ACTA NEUROCHIRURGICA

Acta Neurochirurgica 44, 257--274 (1978)

9 by Springer-Verlag 1978

Proceedings of the 26th Annual Meeting of the Societfi Italiana di Neurochirurgia 24-26 November 1977, Rome, Italy Compiled by

I. Papo* C a r a c e n i , T . A . , C e l a n o , I., Borghi, P. ( I n s t i t u t e o f N e u r o l o g y C. Besta, M i l a n , I t a l y ) : Evaluation of the Results Obtained From the

Surgical Treatment of Patients Affected by Syringomyelia Associated With Chiari Type I Malformation. The data presented were obtained from 46 patients affected by syringomyelia associated with Chiari type I malformation; all cases were diagnosed on the basis of neuroradiologicai examinations. Of 46 patients 30 underwent surgical treatment consisting of posterior fossa decompression and high cervical laminectomy with examination of the upper cervical canal and the foramen magnum. An asymmetric tonsillar prolapse was seen in all cases; frequently a thick band of dural membrane at the junction of the medulla and the spinal cord was found. The other 16 patients did not undergo surgery, and were used as a control group. A quantifiable evaluation of the clinical status of the two groups of patients was thereby performed in order to assess the therapeutic effectiveness of operative treatment. Of the 30 surgical patients, one died of respiratory arrest 48 hours postsurgically. The others showed an improvement in 530/0, a worsening in 27~ and no change in 20%. Unoperated patients showed no change in 370/0, and a worsening in 63~ The follow-up involved a period of 1 to 5 years. The greatest improvement was seen two years postoperatively (71%), while longer follow-up periods resulted in a worsening of the clinical picture (400/0). In conclusion the surgical treatment appears to be effective, but transient if the follow-up is prolonged over many years. The recurrence of the progression of the disease may be due either to the normal progression of syringomyelia or to the reestablishment of arachnoiditis. C a r a c e n i , T . A . , C e l a n o , I., Borghi P. ( I n s t i t u t e of N e u r o l o g y C. Besta, M i l a n , I t a l y ) : Clinical Aspects of Chiari Mal]ormations. 41 patients presenting a Chiari malformation were considered. The patients were divided into two groups: the first group consisted of 30 patients affected Author's address: Prof. Dr. I. Papo, Secretary of the Societ~i Italiana di Neurochirurgia, Ospedale Generale Regionale, 1-60100 Ancona, Italy.

0 0 0 1 - 6 2 6 8 / 7 8 / 0 0 4 4 / 0 2 5 7 / 8 03.60

258

L Papo:

by Chiari type I malformation plus syringomyelia, and the second group consisted of I 1 patients affected only by Chiari type I and type II malformations. In the first group the presenting symptoms and the objective signs affect mainly the upper limbs and the cervical region; the clinical picture is typical of a syringomyelic syndrome. The second group is characterized by a more frequent involvement of brain stem and particularly of medulla oblongata. The relative frequencies of different symptoms and signs are discussed. From these observations it is possible to affirm that the clinical pictures of the two groups of patients are clearly different, and therefore we suggest that we are dealing with two separate entities, even if there are several common features in these two groups of patients. Beiloni, G., C a r d a r e l l i , M., Di Rocco, C., Rossi, G.F. ( I n s t i t u t e of Neurosurgery and Radiology of the University Cattolica, Roma, I t a l y ) : Extra-Axial Subarachnoid Cyst of Posterior Fossa: Clinical

Diagnostic Studies. Six cases--four children and two adults--of posterior fossa extra-axial cyst were treated in our clinic within the last three years. Signs of a space-occupying lesion were prominent in the two adult patients, while hydrocephalus was the most striking findings in the four children. The diagnosis was made by means of retrograde brachial angiography and pneumo-encephalography; it was confirmed by surgery in five cases (the sixth one refused surgical treatment). In one child RHISA cisternography was also performed. Contrary to the majority of the reports in the literature, in all our patients the lesion filled following spinal air injection. In no case was ventriculography necessary. The permeability of the cyst to the gas injected by the lumbar route in our hydrocephalic children does not support the hypothesis of a blo& in the CSF circulation as the main pathogenic factor for the ventricular enlargement. The findings provided by the lumbar subarachnoid infusion test appear relevant: in fact, defective CSF absorption was in evidence in all of our hydrocephalic children. In one case (the only one who underwent RHISA cisternography) a functional deficiency of the peripheral suharachnoid spaces might be postulated on the basis of the inversion in CSF circulation, with a ventricular reflux of the labelled proteins. The information provided by the study of the CSF dynamics can be utilized also for interpreting the negative results which in the same patients may follow the surgical excision of the cyst, even when complete. It is worth noting that in such cases a satisfactory improvement can be obtained by an additional CSF diversion procedure. C o l a n g e l o , M., V i t a l e , C., P i r r o n e , R., D a n i e l e , B., P a l m i e r i , A., A m b r o s i o , A. ( C h i l d r e n ' s H o s p i t a l o f N a p l e s , N e u r o s u r g i c a l D i v i s i o n , N a p l e s , I t a l y ) : Arachnoidal Cysts and Enlargement of the Cerebro-

spinal Fluid Space in the Posterior Fossa. A series of eight cases of arachnoid cysts in the posterior fossa is reported. The patients were in the paediatric age group (less than 13 years old). Classification was according to the locations of the cysts. Treatment consisted of suboccipital craniectomy and complete removal. There was no operative death, and the patients had essentially complete recoveries.

Proceedings of the 26th Annual Meeting

259

Furthermore, since 1973 264 air studies of hydrocephalus have been performed, and 26 patients were found to have an abnormal enlargement of the cisterna magna. Eighteen of these patients had cerebellar and pyramidal symptoms and signs. Their neurological status was improved by the reestablishment of normal cerebrospinal fluid circulation, by shunting both from lateral ventricle and cisterna magna. When a shunt was not working well the patient sometimes showed the same clinical picture again. We suggest that an abnormal dilatation of the cisterna magna may play a role as a posterior fossa space-occupying lesion, and that it is extremely important to make a diligent search of the posterior fossa in cases of hydrocephalus.

