BackgroundEndoscopy is becoming increasingly popular for the neurosurgical management of intraventricular lesions and has recently been accepted as an effective alternative approach to open surgery. The deep location of intraventricular lesions makes the microsurgical approach difficult. Moreover, many intraventricular tumors do not require aggressive neurosurgical treatment. Some of these lesions are even associated with hydrocephalus or an enlarged ventricular system.MethodsWe collected the data of 32 patients affected by purely intraventricular lesions in the lateral or third ventricles who underwent 33 endoscopic intraventricular procedures from 2006 to 2011. We classified the lesions according to their location within the ventricles so as to plan the best endoscopic trajectory. We approached the lesions using rigid and flexible endoscopes through precoronal or supraorbital trajectories according to their localization and the presence of hydrocephalus. In many procedures we used neuronavigation.ResultsThirty-three endoscopic intraventricular procedures were performed in 32 patients; 27 procedures were performed via the precoronal, and 6 procedures via the supraorbital frontopolar approach. A complete excision of the lesion was obtained in only three cases. In all other cases, a biopsy was taken.ConclusionsOur series shows that an endoscopic approach to intraventricular lesions should be tailored according to localization of the lesion and ventricular size. The complete excision of intraventricular lesions is often impossible with the endoscope, but biopsies allow diagnoses to be obtained in almost all cases.

Rosai-Dorfman disease is a common benign lymphomatous disorder that involves the lymph nodes and other solid organs. Neurological involvement is rare, and an isolated intracranial Rosai-Dorfman lesion even rarer. Whether isolated intracranial Rosai-Dorfman lesions should be defined as Rosai-Dorfman disease or intradural histiocytosis remains debateable. Although these intracranial masses may radiologically mimic a meningioma, some have diagnostically specific radiological appearances. Because isolated intracranial Rosai-Dorfman lesions are so rarely described their best treatment is controversial. Most patients described in published reports underwent surgery followed in selected cases by adjuvant radiotherapy. Medical therapies achieve conflicting results. Our two case reports, a patient with isolated dural intracranial Rosai-Dorfman lesions and another with multiple intracranial lesions, both without lymphadenopathy, should be of interest to neuroradiologists and neurosurgeons managing similar cases.

OBJECT Arachnoid cysts are relatively common congenital intracranial mass lesions that arise during the development of the meninges. They can be complicated by the formation of an ipsilateral chronic subdural hematoma (CSDH) after minor cranial trauma. Treatment of these coexisting conditions remains controversial. In this study the authors describe the anatomical, clinical, and neuroradiological features and outcome in a series of patients whose CSDH associated with arachnoid cysts were managed surgically by draining the hematoma alone and leaving the cyst intact. The authors based this surgical management on histological and neuroradiological observations concerning these associated medical conditions. METHODS A series of 8 patients with CSDHs associated with arachnoid cysts underwent surgery to drain the hematoma though a bur hole. The arachnoid cyst was left intact. Postoperative follow-up included CT scanning and T1- and T2-weighted MR imaging. RESULTS Clinical, anatomical, and radiological observations suggest that because separate membranes cover arachnoid cysts and the related hematoma, arachnoid cysts remain unaffected by the subdural bleeding. In the present study, these observations received support from the neuroimaging appearances, suggesting that arachnoid cysts related to hematoma contained only blood breakdown products from the hematoma that had filtered through the reciprocal dividing membranes. CONCLUSIONS Arachnoid cysts associated with SDH are anatomically separate conditions whose neurological symptoms respond to surgical drainage of the CSDH alone.

OBJECTIVE This preliminary study considers the feasibility and the results of anterior screw fixation in elderly patients with remote Type II axis fractures. Odontoid fractures are the most common fractures of the cervical spine in people 70 years of age or older. In developing countries, direct anterior fracture fixation is replacing posterior fusion in many cases. Recently, it has been demonstrated that patient age does not influence the outcome in terms of fusion after odontoid screw fixation. There is considerable disagreement about correct treatment in the case of remote fractures. In the literature, there have been no studies considering the feasibility and results of anterior screw fixation in elderly patients with remote Type II axis fractures. METHODS From 1989 to 2005, we observed 9 patients over the age of 65 years with isolated Type II remote fractures of the dens. All fractures were considered to be inveterate, as the traumatic events had occurred 6 to 12 months earlier. All fractures were treated with anterior infibulation of the dens with single 3.5-mm cannulated screws. RESULTS A bony fusion was radiologically documented in 7 patients (77%) 4 to 16 months after the intervention. In 1 patient, a fibrous union was observed. The neurological status remained unchanged in all patients, and no patients showed any neurological impairment at the time of follow-up. CONCLUSION According to our preliminary study, the technique appears to be feasible for remote axis fractures within 12 months of trauma, and it seems to be safe for elderly patients. Further data from additional studies are needed.

