Biomedical subjects
Publications and source records attributed to L Palma.
We report two cases of peroneal nerve compression caused by an intraneural synovial cyst and discuss the pathogenesis, clinical and electrophysiological diagnosis, and treatment of these uncommon lesions in the light of the salient published work on the subject.
Forty-five (9.9%) of 453 pituitary adenomas operated on between January 1973 and November 1988 demonstrated hemorrhagic changes at surgery: 24 had a blood collection, 12 had a blood collection associated with hemorrhagic necrosis, and 9 had hemorrhagic necrosis. Thirteen patients (28.9%) experienced the acute symptoms of pituitary apoplexy, whereas another 32 had an "asymptomatic" hemorrhage, that is, the clinical course was comparable to an uncomplicated adenoma. Nineteen tumors (42.2%) showed marked suprasellar extension, 8 (17.8%) showed moderate extension, and 11 (24.5%) showed slight extension; another 2 (4.4%) were laterosellar and 5 (11.1%) were intrasellar. Invasive behavior was present in 32 cases (71.1%) and this may suggest another hypothesis to explain the pathogenesis of tumoral hemorrhage. The incidence of hemorrhagic complications in invasive adenomas with marked suprasellar extension was particularly impressive; therefore, we do not suggest preoperative bromocriptine treatment in this type of tumor. Two of 14 patients operated on by the transcranial route died after surgery, whereas there was no operative mortality in the 31 patients operated on by the transsphenoidal route. It proved advantageous to operate as early as possible, even during the acute phase of pituitary apoplexy. The transsphenoidal approach gave the best results, but to achieve satisfactory late results multidisciplinary treatment was necessary, namely, postoperative radiotherapy in 23 patients, bromocriptine in 12, and endocrine replacement therapy in almost all. In an average follow-up period of 6.2 years, 5 (11.1%) symptomatic recurrences were observed.
The growing skull fracture of childhood is a well-known but variously interpreted syndrome. Attempts have been made to find different pathogeneses for clinical and pathological patterns that are really successive phases of a single process, arising from the interaction of three basic conditions: (1) head injury with a large gaping fracture; (2) corresponding dural tear; (3) occurrence nearly always in infancy (the first year of life or period of maximum brain growth). This combination of factors alters the normal distribution of the intracranial pressure vectors and the fracture behaves like a "neosuture" with abnormal growth of the skull on the injured side. Simultaneously, the ventricular system tends to deform, dilating and shifting towards the side of the fracture. Three cases, successfully treated at a very late stage, are described. The good surgical results confirm the validity of the surgical method and its underlying theoretical basis.
23 patients with unilateral internal carotid artery stenosis (greater than 70%) and contralateral internal carotid artery occlusion in the neck are reported. The symptoms are referable to the side of the occlusion in 13 cases (57%), to the side of stenosis in 7 cases (30%) and non-localizing in 3 cases (13%). All 23 patients had a carotid endarterectomy performed on the side of the stenotic lesion. There was no operative mortality. Late neurological symptomatology after surgery was referable to the side of stenosis in 13% and to the side of occlusion in 9%. The authors consider that, in cases of significant stenosis (greater than 70%) of an internal carotid artery with a contralateral occlusion, preference should always be given to end-arterectomy of the stenotic side, reserving extra-intracranial by-pass of the occluded side for patients who remain symptomatic after endarterectomy of the stenotic side.
A series of 42 cases of monstrocellular brain tumour (MBT) who received surgery over a 34 year period is reviewed with the aim of gaining more understanding of the biology of this oncotype. A case of benign pleomorphic xanthoastrocytoma was identified among the cases and is discussed in another paper. In this series, as in most others taken from the literature, MBTs were more frequent in young subjects (55% were under 50 years of age and 17% were children) and presented as a superficially located (63%), often sharply circumscribed (42%) mass. The mean survival time for 24 patients treated by surgery and radiotherapy (RT) was 57 weeks compared to 32 weeks for 12 treated by surgery alone (p less than 0.02). Patients younger and older than 50 years showed the same survival and the slightly better course of children did not reach statistical significance. Besides postoperative RT, the only other factor that showed a significantly positive influence on survival was the presence of a definite lymphocytic infiltration (LI) in the tumour (p less than 0.05). This result confirms our previous study on the prognostic influence of LI in glioblastoma (GB). Actually, we noted that the prolonged survival of both MBT and GB patients exhibiting a definite LI (67% and 11.5%, respectively, in the two series) was strikingly similar. We conclude that MBT is a peculiar oncotype with a probably better prognosis than GB in the majority of cases. Lymphocytes seem to play a major prognostic role and giant-monstrous cells are indirectly implicated, reasonably enhancing the host's immune response by magnifying the antigenic stimulus.
A case of a lumbar mesenchymal chondrosarcoma is reported. Radical removal of the lesion, irradiation, and chemotherapy led to a long and favorable outcome in this patient.
A case of septic cavernous sinus thrombosis is described which was observed with high resolution computed tomography (CT). The significant CT findings in cavernous sinus thrombosis (CST) include irregular filling defects within a widened enhancing cavernous sinus. Concomitant findings are unilateral or bilateral swelling of the orbital soft tissues and sinusitis.