Bollati, A.*, Gandolfini, M.':, Marini, G. *, Gaini, S.**, Giovanelli, M. **, Tomei, T. ** (* Department of Neurological Surgery, Ospedale Regionale, Brescia, and ** Neurosurgical Clinic of the University, Milan, Italy): Posterior Fossa Arachnoidal Cysts. During the last few years we have treated eight cases of infratentorial arachnoidal cysts. This paper is intended to be a contribution to the understanding of the pathogenetic and diagnostic problems raised by this uncommon lesion of the posterior cranial fossa. We had four children and four adults. We may say that in all the children and in two of the adults the cystic lesion was a congenital malformation, following Gardner's classic theory, while in the other two the lesion was acquired, after bacterial meningitis in one case and after head injury in the other. Since the clinical syndrome is totally aspecific, neuroradiology (ventriculography and vertebral angiography) is important. The morphology of the fourth ventricle is most significant: in all our cases the fourth ventricle was of normal size but was indented and shifted anteriorly and superiorly, due to the presence of the cyst posterior to it. This finding is fundamental in the differential diagnosis from the Dandy-Walker syndrome. We point out that in five cases ventriculography gave direct visualization of the cyst, while in the other three it gave evidence of exclusion of the cyst from the CSF space. In the case of an infratentorial cyst, angiography confirms the absence of any cerebellar dysgenetic malformation. Besides this, the venous phase shows a typical picture, "high embryonal", of the torcular and transverse sinuses. The morphology of the "torcular angle" is like an inverted Y, which is the same with a congenital arachnoidal cyst and with the Dandy-Walker syndrome. In two of our adult patients we were able to use the CAT, which gave us a correct diagnosis with regard to nature and location. The differential diagnosis is between congenital arachnoidal cysts, the Dandy-Walker syndrome, acquired arachnoidal cysts, and all the space-occupying lesions of the posterior fossa. In the Dandy-Walker syndrome we have two typical signs, cerebellar dysgenesia and an extremely dilated IV ventricle. In seven cases we obtained a complete surgical removal of the cyst, while in the remaining patient, in whom we could not perform such an operation because of his general condition, we shunted both lateral ventricles and the cavity of the cyst. In six cases the postoperative course was uneventful with amelioration of the clinical status. We had two deaths, one from late meningoencephalitis and

260

[. Papo:

the other (a four-months infant) from respiratory disturbances during the first postoperative day. Histology showed the cyst wail to be arachnoidal tissue. From a nosological point of view we point out that the difference in the alteration of the dural venous sinuses is linked to the time at which the pathogenetic agent has acted: if this happens before the ninth week of uterine life the cystic lesion interferes with the posterocaudal development of the teleneephalon. We should therefore make a distinction between arachnoidal cysts developed before and after the third month of uterine life, and not only between congenital and aquired lesions.

Tomei, G., Gaini, S.M., Zavanone, M., Carnelli, L. * (Neurosurgical Department of the University of Milan, and * Paediatric Department of the University of Milan, Italy): On Familial DandyWalker-Syndrome. Observation at the Neurosurgical and Paediatric Departments of the University of Milan of two sisters affected by Dandy-Walker syndrome led us to suspect heredity in the aetiopathogenesis of this malformation. The presence of an agenesic or hypoplastic vermis in the DW syndrome renders it comparable to the "familia vermis agenesis". The frequent association of both with other middle line dysgeneses, such as encephaloceles, cranioschisis and corpus caltosum agenesis make us suspect a possible hereditary factor for the DW syndrome. Furthermore the embryological data confirm the possibility that common pathogenetic factors play a role in determining both DW syndrome and familia vermis agenesis, the teratogenic stimulus working within the ninth week of intrauterine life. Lastly, reports on cases of corpus callosum agenesis and vermis agenesis in patients whose parents or ancestors were blood relatives, and reports on cases of DW syndrome in brothers led us to think that this malformation, too, could be transmitted according to autosomic recessive inheritance. Therefore, when one of these malformations is observed in a child, the risk that a brother may be affected by the same illness is not 3-50/0, as in the multifactorial inheritance to which all the major malformations of CNS are attributed, but 25% as in all cases of recessive hereditary transmission. The chromosome map of one of our cases and his parents showed a variant 9 ph + chromosome which, although not having a definitive pathological significance, has frequently been found in cerebropathic cases and in their parents. This observation justifies further studies of prevention in this field.

Benericetti, E., Dorizzi, A., Monolo, L., Scialfa, G., Tarfani, A. (Division of Neurosurgery, Ospedale Civile, Lecco, Italy): Peculiar Radiological Features in Two Cases of Hydrocephalus Due to Impervious Luschka, and Magendie Foramina. The Authors describe two cases of fourth ventricle hydrocephalus due to impervious Luschka and Magendie foramina which, unlike the numerous cases reported in the literature, present peculiar clinical and radiological features.

Proceedings of the 26th Annual Meeting

261

Despite age differences (6 and 54 years) the two clinical pictures show several points in common: ataxia when walking, violent occipital pain, bilateral dysmetria with the forefinger-nose test, and first gree horizontal nystagmus. There were similar neuroradiological pictures. In both cases we found considerable dilatations of the lateral recesses that seemed to end in cystic, finger-like protrusions. Positive contrast ventriculography in one case showed that these paraventricular formations were not communicating with the subarachnoid space. In the other one, on the contrary, after air ventriculography these formations appeared like two enormous pontocerebeltar cisternae, and only a "dynamic" study with repeated changes from a prone to a supine position was able to show the trapping of air in a system of cavities formed by the ventricles and by the above-mentioned sac-like formations extensively communicating with the fourth ventricle but not with the arachnoid space. As a proof of this, in the following days the lumbar injection of air partly filled the cisternae in the pontocerebellar corner. From there the gas did not diffuse into the fourth ventricle but into the remaining subarachnoid space. In one of the two patients the very sharp occipital pain, the first degree nystagmus and the stiffness in the back of the neck did not recede even after external shunting even though the fluid pressure was within normal values both in the lateral ventricle and at the lumbar level. These symptoms regressed slowly inducing us to formulate the hypothesis of a cerebello-vestibular syndrome due to the compression of the restiform body flocculus and vestibular structures by the extremely dilated lateral recesses. O c c h i p i n t o , E., P o m p i l i , A., R i c c i o , A. ( D i v i s i o n o f N e u r o s u r g e r y , R e g i n a E l e n a I n s t i t u t e , R o m e , I t a l y ) : Can One Diagnose the Exact