The aetiopathology, clinical features and treatment of arachnoid cysts (AC) are still extremely controversial topics. The posterior fossa is the second most common site of these lesions, since they are often detected in the cerebellar or cerebellar-cistern region. Despite this, almost all the cases of non-surgical reduction of an AC reported in literature concern cysts of the middle fossa, whereas only two cases of spontaneous reduction of a posterior fossa AC has been described in literature. A complete review of the literature regarding this topic has been collected and discussed. The authors present a case of spontaneous reduction of an arachnoid cyst situated along the midline of the posterior cranial fossa with regression of all neurological symptoms. This 43-year-old man presented increasing nuchal headache with vomiting and nausea, simulating subarachnoid haemorrhage. CT and MRI documented an arachnoid cyst along the midline of the posterior fossa compressing the mesencephalon. The patient did not present any family history of this pathology nor had suffered head trauma. The patient was only given analgesics to relieve painful symptoms. After 30 days, spontaneous resolution of all the neurological symptoms took place. A 2 months, MRI control documented marked reduction of the cyst without any evident brain compression. The feasibility of a wait and see policy in such cases is discussed.

The authors describe the unique case of a patient who had undergone posterior stabilization of the lumbar spine complicating the course of a lymphatic fistula. A lymphatic fistula is a rare complication of posterior lumbar surgery. Predisposing factors include individual anatomy, scarring adherences due to previous abdominal operations or surgical maneuvers deep in the plane of the transverse processes. Because the onset of lymphatic fistulas is subtle, and because they are associated with a high mortality rate and require multidisciplinary treatment, care is needed to avoid misdiagnosing these lesions as the more common cerebrospinal fluid fistula.

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.

OBJECTIVE AND IMPORTANCE:Although the clinical and histological features of the pathological entity of spinal arachnoiditis ossificans (AO) have been established for some time, less attention has been paid to the treatment. We propose a classification of spinal AO evaluating the possibilities and indications for surgical or conservative treatment.CLINICAL PRESENTATION:Type III has a lumbar localization, presents with less neurological involvement, and usually requires conservative treatment. In Types I and II, which are usually thoracic, clinical worsening justifies surgical decompression or partial removal, whereas total removal is rarely achievable.INTERVENTION:The literature was reviewed, and the reports on three patients were added to the published cases. On the basis of a reappraisal of the computed tomographic and magnetic resonance imaging documentation and the surgical descriptions, the cases of AO were classified into three types: semicircular (Type I), circular (Type II), and englobing the caudal fibers (Type III). The indications for treatment were evaluated in terms of surgical possibilities and outcome.CONCLUSION:The classification proposed on the basis of radiological findings allows sufficient clinical differentiation of AO and evaluation of the possibilities for surgical treatment. The latter is conditioned by the type of arachnoiditis, degree of neurological involvement, and presence of any concomitant pathological findings.

Five patients who developed an intracranial glioblastoma after a kidney transplant are described. All patients underwent surgical removal of the lesion and eventually radiation therapy, but none of them is still alive at follow-up. The possibility of tumours occurring in transplant recipients is a recognised entity and several series have been reported. Nevertheless, little consideration has been paid to post-transplant gliomas and a precise evaluation of this risk is still lacking. Several hypotheses have been proposed to explain a possible link. One possible factor may be the immunosuppressive state of recipients as a result of post-transplant administration of immunosuppressive drugs, as it is known that gliomas have an higher incidence in HIV-infected patients. However, it is not yet clear whether immunosuppressive drugs function as a direct transforming factor.

