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Ki-67 is a marker of proliferation activity associated with invasiveness and prognosis in human tumors.The aim of the study was to evaluate the Ki-67 index prognostic relevance in a group of acromegalic patients who underwent transsphenoidal surgery for a GH-secreting pituitary adenoma.We selected 68 consecutive acromegalic patients referred to our hospital during a 5-yr period. The Ki-67 index was determined by immunohistochemistry on tissue samples obtained from each adenoma after surgery. Those patients who were not completely cured after surgery began medical therapy with somatostatin analogs (SSAs). Periodical pituitary magnetic resonance imaging and hormonal evaluation were performed during the follow-up.Twenty-eight of 68 patients were cured after surgery (41%). Among the 40 patients treated with SSAs, 13 were considered uncontrolled. Pituitary magnetic resonance imaging showed residual/recurrent disease in 25 of 68 patients after 6 months. No correlation was found between Ki-67 index and age, tumor size, GH, or IGF-I plasma levels. Tumors described as having cavernous sinus invasion had a higher mean Ki-67 index as compared with noninvasive tumors (P0.01). The Ki-67 index was significantly lower in tumors in patients cured after surgery as compared with patients considered not cured (P0.01) and in tumors in patients controlled by SSA therapy as compared with patients considered as uncontrolled (P0.05).The Ki-67 labeling index may predict clinical outcome in postsurgical management of acromegalic patients. We suggest routine Ki-67 evaluation in GH-secreting pituitary adenomas.

ObjectiveWe reviewed our series of olfactory groove meningiomas (OGMs) with the aim to relate the surgical approach with outcome and to define clinical and pathologic predictors of prognosis.MethodsNinety-nine patients who underwent 113 craniotomies at our Institution between 1984 and 2010 were entered this study. The relationship between surgical approach (bifrontal, fronto-orbito-basal, and pterional) and either tumor diameter, extent of tumor resection, complication rate, need of reoperation, and Karnofsky Performance Status (KPS) was analyzed. The impact of age (≤70 vs. >70 years), sex, tumor diameter (

OBJECTIVE: The endoscope has recently been applied to the supradiaphragmatic transsphenoidal approach, but only case reports dealing with different pathological features have been described. The authors present their experience with this technique in 10 patients with craniopharyngiomas. METHODS: A pure endoscopic endonasal technique was used. From November 1998 through May 2005, four males and six females with a craniopharyngioma, either purely supradiaphragmatic (six patients) or with a significant suprasellar component (four patients), were treated. The tumors had a mean diameter of 2.9 cm (range, 1–4 cm); four patients had a major prechiasmatic component and six had a retrochiasmatic one. RESULTS: Seven total, one subtotal, and two partial resections were obtained. Vision symptoms improved significantly in six out of eight patients. Endocrine function did not improve after surgery, and diabetes insipidus was the most frequent deficit, although it was transient in five out of eight patients. Cerebrospinal fluid leak was the most frequent complication and required reoperation in two patients. Postoperative obesity occurred in two patients. No recurrence has yet been documented in the total resection group. The mean follow-up period is 37 months (range, 3–75 mo). CONCLUSION: The endoscopic technique allows results comparable with the best microscopic series. We think that this technique increases the safety of the procedure because of improved vision. Further studies are required to better define the exact location of the tumor with respect to the arachnoidal plane, the extra-arachnoidal craniopharyngioma being the most suitable for a radical removal using a transsphenoidal supradiaphragmatic approach.

✓ Idiopathic spinal cord herniation (ISCH) is a rare, although increasingly recognized, cause of myelopathy. It is the result of an anterior dural defect in the thoracic spine through which the spinal cord herniates. Surgical restoration of the herniated cord to its normal position is usually followed by significant improvement in patients' clinical status. Differing surgical techniques have been used to manage the dural defect. In this report the authors discuss the cases of five patients (four women and one man) with ISCH treated during a 13-year period. Clinical and imaging findings in each patient are reported. Two different surgical techniques were used to treat this condition: dural defect enlargement in two cases and dural patch secured with stitches in three. The intra-and postoperative findings are discussed in relation to the two surgical techniques. Based on the results and complications in these five cases, the authors now believe that ISCH should be treated, when feasible, by using a dural patch to close the dural defect at the site of the herniation.