Nature of an Aqueductal Stenosis by Radiological Means? The problem is the differentiation between tumorat, inflammatory, and realformative aqueductal stenosis on neuroradiological grounds. CAT scan is of paramount importance for a correct diagnosis of brain malformations, because of the "gestalt" view, but some pathological features must be seen in the sagittal plane. If there is no technical way of doing a CAT scan in the sagittal plane these features remain undiagnosed. This neuroradiological investigation is therefore not very appropriate in diagnosing aqueductal stenosis. Ventriculography with watersoluble contrast medium is preferred. However, when there is a total blo&age the diagnostic criteria needed to differentiate tumoral from non-tumoral aqueductal stenosis are missing. Angiography may clear up the doupt in these cases. We must ask ourselves whether the typical aspects of malformative stenosis are recognizable by any radiological means. Certainly a bifurcate aqueduct, or one which is obstructed by a septal membrane, is obvious. Association of other malformative findings may lead us to the right diagnosis, even if a tumoral aqueductal stenosis may coexist together with brain malformations. In most cases the aqueduct is considered malformative when its appearance is deformed, thin, or tortuous. But all these findings are not conclusive because the same morphological appearances are sometimes observed in tumoral lesions. On the other hand a certain differential diagnosis between malformative or inflammatory stenosis is not always possible. Aqueduct thinning may indicate inflammatory lesions. We think that the general clinical picture or the neuroradiologlcal demonstration of ventriculitis is more important for the right diagnosis.

262

[. Papo:

The conclusion is that the correct diagnosis of the true nature of an aqueductaI stenosis is not always possible without surgical exploration or autopsy. D e Benedittis, G., D u c a t i , A., E t t o r r e , G., G r a n a t a , G. ( N e u r o surgical D e p a r t m e n t o f the U n i v e r s i t y o f M i l a n , I t a l y ) : A New

Approach to Hypertensive Traumatic Pneumocephalus: VentriculoExternal Drainage. Pneumocephalus is a fairly rare complication of head trauma (0.8o/0): the air collection can be epidural, subdural, or subarachnoid according to the site and the extent of the defects in the cranio-cerebral layers. Delayed hypertensive intraparenchymal ventricular pneumocephalus--although the rarest (5~ of all)--raises peculiar problems in diagnosis, and requires active treatment. The authors review the literature and present two personal cases of intratemporal pneumocephalus succesfully treated by ventriculo-external drainage. The pathogenesis of PNX is discussed, and the rationale of the proposed treatment is debated and compared with previous surgical techniques. Finally, correlation between clinical recovery of the patients and features at CT scan of the lesions is drawn. V i o l a , L., G r a z i u s s i , G., G r a n a t a , F., Schisano, G. ( N e u r o s u r g i c a l D e p a r t m e n t s o f P e l l e g r i n i a n d S. G e n n a r o H o s p i t a l s , N a p l e s , I t a l y ) :

Non-Tumoral Aqueduct Stenosis. Sixteen cases of non-tumoral aqueduct stenosis, probably due to congenital malformations, are considered in the present communication. Aetiological and pathological features are mentioned briefly. Subsequently, the clinical syndrome presented by sixteen patients has been examined. The average age of the patients in this series is fifteen years. The average duration of illness and symptoms is twenty months. The first sign of the disease was epilepsy in three patients. Evidence of raised intracranial pressure was the main finding in fifteen cases. Cerebellar signs were detected in 430/0 of our cases. The diagnosis was always establihed by ventriculography: air and contrast were used in 500/0 of our cases, while either air or contrast was used in the remaining cases. Pneumoencephalography was also performed in nine cases. In this series a shunt was performed in all cases: i3 patients had a ventriculo-atrial shunt, while three patients were treated by ventriculo-peritonea[ shunts. Finally, the results and complications of the present series were discussed. G a i n i , S . M . , G i o v a n e l l i , M., T o m e i , G., Z a v a n o n e , M. ( N e u r o surgical D e p a r t m e n t of the U n i v e r s i t y o f M i l a n , I t a l y ) : Non-

Tumoral Aqueductal Stenosis. Hydrocephalus in Adults. Out of 176 cases of non-tumoral hydrocephalus in the adult (over the age of 15) observed at the Neurosurgical Department of the University of Milan in the last 15 years, 39 (22~ were affected by an aqueductal stenosis. Our series concerns 23 females and 16 males aged between 15 and 65 years. Intracranial hypertension syndrome was the most frequent cause of admission (23 patients) followed by oculomotor palsy (8 patients), amenorrhea or dysmenorrhea (3 patients), and CSF rhinorrhoea (2 patients).

Proceedings of the 26th Annual Meeting

263

In all cases the non-tumoral nature of the hydrocephalus was shown by tomopneumoencephalography or CT scan, or both. Twenty eight patients underwent extrathecat CSF shunt procedure (medium pressure valve), 6 underwent VCS (Stookey and Scarff), and 5 VCS (Torkildsen). Surgical mortality was two in the Stookey and Scarff series, and two in the Torkildsen series. Of the patients who underwent extrathecaI CSF shunts, one died four days after surgery, and two after one and three months because of valve insufficiency. Finally the authors present and discusse the results at follow up of 33 patients evaluated by psychometric tests and CT scans.

