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A series of 64 consecutive cases of children with neuroepthelial tumors of the cerebral hemispheres operated on from 1966 to 1983 is analyzed with regard to the long-term survival rate and the quality of life at late follow-up. At the time of the diagnosis the age of the patients ranged from 8 months to 15 years (mean age 7.6 years), and the relative incidence of these neoplasms was found to be about the same (37%) in the subgroups from 5 to 10 years and 11 to 15 years. It was only 9% in patients below 2 years of age. Tumor removal was radical in 84% and partial in 16% of the cases. The overall operative mortality was 14%, although it has been 4% since 1977. At histology, grade I and II lesions were found to account for 70% of the cases, and of the remaining 30% of the cases 8% were grade IV anaplastic lesions. The survival rate of the 55 survivors was calculated according to the actuarial life-table analysis. It was 62% at 5 years and 40% at 15 years. The survival rate at 5 years was 80% for low grade (I and II) tumors while it was 25% for high-grade malignancy (III–IV) tumors. The quality of life was assessed in all 29 patients with long-term survival (disease-free state lasting for at least 5 years) by adopting a specific protocol, which included repeated CT studies and neuropsychological evaluation. A more favorable prognosis was established for children operated on when over 6 years of age and with frontal and parietal neoplasms, while a poor functional prognosis was observed in children below 6 years of age and with temporal lobe tumors.

Between 1956 and 1987 operations were performed on 36 patients below the age of 20 years for epidermoid and dermoid cysts of the central nervous system. Seventeen tumors were intracranial intradural lesions (47%): 12 were located in the supratentorial region (71%) and 5 were located in the infratentorial region (29%). Ten of these tumors (59%) were seated along the midline structures. The clinical presentation was consistent with the location of the tumors. The neuroradiological diagnosis was mostly made with the aid of pneumoencephalography, computed tomography (CT), nonionic contrast medium CT cisternography, and magnetic resonance imaging. Complete removal of the tumor contents was performed in all cases but one, although the completeness of removal of the tumor capsule could not be exactly estimated in some patients. At late follow-up only two tumor recurrences were observed. Radical removal of the tumor capsule of these congenital tumors, even when it is connected to vital neurovascular structures, seems advisable in patients who become symptomatic within the first two decades of life.

The authors review 71 patients with triventricular hydrocephalus in whom a contrast-enhanced CT scan did not show any tumoral or vascular lesion that could have caused the hydrocephalus. The patients were subdivided into three age groups. The results of the neuroradiological examination, the surgical treatment, and the complications of the shunt procedure are analyzed, with special reference to the high number (13) of periaqueductal alterations of signal pattern found on MRI (interpreted as a "slow growing" neoplasm) and to the incidence and causes of shunt malfunction.

The potential of gene therapy strategies for malignant gliomas that are based on retroviral-mediated transfer of a "suicide gene" such as Herpes Simplex Virus-thymidine kinase HSV-tk and subsequent treatment by a prodrug (ganciclovir, for example), has been emphasized by the promising results obtained by several groups. However, further experimental data as well as preliminary clinical results indicate that the low efficiency of retroviral-mediated gene transfer in vivo as well as difficulties for the diffusion of the prodrug inside the tumour mass can limit the efficacy of this form of gene therapy. To achieve a more effective limitation of tumour growth other approaches may be combined with the "suicide gene" strategy and the enhancement of the immunological response to the tumour by cytokine gene transfer is prominent among these approaches. The authors' experiments in nude mice confirm the antineoplastic role of IL-4 and encourage testing the effects of the simultaneous transfer of IL-4 and HSV-tk genes in immunocompetent animals.

During the first 10 years of this century the transsphenoidal (TNS) approach was developed to treat pituitary tumors (Cushin 1932), but the limitations of this route in removing tumors other than pituitary adenomas were soon recognized. Craniopharyngiomas are rarely confined to the sella turcica (Carmel 1985); their capsule is frequently firmly adherent to suprasellar vascular and nervous structures and their consistency is variable, but often quite hard. Today, the preferred treatment of craniopharyngiomas is radical surgical removal at the first attempt (Yasargil et al. 1990; Hoffman et al. 1992), and given these premises the question arises as to whether the TNS approach has a role in the treatment of these tumors.

An 11-year-old boy, treated for acute lymphatic leukemia at the age of 2 with intrathecal injections of Methotrexate, presented with a two year history of pain and signs of lumbo-sacral lesion. MRI, myelography and myelo-CT demonstrated an intradural L4-L5 epidermoid tumor which was removed. Iatrogenic implantation of epithelial cells at the age of two with lumbar punctures is most likely. Decline in incidence of lumbar iatrogenic epidermoid cysts, now an exceedingly rare event, is probably related to improved needles for lumbar punctures.