Ten days after surgical evacuation of a left hemisphere chronic subdural hematoma (figure, A), a 57-year-old man presented with sudden right arm monoparesis and dysarthria, associated with local scalp swelling. Neuroradiologic examination documented a cerebral herniation through the previous craniectomy (figure, B through E). Urgent enlargement of the craniectomy and duroplasty were performed (figure, F). The patient's condition improved dramatically, though fine movements of …

Correspondence to: Dr Giovanni Sabatino, Institute of Neurosurgery, Catholic University, L go A Gemelli, 8, 00168 Rome, Italy giosaba@inwind.it A 30-year-old man presented with gradually worsening gait disturbances. Neurological examination showed an ataxic gait associated with mild paraparesis; the legs were hyper-reflexive, with a Babinski sign on the left leg. The patient underwent a spine MRI, which did not show any pathological abnormalities. After a few days he developed dysmetria in his left side and vertigo. Cranial MRI showed a tumour in the middle clivus (arrow, figure) and a contiguous cyst (asterisk, figure) that was compressing and dislocating the pons, both of which were hypointense in T1-weighted images. A transsphenoidal approach was used to excise the lesion that eroded the dural membrane ventral to the pons. An arachnoid cyst was found dorsally to the tumour and excised. Histological examination showed a typical chordoma. Postoperative MRI showed that the tumour had been removed completely and the cystic lesion had disappeared. After surgery, the patient had a transient worsening of paraparesis, which had improved substantially by the 9-month follow up. We postulate that the tumour, after eroding the dura, created a local flow alteration to the cerebrospinal fluid and formation of the cystic lesion. The unusual clinical presentation was probably a result of the arachnoid cyst compressing and dislocating the pons, rather than the chordoma, which commonly presents with a palsy of the sixth nerve.

to determine variables favouring good surgical outcome in posterior epilepsies. Fourteen patients submitted to epilepsy surgery were included in the study. The epileptogenic zone was located in temporo–parieto–occipital areas as assessed by both invasive and non-invasive pre–surgical evaluation. Several variables (age at first seizure; age at surgery; disease duration; type, frequency and clinical semiology of seizures; presence of lesion; scalp ictal and interictal EEG; localization and extension of epileptogenic zone; completeness of surgical resection) were compared (Fisher’s exact test) with freedom from seizures to determine whether surgical outcome (Engel’s classification) could be related to any of them. Seven patients were seizure free (Ia) and very satisfying results were obtained for 3 patients (2 Ib, 1 Ic). New post–surgical visual deficits occurred only in 3 patients. Surgical outcome was related significantly to two variables: scalp ictal EEG (focal versus non–focal; p: 0.014) and completeness of surgical resection of epileptogenic zone (p: 0.0023). A significant trend towards a better outcome for focal interictal intracranial activity versus a nonfocal one (p: 0.07) was found. The correlation between completeness of epileptogenic zone resection and surgical outcome suggests that a presurgical protocol, allowing a precise definition of the area of resection, could help in obtaining more satisfying results in posterior epilepsies.

Since its inception, one of the major issues in transsphenoidal surgery has been the adequate visualization of anatomical structures. As transsphenoidal surgery evolved, technical advancements improved the surgical view of the operative field and the orientation. The operating microscope replaced Cushing's headlight and Dott's lighted speculum retractor, and fluoroscopy provided intraoperative imaging. These advances led to the modern concept of micro-surgical transsphenoidal procedures in the early 1970s. For the past 30 years the endoscope has been used for the treatment of diseases of the sinus and, more recently, in the surgical treatment of pituitary tumors. The collaboration between neurological and otorhinolaryngological surgeons has led to the development of novel surgical procedures for the treatment of various pathological conditions in the skull base. In this paper the authors review the history of the endoscope—its technical development and its application—from the first endoscope described by Philipp Bozzini to the First World Congress of Endoscopic Skull Base Surgery held in 2005 in Pittsburgh, Pennsylvania. Specifically, in this review the history of endoscopy and its application in endonasal neurosurgery are presented.