Mingrino, S., Scanarini, M. (Department of Neurosurgery of the University of Padova, Italy): Treatment of Pseudo-Tumoral Encephalopathy. This study is based on 11 cases with a typical clinical picture: headache, vomiting, marked bilateral papilloedema, negatve neuroradiological findings, and increased intracranial pressure (ICP). In each case a high dose (50-70 rag) of escin * was administered intravenously, and the effect during measurement of ICP was observed. In seven cases the drug caused a significant hypotensive effect within ten minutes. In these cases the treatment with escin (40mg every 6-8 hours) was continued for three days; measurement of ICP after this period showed normal pressure in all cases. Oral treatment was then continued at the same dosage for 20-30 days, and the patients discharged. All patients showed complete remission of the clinical syndrome and fundus normalization. Follow-ups after a year showed no recurrence. In three cases the treatment with escin was unsuccesful; these patients were given dexamethasone with normalization of the syndrome. Another case that presented a severe picture of intracranial hypertension and visual impairment was treated with escin and dexamethasone without positive result. The patient improved with external CSF drainage, and was then treated by a shunt procedure that induced remission of the syndrome. It is thus reasonable to suggest that various types of pseudo-tumor cerebri exist, not only because of different aetiologies, but an account of the responses to different treatments. The favourable effect of escin may represent, in our opinion, an indirect contribution to Johnston's hypothesis 1 that pseudo-tumor cerebri originates from a primitive alteration of arachnoid villi with reduced resorptive capacity. Escin may improve resorption of CSF by its tensioactive effect at the level of the pacchionian granulations and dural sinuses. Welch and Friedmann 2 demonstrated experimentally an augmented flow through the microtubular system of the villi by adding a tensioactive agent to the liquid of perfusion. References * Johnston, J., Reduced C.S.F. absorption syndrome. Lancet 25 (1973), 418--420. Welch, K., Friedmann, V., The cerebrospinal fluid valves. Brain 83 (1960), 454--469. * Reparil IBI. 18

Acta Neurochirurgica, Vol. 44, Fasc. 8--4

264

I. Papo:

Bernasconi, V . * , Bettinelli, A. *, G i o v a n e l l i , M. **, G a i n i , S. M. **, D u c a t i , A . ** (* I n s t i t u t e of N e u r o r a d i o l o g y a n d ** I n s t i t u t e o f N e u r o s u r g e r y , U n i v e r s i t y o f M i l a n , I t a l y ) : Primary Empty Sella:

Report on 40 Cases. The anatomo-radiographic feature known as "primary empty sella turcica" is not an infrequent finding in patients who receive tomopneumoencephalography for sellar enlargement ascribed to pituitary adenoma. Two hundred and sixty eight such patients underwent encephalography at the Neuroradiology and Neurosurgery departments (University of Milan) in the period 1969-1976; 42 among them (14~ showed a large amount of air in the selta turcica. On admission 700/0 of patients complained of persistent headache, and 50o/0 showed signs of possible diencephalic a/or pituitary involvement or both; two had CSF rhinorrhea, five had visual field defects, and four had papilloedema. In 40 patients sellar enlargement was symmetrical; as seen in AP tomograms, a sag in the floor was such that its centre was, on average, 4 mm deeper than lateral edges. The structure of the sellar wall was generally well preserved, and the cortical layer was fairly well calcified. Sellar morphology, both on plain skull films and tomography, was of one of the two following types: a) commonly roundish sella, the longitudinal diameter prevailing over the relatively narrow aditus (pot-shaped sella); b) a rarer deep cylindrical sella, in which the aditus and the longitudinal diameter were almost the same size (glove finger-shaped sella). At tomopneumoencephalography, the bulk of the sella was symmetrically filled with air, the remnants of the pituitary being easily identifiable, usually close to the floor and the base of t~'e dorsum. A thorough endocrinological evaluation was achieved in 28 of these 40 patients. Basal pituitary hormone levels were normal; in 24 slight alterations were evident in stimulation-inhibition tests. On the basis of these clinical radiological and endoerinological findings, we labelled this group as "primary empty sella cases". In the other two patients, skull X-rays and tomopneumoencephalography showed focal erosions in the sellar floor, and asymmetrically arranged air in the sella. Endocrinological studies showed one of these patients to be a PRL secretor. A microadenoma was excised by trans-sphenoidal surgery. In the other patient only slight endocrine impairment was evident. Three main points should be stressed a) from examination of sellar morphology and structure on plain skull films and tomography one can forecast an empty sella in a large percentage of patients, b) tomopneumoencephalography and, more recently, CT scan (five cases in our series) are the only reliable means of reaching the right diagnosis, c) nevertheless, endocrinologieal evaluation is mandatory; if significant endocrine disorders are present a co-existing pituitary adenoma is to be expected. Yet endocrine tests alone are unable to differentiate between empty sella and non-functioning pituitary adenoma. G i o v a n e l l i , M., G a i n i , S. M., D u c a t i , A., T o m e i , G., M a t t e i , A. *, R o n d e n a , M . * * ( N e u r o s u r g i c a l D e p a r t m e n t o f the U n i v e r s i t y o f M i l a n , * C h a i r o f G y n a e c o l o g i c a l E n d o c r i n o l o g y of the U n i v e r s i t y o f M i l a n , ** 2 n d M e d i c a l Clinic, E n d o c r i n e U n i t of the U n i v e r s i t y of

Proceedings of the 26th Annual Meeting

265

Transsphenoidal Microsurgery of Prolactin Secreting Pituitary Tumours. Milan, Italy):

