questioned.

Background: Primary leptomeningeal astrocytomas are rare intracranial tumors. These tumors are believed to originate from cellular nests which migrate by means of aberration, ultimately settling in the leptomeningeal structure. They may occur in both solitary and diffuse forms. The literature reports only fifteen cases of solitary primary intracranial leptomeningeal astrocytomas.