Hypoglossal-facial nerve anastomosis (HFA) is the most popular surgical procedure to reinnervate facial muscles after injury of the facial nerve. Section of the hypoglossus causes paralysis and atrophy of the hemi-tongue. In the attempt to overcome this consequence, the hemihypoglossal-facial nerve anastomosis (HHFA) has been proposed and only a half of the main trunk of the hypoglossus is connected to the distal stump of the facial nerve. In the rat, we have studied experimentally the anatomical nuclear changes after HFA and HHFA with the aim of establishing the quantitative motoneuron innervation of facial muscles obtained with each one of the two operative options. Horseradish peroxidase (HRP) injected in both types of anastomosis labeled not only hypoglossal motoneurons, but also facial motoneurons. HFA appeared to offer a significant quantitative motoneuron innervation higher than HHFA and then a higher probable better functional recovery. Both HFA and HHFA performed immediately after section of the facial nerve in rats did not result in a phenomenon of motor hyperinnervation. In our experimental model, the proximal facial nerve stump was coagulated at the stylomastoid foramen to avoid regeneration. Then, the labeled motoneurons into the facial nucleus could really be the expression of axonal projections from facial motoneurons to the hypoglossus nerve and facial muscles. No labeled motoneurons were seen contralaterally as we observed previously after section and repair of several nerves.

BACKGROUND: Giant cysts of the midline, not associated to a tumor, are exceptional finding in the brain of adults. Here we present two cases of symptomatic giant cerebral cysts of the midline occurred in an elderly and in a young adult patients both treated with mini-invasive unilateral neuroendoscopic procedure. In the recent literature (since 1999) similar cases have not been reported. Beside the clinical report, review of literature and major anatomical features of the region are described. CASE DESCRIPTION: These two adults (82 and 41 years old respectively) had a slow progressive development of headache, gait disturbances, memory impairment and urinary incontinence. Magnetic resonance imaging showed giant cyst of the midline and hydrocephalus. Surgery with the endoscopic procedure, through a right frontal burr hole, was followed by clinical and radiological improvement. CONCLUSION: Giant cerebral cysts of the midline in adults can be successfully treated through a neuroendoscopic monolateral approach that comprehends multiple openings, diffuse coagulation of the capsule, and careful releasing of capsule-ependyma adherences. Knowledge of major anatomical and developmental details of the septal region is necessary to avoid complication in a mini-invasive surgical procedure.

Background: Solitary Fibrous Tumour (SFT) is a rare tumour occurring mainly in the pleural cavity, with less than 100 cases reported in the Central Nervous System, where it typically presents as a meningeal-based lesion. We describe the case of a SFT located in the fourth ventricle and briefly review the pertinent literature. Case report: A 61-year-old man presented with a 6-month-history of dizziness, nausea and gait imbalance. Brain magnetic resonance imaging revealed a contrast enhancing, space occupying lesion in the fourth ventricle, with no dural attachment. The patient underwent a sub-occipital craniectomy and total excision of the lesion. Histological examination documented a SFT. The patient is recurrent free at the 2-year follow-up. Conclusion: Although uncommon, SFT should always be included in the differential diagnosis of intraventricular tumours. SFTs of the fourth ventricle are usually benign tumours. Surgery remains the treatment of choice.

Object. In this study the authors compare the clinical outcomes after particle embolization of hemangioblastomas in the cerebellum and spinal cord. They also review the literature of similar cases. Methods. Seven patients with hemangioblastomas in the spinal cord (four patients) and cerebellum (three patients) underwent preoperative embolization at the authors' center. Magnetic resonance imaging and selective angiography studies as well as histological diagnoses were available in all patients. Embosphere particles (trisacryl gelatin microspheres) were used in all cases. The smallest particle diameter ranged from 100 to 300 μm at the beginning of embolization in all patients. The outcome of embolization was favorable in patients with spinal cord hemangioblastomas, but it was unfavorable for those with cerebellar hemangioblastomas; acute tumor bleeding and death occurred in all of the latter cases. The outcomes following embolization are very different for these two locations possibly because of the different capillary sizes. Conclusions. The authors no longer use particle embolization to treat cerebellar hemangioblastomas.