Since the introduction into clinical practice of radioimmuno-assay of human prolactin in the Neurosurgical Department of the University of Milan 41 pituitary tumours (9 males and 32 females) were found to have elevated basal serum PRL levels. Their ages ranged from 16 to 61 years. These patients have been operated on by transsphenoidal microsurgery. Among the 41 PRL secretors 24 patients had as the main indication for surgical treatment amenorrhoea with or without galactorrhoea. They showed normal sellar morphology (three cases) or only slight focal alterations without discontinuity of sellar outlines. Expansive features on admission constituted the main indication for surgical treatment in the other 17 PRL secretors; they represent the 73% of turnouts that, before introduction of radioimmuno-assay for human prolactin, would have been diagnosed as non-secreting chromophobe adenomas; tomopneumoencephalography showed suprasellar expansion in 14 cases, which were then investigated by unilateral or bilateral carotid angiography. Visual functions were impaired in all 14 patients. In the remaining three patients the tumour had grown downward and laterally, and sellar morphology was markedly altered without visual impairment. Computerized axial tomography (CAT) with and without contrast injection integrated the investigation of the last 15 patients admitted. A complete endocrine study was performed in all the patients before and after surgery. Evaluation of results has taken into account a multiplicity of factors: sellar changes, suprasellar expansion, surgical procedures (selective vs. radical ablation of the sellar content). In 24 patients with an amenorrhoea syndrome with or without galactorrhoea, trans-sphenoidal microsurgery alone lowered serum PRL to values less than 25 ng/ml in 19 (80%). In PRL secreting adenomas with expansive features, postoperative decrement of serum PRL (normal values being obtained in just 4 out of 17 patients) does not positively correlate with improvement of visual functions (87% of cases). As a consequence, in this group radiotherapy becomes imperative in order to maintain improved visual conditions and prevent later recurrences. Fraioli, B. ( N e u r o s u r g i c a l I n s t i t u t e of the U n i v e r s i t y of Rome, I t a l y ) : Trigeminal Neuralgia: Results in 114 Patients Treated by

Means of Controlled Differential Thermocoagulation of the Gasserian Ganglion and Retro-Gasserian Rootlets. One hundred and fourteen patients suffering from trigeminal neuralgia, 103 of whom were suffering from "essential" trigeminal neuralgia, were treated by the technique of percutaneous controlled thermocoagulation of the Gasserian ganglion a/or retro-gasserian rootlets or both, with the difference from the technique of Sweet and Wepsic that we used fluoroscopic control during the entire procedure. Except for one case of posttherpetic neuralgia, neuralgia was abolished in all patients and in almost all patients painful facial sensation was abolished, while tactile sensation was preserved, at least partially: in only two patients did unwanted anaesthesia occur in the trigeminal divisions treated. Moreover, in all 18"

266

I. Papo:

patients but three the thermocoagulation was confined exactly to the divisions that the operator wanted to make analgesic; and in the majority of the patients suffering also, or only, from first division neuralgia, the corneal reflex was preserved, making this division only hypalgesic. In a follow-up ranging from four months to two years, two patients showed relapse of the neuralgia, but both underwent a second succesful procedure. The only significant complication was a transitory unilateral weakness of mastication in five patients. The longest period of hospitalization was 24 hours. Broggi, G., Fiacchino, F. ( I n s t i t u t e o f N e u r o l o g y C. Besta, M i l a n , I t a l y ) : Percutaneous Differential Thermal Rhizotomy of Glosso-

pharyngeal Nerve. Glossopharyngeal neuralgia is a rare syndrome compared with trigeminal neuralgia, but is equally distressing. Medical treatment (Carbamazapine, Dyphenylhydantoin) has a fair success in only a few cases; because of this, surgical treatment is the therapy of choice. The most common surgical technique is the intracranial section of the rootlets of the glossopharyngeal and some of the vagus nerve rootlets in the posterior fossa. A percutaneous approach to the glossopharyngeal nerve at the lateral part of the foramen lacerum posterior has been suggested hy Sweet, allowing a differential thermal RF rhizotomy of the nerve. The present report deals with two cases successfully treated with this percutaneous technique at the Istituto Neurologico, Milan, in the last six months. Technical details, neurophysiological tests during surgery, and results were discussed. D e Benedittis, G. ( N e u r o s u r g i c a l Clinic, U n i v e r s i t y o f M i l a n , I t a l y ) : A New Strategy for Chronic Pain Control: The Multi-Modal

Approach (Preliminary Report). Chronic pain is not simply a function of the amount of bodily damage alone, but is a complex psychological experience which is influenced by multiple interactive determinants such as cognitive and affective factors and learned behaviour. In this respect total pain relief cannot be realistically pursued, whatever therapeutic trial is attempted (surgical, pharmacological etc.). The author proposes a Multi-Modal Approach (MMA) to pain control which provides recognition of the psychological contribution to pain perception and response. This new strategy includes hypnosis, psychotropic drugs, and conditioning. Hypnosis is a powerful tool in the relief of psychogenic and somatogenic chronic pain, probably by triggering central mechanisms of pain inhibition. Psychotropic drugs, particularly tricyclic antidepressants, sometimes in combination with phenothiazines, provide significant reduction in depression and anxiety (so often associated with pain), and enhance a morphine-like analgesia by activating opiate-like factors such as encephalins and endorphins. Conditioning, including the use of biofeedback, extinguishes pain-related behaviour patterns, and increases pain-incompatible responses. Sixteen chronic pain patients have been treated by Multi-Modal Approach (MMA). Represented pain syndromes included trigeminal neuralgia (1 case),

Proceedings of the 26th Annual Meeting

267

atypical facial neuralgia (4 cases), intercostal nerve pain (2 cases), cancer pain (Pancoast syndrome: 1 case), cervical pain (2 cases), low back pain (2 cases), coccydynia (1 case), painful spasm (1 case), phantom limb pain (1 case). Relief of pain has been achieved in 14 out of 16 patients, i.e., 87%. Failure in two patients primarily depended upon psychotic patterns and secondary gains. The considerable effort and time demanded of the patient and the c]inician represent the significant limiting factor in the course of the treatment. The degree of relief obtained, the lack of response in almost all cases to previous therapy, and Iong-lasting effects (2 transient relapses only at follow-up) suggest most strongly that MMA provides an important approach for chronic pain reduction, particularly for those pain states which cannot be brought under satisfactory control by local anaesthetics or even by neurosurgical techniques.

Forni, C., Cappricci, E. (Department of Neurosurgery of the University of Milan, Italy): Long Term Results of Traumatic and Surgical CSF Fistulae Treated by a Continuous Lumbar Subarachnoid Drainage Closed System. Twenty-six patients with CSF fistulae have been treated by continuous lumbar subarachnoid drainage, with complete healing. Fistulae were of traumatic origin in twelve patients. Nine had rhinorrhoea and three otorrhoea (one bilateral). In the remaining fourteen patients the fistula followed surgery: nine had rhinorrhoea following trans-sphenoidal procedures; four had CSF leaks from surgical wounds. The technique of the treatment has been described elsewhere (II Policlinico, sez. Chir., in press). External drainage lasted on average 8-10 days, with minimal incidence of septic complications (tWOpatients). The patients were submitted to long term follow up for up to thirty-two months, and none of them complained of recurrence of the fistula or other complications.