A series of 81 patients operated for intramedullary spinal cord tumours over a span of 12 years (1975-1986) is presented. The mean age of the patients was about 37 years and 9 patients were in the paediatric age (0-15 years). In 29 cases (36%) the tumours were located within the cervical region; in 34 cases the tumours were located in the thoracic region (42%) and in 18 cases the tumours were located within the medullary cone (22%). Ependymoma accounted for 52% of the cases (42 cases), astrocytoma for 20% (16 cases), lipoma for 7% (6 cases), hemangioblastoma for 6% (5 cases), metastatic tumours for 5% (4 cases); in the remaining 8 cases (10%) rare or very rare spinal tumours were found. The 9 patients in the paediatric age and 8 additional cases who had undergone previous surgery were then excluded from this review. In 59% of the patients with ependymoma and in 90% of the patients with astrocytoma severe neurological deficit were already present before the operation. Total tumour removal was accomplished in 81% of the cases with ependymoma, total or subtotal removal was achieved in 50% of the cases with astrocytoma. At long term follow-up study fair or good functional results were observed in 19 out of 41 cases of ependymoma (46%) and in 3 cases out of 10 of astrocytoma (30%). The surgical outcome was mostly related to the preoperative neurological conditions and to tumour malignancy grade.

In spite of differences in their histological appearance tumours in the lateral ventricles may be considered as a single group on account of the similar clinical picture and the similarity of radiological and surgical approach (1, 5, 8).

The surgical approach to cerebral giant aneurysms is still a source of great concern. We describe our experience with giant aneurysms of the anterior circulation and discuss the different surgical techniques adopted. During the period January 1972-December 1985, a total of 33 patients were operated upon at the Istituto Neurologico "C. Besta" of Milan for a giant aneurysm of the anterior circulation. Nineteen cases had suffered subarachnoid haemorrhage before admission; in 14 cases the hospitalization was due to evidence of mass effect on the surrounding neurovascular structures. All aneurysms were directly approached: in 24 cases the neck was occluded by a suitable clip, in 4 cases intramural thrombosis was attempted, in 3 cases the aneurysms were definitively trapped and in one case aneurysmorrhaphy was performed after resection of the sac. Operative mortality was 12%. Long-term follow-up shows good results whenever exclusion of the aneurysm from cerebral circulation had been achieved, either after removal of the sac or not; on the contrary, only fair or poor results were evident when other surgical techniques were adopted, either electively or out of necessity. The importance of intraoperative protection and monitoring of brain function is stressed.

This is the third case, reported in the literature, of transient cortical blindness that occurred during treatment of testicular carcinoma with cisplatinum, vinblastine and bleomycin. The presence of transiently pathological computerized tomography and brain scan suggests that this alarming event may not only be a toxic side effect of chemotherapy, but also a symptom related to eradicable subclinical metastases.

From September, 1972 to December, 1976, 102 consecutive patients operated on for glioblastoma multiforme were randomized, after total or subtotal tumor resection, to receive irradiation alone, irradiation plus BCNU or irradiation plus CCNU. BCNU and CCNU adjuvant chemotherapy was repeated every 6--8 weeks as long as the patients remained in complete remission. Patients were comparable for median age, type of surgery, and histological grade III and IV. Radiotherapy was administered at the tumor dose of about 5000 rads in all three groups. The percent of optimal dose administered was 96% for BCNU and 93% for CCNU. In the group treated with radiotherapy alone (32 cases) the median survival was 10.5 months, while in the groups treated with BCNU (34 cases) and CCNU (36 cases) the median survival was 12 and 16 months, respectively. Both relapse-free (P = 0.05) and total survival (P = 0.03) were significantly improved only in patients who were treated with radiotherapy plus CCNU compared to patients receiving radiotherapy alone after surgery. Present results show that in resectable glioblastoma multiforme, a slightly improved survival rate can be achieved by the prolonged use of adjuvant CCNU following maximal surgical resection and radiotherapy. The cure rate was not improved.

Since 1974 anterior discectomy without fusion for cervical discopathy has been adopted at the Istituto Neurologico of Milan, according to some technical modifications suggested by HIRSCH (4), BOLDREY (1), SUSEN (9), MURPHY and GADO (6). In most cases we have employed the operating microscope.

The clinical, radiological and histological findings of a huge olfactory grooves meningioma in a 14 years-old girl are described. Good result after complete removal is stressed and concerning literature is reviewed.

Spontaneous spinal epidural haematomas are rare and in only about 10% of the reported cases has the vascular sources of the bleeding been detected. A case of acute cerivcal epidural haematoma, arising fro a ruptured vascular malformation, successfully operated on, is presented. Clinical, neuroradiological, and pathological findings are described in detail. Significance of postoperative selective spinal angiography is discussed.

Enzymatic determinations of four enzymes, Arylsulphatase A (ARSA), alpha-iduronidase (IDUA), beta-galactosidase (GLB) and hexosaminidase were performed in 19 cases of meningioma. Gene dosage effect was demonstrated for ARSA and IDUA; preliminary evidence for mapping a "protective protein" of GLB in the region 22pter----q11 was also obtained.