The aim of this paper was to report on further experience with a new technique for reanimation of the facial nerve. This procedure allows a straight end-to-side hypoglossal–facial anastomosis without interruption of the 12th cranial nerve or the need for graft interposition. It is technically demanding and time consuming but offers an effective, reliable, and extraordinarily quick means of reinnervating the facial muscles, including the orbicularis oculi muscle, thus avoiding the need for a gold weight in the eyelid or a fascial sling.

A 25-yr-old woman was admitted to the Neurosurgery Department with the diagnosis of a medically resistant prolactin (PRL)-secreting microadenoma. Serum PRL levels ranging between 30 and 90 ng/ml had been discovered 2 yr before in a routine gynecological assessment. Magnetic resonance imaging (MRI) disclosed an image compatible with a pituitary microadenoma (Fig. 1). The patient underwent medical treatment with cabergoline (upto0.5mg/d),withoutsignificantvariationsofbothserum PRL and neuroimaging at 1 yr. Hence, medical therapy was withdrawn. When she came to our attention, she denied any history of irregular menses and galactorrhea as well as drugs or other possible causes of hyperprolactinemia. She had had a normal pregnancy 3 yr before. Pituitary hormonal assessment documented normal values with the exception of PRL that was 54 ng/ml (normal values, 3.5–15.5 ng/ml). Testing for macroprolactin yielded positive results showing a 35% recovery, in line with the expected presence of macroprolactin. A review of the patient’s MRIs showed that the signal alteration corresponded to the insertion of a sphenoid septum and was stable also in dynamic sequences. The patient was discharged home. Macroprolactin should be suspected when a patient’s clinical history or radiological findings are inconsistent with the PRL values (1–3). A focal artifact on sellar MRI, closely related to the junction between sellar floor and sphenoidal septum, may mimic or obscure a microadenoma (4, 5). In this case, we had the association of a biochemical and a neuroradiological pitfall. The clue for a correct diagnosis was given by the patient’s history and clinical status. Acknowledgments

In a 16-year-old boy with headache; deficit of third, sixth, and eight left cranial nerves; and retinal hemorrhagic papilledema, MRI showed multiple craniospinal lesions (figure 1, A through D). Cysticercosis was suspected, but MRI spectroscopy suggested a neoplasm (figure 1E). The surgically removed cisterna magna solid and cystic lesions were a choroid plexus papilloma …

Summary Purpose: To describe repetitive movements of the right arm possibly originating from the ipsilateral SMA area in two drug-resistant epileptic patients. Methods: Two epileptic patients (one female, one male, 35 and 36 years old, respectively) were submitted to pre-surgical evaluation including history, neurological examination, long-term video-EEG monitoring, interictal and ictal SPET, MRI and fMRI, neuropsychological assessment. Invasive recordings (stereoelectroencephalography) were also performed. Results: In both patients ictal semiology was characterized by very stereotyped repetitive right arm movements, i.e. tapping towards the thorax (movement rate of 6–7Hz and 3–4Hz for the two subjects, respectively). Seizures in the first patient, whose epilepsy was cryptogenetic, originated from the right pre-SMA area, which was surgically removed. She is seizure free 2 years after the operation. In the second patient, in whom a right pre-frontal post-abscess porencephaly was disclosed, the epileptogenic zone included the lesion and surrounding areas, while the SMA area was involved less consistently. Conclusions: Even if, according to literature, SMA epilepsy is predominantly characterized by postural manifestations, ipsilateral repetitive movements could be a relevant sign in this kind of epilepsy, as showed in our first patient. The presence of similar semiology in the second patient, might suggest that the symptomatogenic zone involved SMA area.