De Santis, A. *, Marossero, F. *, Pagni, C. A. **, Rampini, P. * (* Neurosurgical Clinic of University of Milan, Italy, ** II Neurosurgical Clinic of University of Turin, Italy): Follow-up o] 52 Young Patients With Early Post-Traumatic Seizures. The authors present a follow up of 52 young patients (ages between 2 months and 14 years) who presented with post~traumatic seizures within two weeks after traLlma.

Early epileptic seizures were partial in five cases, generalized in one case, and not classifiabile in two. All the patients were submitted to clinical and EEG control 1 to 17 years after cranio-cerebral trauma. Eight patients, or 15.3~ had epileptic seizures after dismissal from the hospital. Seven of the eight with late epilepsy had severe cranio-cerebraI trauma with long-lasting coma, while one had no impairment of consciousness.

268

I. Papo:

During hospitalization four patients were submitted to surgical procedures. Four received only medical treatment. Late post-traumatic seizures were in three cases partial with complex symptomatology (psychomotor attacks), in one case partial motor, in one case partial motor with secondary generalization, in one case partial with loss of consciousness alone. Six patients had single or few attacks, and two patients had monthly seizures. In all cases seizures were easily controlled by antiepileptic medical treatment. About one third of the 52 patients received preventive antiepileptic medical treatment. It must be emphasized that the majority (seven out of eight) of the patients who developed late post-traumatic seizures received no preventive treatment. In conclusion we can state that early post-traumatic seizures in children have a favourable prognosis. Late post-traumatic seizures occur in only 15.3% of patients who had epileptic fits during the first two weeks following cranio-cerebral trauma. Seizures usually occur only once or very seldom and are easily controlled by medical treatment. Type and degree of cerebral trauma, impairment of consciousness, and surgical treatment are factors of the utmost importance for the appearance of late posttraumatic epilepsy.

Alexandre, A. *, Nertempi, P. **, Farinello, C. ***, Rubini, L. * (* Division of Neurosurgery, ** Division of Neurology, Section of Neuropsychology, *** Division of Rehabilitation Medicine, City Hospital, Vicenza, Italy): Alterations of Memory in Head Injuried Patients; A Study Based on Kimura's Test. Recognition memory and learning ability were evaluated in a series of 35 head injured patients who had undergone surgery by means of Kimura's test. This test consists of the presentation of 8 series of 20 figures, half geometric, half nonsense, among which the patient is expected to recognize the recurring ones. The impairment of recognition memory and learning ability is expressed by reduction in correct score, and increase of false negatives (failure to identify recurring figures) in respect of the control group. This deficit is in our patients directly proportional to the neurological syndrome of the acute phase, to the presence and extension of cerebral damage, and to the duration of posttraumatic amnesia. This last correlates particularly to the number of false negatives. The number of false positives (identifying as a recurring "new" figure) on the contrary does not vary in the various syndromes compared to the controls. The different behaviour of the two kinds of errors is probably the expression of the decreased learning ability. Elderly patients significantly performed worst. The side of the cerebral lesion significantly affects the results: left hemisphere injuries cause worse performances and specifically compromise the codification of verbal stimuli, represented by geometric figures. The analysis of our results on the ground of the time elapsed from impact confirms the hypothesis of Brooks that the possibility of recovering intellectual functions is exhausted in a few months. This observation underlines the importance of the early application of rehabilitation therapy.

Proceedings of the 26th Annual Meeting

269

Solero, C. L., S a v o i a r d o , M., M i g l i a v a c c a , F., Passerini, A. ( I n s t i tute of N e u r o l o g y C. Besta, M i l a n , I t a l y ) : Determination of CSF

Shunt Patency With Water-Soluble Contrast Medium. Since September 1974 113 determinations of patency of various CSF shunting devices have been performed at the Neurological Institute of Milan using watersoluble contrast media. Out of this number, 89 examinations were performed on 58 children and 24 examinations on 17 adults. Generally both parts of the shunting system were controlled, but, when the ventricular or the cardiac or peritoneal catheter had to be changed because of an obvious malposition, only the other segment was studied. Through the ventricular catheter in a cooperative patient a full ventriculographic study can be made with minimal amounts of contrast medium. Therefore, this examination allowed the recognition of the ventricular size, and brought also, in a few cases, the discovery of a new unexpected pathological process. The injection of the distal catheter in the pathological cases demonstrated its block, level of disconnection, malposition, and sleeve or cyst formation. This examination is safe, rapid, and reliable, and is very easy to perform with shunting devices which have double-dome reservoirs. Therefore, even if CT scanning has decreased the number of these studies, we feel that this kind of examination is a very useful tool in the assessment of the patency of CSF shunting systems, because it allows the recognition of the exact level of malfunction, upon which the neurosurgeon has to operate. G i u n t a , F., M a r i n i , G., Bollati, A., Lenzi, A. ( D e p a r t m e n t of N e u r o s u r g e r y of the R e g i o n a l H o s p i t a l of Brescia, I t a l y ) : Perfusional

Brain Scanning in the Diagnosis and Surgical Treatment of Cerebral Ischaemic Disorders. Cerebral ischaemic disorders are now examined for possible revascularization, and constant efforts have therefore been made to improve clinical and instrumental diagnosis. Perfusional Brain Scanning (PBS) of the internal carotid artery gives evidence of the vascular disorder and parenchymal damage. We used this technique in different lesions of the Central Nervous System (i.e., vascular malformations, tumours, epilepsy, trauma, and cerebrovascular diseases). Recently we focussed our attention on ischaemic lesions, particularly transient ischaemic atta&s. The intra-arterial injection of particles labelled with an isotope has been used to visualize the arteriolar bed of a target organ for several years. At the beginning macro-aggregates of human serum albumin were used, but this prooved to be dangerous in CNS studies. We used microspheres (30 micron) for safety and for uniform distribution of the tracer. The injection of 1 or 2 mC of Tc 99-labelled microspheres of human serum albumin (200,000 particles in 0.5 or 1 ml) embolizes the arteriolar bed at a site where there is remarkable collateral supply. Thirteen patients with TIA and nine with stabilized neurological deficit of ischaemic origin were studied with PBS. Preliminary studies with angiography, brain scintigraphy, CT scan, and EEG were also accomplished. PBS was altered in twelve of the thirteen TIA's and in all stabilized neurological lesions. Angiography, scintigraphy, CT scan, and EEG gave us less information.