Radiotherapy and more recently radiosurgery represent important therapeutic methods for the treatment of tumors and arterovenous malformations affecting the central nervous system, even though several significant side-effects have been described (radionecrosis, tumors, etc.). Gliomas induced by radiation therapy are decidedly unusual, and the first descriptions of this association only appeared in the 1960s. The pertinent literature was reviewed to yield 116 cases in which a glioma developed after radiotherapy for cranial pathologies (included 10 personal cases treated in our Institution). One of our patients had undergone radiosurgery for a cavernous angioma. Patients who developed a radiation-induced glioma were younger, as a group, than those affected with so-called “spontaneous” gliomas. The tumor originated in the previously irradiated area, after average doses of 32 Gy and an average latency period of 9.6 years in accordance with the findings reported by the authors and in our experience as well. Radiotherapy had most frequently been performed for acute lymphoblastic leukemia. Our Case 10 is the fourth case of intracranial tumor arising after radiosurgery to be described in the literature. Though rare, gliomas may represent a late complication of radiation treatment. The behavior of the radiation-induced variety of glioma does not seem to differ significantly from that of its “spontaneous” counterpart. Late complications of the radiosurgery are probably underestimated because of the relatively recent introduction of this technique. On the contrary, these should be scrupulously evaluated when deciding whether to employ this method for therapeutic purposes for relatively benign or congenital lesions (which generally affect young patients with a long life expectancy).

Le cisti aracnoidee (CA) sono patologie congenite da aberrato sviluppo delle meningi spinali , e nella maggior parte dei casi risultano completamente asintomatiche, tanto da venir spesso riconosciute casualmente in corso di esami radiografici condotti per altri scopi diagnostici . Da studi ultrastrutturali, esse risultano confinate tra gli strati del foglietto aracnoideo esterno, e contengono liquido simil-liquorale . È stata dimostrata la loro possibile comunicazione con lo spazio subaracnoideo, attraverso la quale una CA può eventualmente aumentare di volume e diventare clinicamente sintomatica . Nei pazienti portatori di una CA è stata verificata una maggior incidenza di ematomi subdurali cronici 8 sebbene ad oggi la precisa causalità di questa associazione rimanga poco chiara. In diversi lavori sono state chiariti i caratteri radiologici di queste lesioni da sole e associate ad ematoma subdurale cronico . In diversi casi segnalati in letteratura, le indagini TC e RM hanno rivelato un segnale intracistico come da avvenuta emorragia . Il miglior trattamento delle cisti aracnoidee associate ad ematoma subdurale cronico non è stato ancora stabilito definitivamente, e ultimamente alcuni autori suggeriscono di procedere all’evacuazione dell’ematoma senza aggredire chirurgicamente la cisti .

BACKGROUNDRadiotherapy and more recently radiosurgery represent important therapeutic methods for the treatment of tumors and arterovenous malformations affecting the central nervous system, even though several significant side-effects have been described (radionecrosis, tumors, etc.). Gliomas induced by radiation therapy are decidedly unusual, and the first descriptions of this association only appeared in the 1960s.METHODSThe pertinent literature was reviewed to yield 116 cases in which a glioma developed after radiotherapy for cranial pathologies (included 10 personal cases treated in our institution). One of our patients had undergone radiosurgery for a cavernous angioma.RESULTSPatients who developed a radiation-induced glioma were younger, as a group, than those affected with so-called "spontaneous" gliomas. The tumor originated in the previously irradiated area, after average doses of 32 Gy-and an average latency period of 9.6 years in accordance with the findings reported by the authors and in our experience as well. Radiotherapy had most frequently been performed for acute lymphoblastic leukemia. Our Case 10 is the fourth case of intracranial tumor arising after radiosurgery to be described in the literature.CONCLUSIONSThough rare, gliomas may represent a late complication of radiation treatment. The behavior of the radiation-induced variety of glioma does not seem to differ significantly from that of its "spontaneous" counterpart. Late complications of the radiosurgery are probably underestimated because of the relatively recent introduction of this technique. On the contrary, these should be scrupulously evaluated when deciding whether to employ this method for therapeutic purposes for relatively benign or congenital lesions (which generally affect young patients with a long life expectancy). (C) 2003 Elsevier Inc. All rights reserved.