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Twenty cases of infantile triventricular hydrocephalus from non-tumoural aqueductal stenosis were treated by ventriculocisternal shunt following RISA cisternography. In 11 cases RISA cisternography showed a normal pattern of CSF circulation. One patient was lost to follow-up. Two had their intrathecal shunt converted into an extrathecal one because of postoperative meningeal infection. Of the remaining 8 patients, 7 had good and 1 fair long term results. In 9 cases RISA cisternography presented an abnormal pattern without indicating a definite impairment of CSF absorption. Slow flow of the tracer leading to its complete disappearance from 36 to 48 hours and 48 to 72 hours was observed respectively in 7 and 2 patients. In both the latter as well in two of the other seven an extrathecal shunt had to be employed (44%). A retrospective analysis to assess the predictive value of CSF absorption test by RISA in the selection of this kind of intrathecal shunt is made.
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A case of primary brain neoplasm is reported that developed 11 years after prophylactic brain irradiation and intrathecal methotrexate (MTX) given for acute lymphocytic leukemia (ALL) at the age of 3 years. Cases of supposed postirradiation gliomas in children seem to have increased in recent years, particularly following apparently successful treatment for ALL or medulloblastoma. This increase might reflect the increased number of long-surviving cancer children and thus suggest that brain irradiation may be a potential risk factor in this population. After reviewing some general data on neurooncogenesis, two points are stressed: (1) the child's brain is particularly susceptible to the mutagenic effects of ionizing radiation owing to physiologically active postnatal glial cell proliferation, which takes place in the cerebral hemispheres, especially during myelinogenesis; (2) MTX could promote glial neoplasm by enhancing reparative glial cell proliferation. Prospective studies seem necessary to show whether or not prophylactic brain radiation in ALL plays an oncogenetic role. Nevertheless, besides recurrent leukemia, leukoencephalopathy, and radionecrosis, the remote possibility of radiation-induced glial neoplasms should always be considered in cases of children treated for leukemia who present with neurological complications.
Impairment of cell-mediated immunity in patients with primary central nervous system (CNS) tumors has repeatedly been reported but data to demonstrate the underlying immunological defect are not univocal. This report concerns a series of 31 patients harboring a glioma in which we studied: peripheral blood T-lymphocyte subpopulations by monoclonal antibody analysis; cellular responsiveness to mitogens; serum immunoglobulin values. The same parameters were also evaluated in 7 cases of intracranial meningioma and in 8 patients affected by non-proliferative, non-inflammatory CNS diseases. Thirty age-matched healthy volunteers formed the control group. Neither impairment of T-cells as regard to number, responsiveness and subsets, nor abnormal Ig values were found in these groups. However two patients, harboring respectively a third ventricle low grade astrocytoma and an anterior callosal glioblastoma, presented a striking T-cells impairment. These findings might suggest a correlation between hypothalamus and immune system, as already postulated by several previous experimental and clinical studies.
We report a unique case of exclusively intrasellar tuberculoma. The patient was operated on by the transsphenoidal approach, which allowed total removal of the lesion and prevented cerebrospinal fluid contamination. After histological diagnosis, the patient was treated with isoniazid, 300 mg daily for 3 months, as prophylaxis against tuberculous meningitis.
The light and electron microscopic findings of a surgically excised intracerebral mass is presented. The ultrastructural study led to definitely exclude both meningioma (that was the original diagnosis at surgery) and intracerebral schwannoma, while substantiating the uncommon final diagnosis of fibroma. The true intracerebral fibroma has exceptionally been described in the past. The seven so far reported cases are shortly reviewed.
This study concerns 51 cases of cystic pilocytic astrocytoma of the cerebral hemispheres. At operation these tumors closely resembled cerebellar astrocytomas, presenting as a big cyst contiguous with the lateral ventricle and containing a small mural nodule. The nodule was in a deep location in 26 cases, and always showed marked contrast enhancement on computerized tomography scans. The most frequent presenting symptom was epilepsy (68%), and the most common sign was papilledema (85%). The major goal of surgery was extirpation of the nodule. The follow-up period of the 34 cases available for long-term review ranged from 6 to 31 years (mean 17 years). Of these, 28 patients (82%) had a good outcome; four (12%) had a fair result, and two (6%) had a poor response. An analysis of these results shows that total extirpation of the mural tumor was associated with the best outcome, whether or not the cyst wall was completely removed. Radiation therapy was irrelevant to the prognosis for these patients. On the other hand, partial excision of the nodule, correlated with the deep location of the tumor, was the cause of the two poor results in this series and resulted in multiple operations for recurrences in two other patients. Nevertheless, two of these patients are still alive and well many years after incomplete surgical treatment. On the basis of this study, the importance of recognizing the occurrence of this "benign" tumor of the cerebral hemispheres is stressed, and the hypothesis of a common origin from subependymal glia of all pilocytic astrocytomas is supported.
The authors present a case of right parietal pleomorphic xanthoastrocytoma that occurred in a 24-year-old man. The patient was originally operated on in 1966, and at that time the diagnosis of monstrocellular sarcoma was made. The patient is still alive and totally symptom-free. A careful reevaluation of the microscopic findings, including positive glial fibrillary acidic protein staining, led to the definite diagnosis of pleomorphic xanthoastrocytoma.
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