270

I. Papo:

The pathological pattern shows a focal or multifocal reduction of radioactivity as an expression of reduced perfusion or impaired microembolization in the ischaemic parenchyma. The presence of a pathological area in TIA, even in neurologically normal patients, suggests that revascularization may prevent a further ischaemic event in the same area.

Pagni, C. A., Forni, C. * (Neurosurgical Clinic of the University of Turin, ':" Neurosurgical Institute of the University of Milan, Italy): Carotid Cavernous Fistulae: Problems of Surgical Treatment. Three patients affected by traumatic carotid cavernous fistula underwent various surgical treatments. In all cases at first embolization was tried by means of an embolus made of muscle fragments tagged with silver wire and tethered to a silk thread. The embolus is carried by blood stream and embedded by pressure against the fistula. In the first case the embolus plugged the fistula, and the patient was completely cured. The embolus was too small in the second case and went through the fistula: the patient was operated on a second time for recurrence of symptoms. In a third case carotid kinking arrested the embolus extracranially; the patient was submitted to a second operation. In these last two cases Fogarty catheters were used. Their tips were pushed up to the carotid syphon to the fistulas, and the balloons were inflated with a radiopaque compound. The balloon filled the syphon, plugged up the fistula, and stopped the blood flow through it, as shown at per-operative angiography. In the patient with carotid kinking it was possible to overcome the obstacle and push the tip of the catheter up to the syphon only by means of a Fogarty catheter No. 5; the patient was cured. Embolization may be made difficult by many circumstancies: kinking of the carotid or excessive size of the embolus may prevent progression of the embotus up to the syphon; emboli of too small a size may go through the fistula. The use of Fogarty catheters is a simpler and safer way to treat CCF. In the third patient mild arterialization of conjunctival veins recurred four months later, and angiographic controls demonstrated the caternous sinus receiving arterial blood from hypertrophic meningeal branches coming from the external carotid artery. The last case demonstrates that even if the complete occlusion of the carotid syphon has been accomplished some symptoms may persist or recur. The causes for this are analyzed and found mainly in arterial ba& flow from small collateral carotid syphon branches bound for the dural wails of the sinus: these are interrupted, and inverted blood flow leaks into the cavernous sinus from the free floating peripheral vessel stumps, due to anastomosis with the dural circulation, producing the minor arterialization residual to the procedure.

Scanarini, M., Mingrino, S., Trincia, G., Zuccarello, M. (Neurosurgical Department of the University of Padova, Italy): Scanning Electron Microscopy of Intracranial Saccular Aneurysm. Four intracranial saccular aneurysms were studied by the scanning electron microscope. The specimens were obtained at surgery from the ruptured aneurysmal wall.

Proceedings of the 26th Annual Meeting

271

The internal surfaces of the aneurysms showed typical inSuries in the appearance of conical crater-like defects, balloons, and inter-cytoplasmatic bridges. In some areas the endothelium was preserved, but with longitudinal convolutions and folds. On the damaged endothelial surface there was an increased number of blood cells (red cells, leucocytes and platelets). The adventitia resembled that of a normal cerebral artery and showed no signs of external pressure, reinforcement or inflammation. In conclusion, the alterations observed are similar to those typical of atherosclerosis and are, most likely, consequent to higher worn out provoked by the blood streams inside the aneurysm. This study is in agreement with correlated transmission electron microscopy and emphasizes the weight of degenerative alterations on development and rupture of intracranial saccular aneurysms.

Nizzoli, V., Tonnarelli, G.P. (General Hospital of Legnano, Italy): Remarks on Three Venous Intracranial Angiomas. Ten cases of cerebral vascular diseases in infancy and childhood occurred in our Neurosurgical Division in the last five years. Two cases had micro-vascular malformations. In a single case a venous angioma was identified: it was in a 14-years-old patient who suffered from a spontaneous intracerebral haematoma presenting as tumour. A second case is a 15-years-old girl hospitalized for a subarachnoid haemorrhage: angiographic studies disclosed a cortical venous malformation. In a third case, a 60-years-old patient, a diffuse venous cerebral angiomatosis was seen at autopsy. Clinically he presented with lasting mental confusion, and organic dementia was suspected. A sure diagnosis was found in the first and in the third case. This report is a contribution to discussion and knowledge about venous vascular pathology which is not supported by an adequate amount of cases in order to allow definitive statements on this subject.

Perria, C., Borzone, M., Guiducci, G., Davini, V. (Neurosurgical Clinic of the University of Genoa, Italy): The CO2 Laser Beam in Surgical Treatment of Cerebral Tumours. Several cases of supratentorial gliomas and meningiomas were operated on since May 1977, with the help of a CO! laser infra-red beam, using a Sharplan 791 H E unit, with an adjustable output up to 50 Watts. Defocussed laser beam has been found useful in direct attack on the tumour, through a vaporization of the neoplastic tissue. The tumour could be progressively excavated. The loss of blood was comparatively less than with the classical method. Haemostasis was quite good with diffuse capillary bleeding, but not with arterial or venous haemorrhages, where the use of electrocoagulation was necessary. Extirpation of meningiomas was easier and less traumatic with the laser beam, and also the destruction of the infiltrating processes of glial tumours was facilitated.

Scottini, M. *, Briani, S. *, Righini, G. C. **, Russo, V. **, Scottini, S. ** (* Division of Neurosurgery, Arcispedale di S. Maria Nuova,

272

I. Papo:

Florence, Italy, and ** Research Institute on Electromagnetic Waves, C. N. R., Florence, Italy): Argon Laser and Fiber Optics Application in Neurosurgery. Preliminary tests have been carried out to study the possibility of application of argon laser ~igl~t and [ibre optics delivery systems to some problems of Neurosurgery. A laser surgery equipment has been assembled, constituted by an argon laser coupled with an optical fibre. At the output end of the fibre a mierolens has been constructed by suitable heating with a COs laser. By means of the microlens the output laser spot size rises qui&ly with the distance between the fibre end and the surgical target; it allows the best choice of the spot size and laser power according to the particular surgical purpose. The focussing properties of the microlens reduce the necessity for a direct contact of the fibre with the brain surface while the strong divergence of the beam from the focus avoids damage of the interior tissues. With this simple device a preliminary test has been performed on the brain of a dead rabbit: we have noticed that the equipment is easy to handle and the incision of the brain substance is sharp without appearent damage to the surrounding tissues. More understanding is required of the mechanism of the action of laser light on living tissues: for this purpose a more powerful argon laser source than that available is also required.

Pluchino, F., Luccarelli, G. (Division of Neurosurgery, Istituto Neurologico "C. Besta", Milan, Italy): Follow-Up of 42 Patients Operated on With Microsurgical Techniques for Peripheral Nerve Injuries of Traumatic Origin. Interfascicular suture with autografts is the technique of choice for repairing traumatic injuries of the peripheral nerves, since it guarantees a more precise alignment of the fascicules and therefore a higher reinnervation of the peripheral stump. This technique, as described by Miilesi, has been used in the Neurological Institute of Milan on 33 Fatients, while direct [nterfasdcular sutures were practised in 2 cases. A microsurgical interfascicular neurolysis without anatomical interruption of the nerve trunk, was performed in seven other cases. Thirty four out of 42 patients have been followed at varying times from a minimum of eight months to a maximum of six years. Microsurgical technique and the optimal intervention time are discussed.

Leonardi, M., Cecotto, C., Fabris, G., Penco, T. (Division of Neurosurgery, Ospedale Civile, Udine, Italy): Lesions of the SeIla Turcica. Tridimensional CT Study. Special CT procedures allow a reconstruction of the coronal and sagittal views of the head obtained through very thin (3 ram) contiguous axial sections. The evaluation of the sellar lesions is very accurate and does not require an extension of the examination time. This method appears to be more informative than traditional ventriculography and pneumo-encephalography.

Proceedings of the 26th Annual Meeting

273

Cerutti, L., Bellotti, C., Geuna, F., Regalia, F. (Department of Neurosurgery, Ospedale Maggiore of N ovara, Italy): Medullary Compression by Spontaneous Epidura! Haematoma. Consideration of Two Cases. Spontaneous spinal epidural haematoma is an uncommon pathological event which can occur acutely, producing a clinical picture so typical and constant that it could almost be classed as a distinct and characteristic "syndrome", or chronically, which is very rare, conforming to the picture of chronic medullary compression. The first of the two cases in this report occurred in the form of sudden and violent lumbar pain, complete paraplegia in a few hours, and anaesthesia below the D l l level. A subcutaneous haemorrhage appeared bilaterally in the lumbar region. The operation revealed a recent epidural haematoma between the levels D 10 and L 2. The second case showed the slow progression of an incomplete Brown-S6quard syndrome with the upper level at D 6 and radicular pain at D 5-1) 6. At operation a chronic haematoma was found in a fibro-angiomatous capsule. The first was clearly a case of venous haemorrhage involving the area of the lumbar veins which, having insufficient valves, are sensitive to every pressure variation in the inferior vena cava (a factor that has been confirmed by the relative frequency of spinal epidural haematomas during pregnancy). The fact that the haenmrrhage occurred--in our cases as in others--in the posterior epidural space can be explained by the fact that the posterior epidural venous plexuses have flaccid walls without support, and for this reason are predisposed to ruptures. The pathogenesis of the second case is difficult to interpret: we could be dealing with a chronic epidural haematoma enclosed in a neoformed capsule, or (more likely) with a dorsal epidural haemangioma inside which there has been a haemorrhage.

Stella, L. *, Pettinato, G. **, Donzelli, R. *, Signorelli, C. D. *, Spaziante, R. *, Tedeschi, G. * (* Neurosurgical Clinic of the University Napoli, ** Institute of Anatomy and Pathology of the University of Napoli, Italy): Malignant Meningiomas: Two Cases of Meningiomas Relapsing as Cancers. The authors describe two cases of meningiomas reappearing in the same places as cancers. The first is an intraventricular meningioma reappearing 15 years later, the other is a parasagittal meningioma twice recurring in a period of two years, and becoming more invasive and anaplastic. The possibility of looking for some features in the clinical histories of these tumours that could predict the unfavourable outcome is discussed.

De Divitiis, E. *, Spaziante, R. *, Cirillo, S. **, Stella, L.*, Donzelli, R. * (* Neurosurgical Clinic and ** Neuroradiological Institute of the University of Naples, Italy): Primary Sellar Chondromas: Observations on Two New Cases. Two cases of chondromas primarily arising from the sella turcica are reported. The authors, reviewing the eight cases reported in the literature, discuss the basic

274

I. Papo: Proceedings of the 26th Annual Meeting

clinical and radiological findings of these turnouts, underlining the difficulties of diagnosis and treatment.

De Divitiis, E., Spaziante, R., Stella, L. (Neurosurgical Clinic of the University of Naples, Italy): Some Technical Modifications of Surgical Treatment of Lumbar Discopathy. The authors' experience in the surgical therapy of lumbar discop~thy is reported. The following technical modifications were adopted: Arciform unilateral incision into deep fascia. - - Interlaminar space widening by scalpel, making no use of rongeurs. - - Sodium succinate methylprednisolone injection into dural sac. - - Early ambulation (12-24 hours). Benefits obtained by these methods are: Earlier disappearance of pain. - Remarkable reduction of hospitalization. - - Earlier return to work.