Biomedical subjects

Roberto Delfini

Publications and source records attributed to Roberto Delfini.

At least 19 recordsLinked to original sources

PubMed2006

Aesthetic issues in neurosurgery: a protocol to improve cosmetic outcome in cranial surgery.

Nowadays, surgical interventions must treat with care the aesthetic impact on the patient, even when a malignant pathology or an patient's advanced age could give the aesthetic issue lower priority. The cranio-facial area is probably the most important anatomical region with regard to the harmony of the human body. Consequently, a step-by-step procedure, applicable regardless of the site and the nature of the lesion, is advisable to minimize the aesthetic impact. We prospectively analyzed 65 patients during a period of 2 years. At 1-year follow-up, all patients were invited to undergo a 3D-multislice CT and to complete a questionnaire with a subjective rating scale about aesthetic impact. The 3D-multislice CT scan didn't show dislocations, depressions or gaps of the bone flap. Nevertheless, five patients complained of some degree of aesthetic injury, or reported a psychological suffering from the aesthetic consequences of surgery. As a control group, we retrospectively reviewed 223 patients. The authors describe their surgical protocol and discuss it in the light of the results of their series.

Adolescent↗

PubMed2006

Magnetic resonance imaging flow void changes after cerebrospinal fluid shunt in post-traumatic hydrocephalus: clinical correlations and outcome.

The assessment of the flow-void in the cerebral aqueduct of patients with post-traumatic hydrocephalus on magnetic resonance imaging (MRI) evaluation could concur the right diagnosis and have a prognostic value. We analysed prospectively 28 patients after a severe head injury (GCS<or=8), with radiological or clinical suspicion of post-traumatic hydrocephalus and a fast flow-void signal in the cerebral acqueduct on T2-weighted and proton density MRI. Twenty-two patients were shunted (n=19) or revised (n=3). Six patients were followed-up without surgery. Twenty out of 22 shunted patients (91%) showed variable reduction of the fast flow-void. Eighteen of the operated patients (82%) presented a significant clinical improvement at 6-month follow-up. All patients (n=2) who had no change of the fast flow-void after surgery did not clinically improve. The six non-shunted patients did not present any clinical or radiological improvement. In head-injured patients, fast flow-void in the cerebral aqueduct is diagnostic for post-traumatic hydrocephalus and its reduction after ventriculo-peritoneal shunt is correlated with a neurological improvement. In already shunted patients, a persistent fast flow-void is associated with a lack of or very slow clinical improvement and it should be considered indicative of under-drainage.

Adolescent↗

PubMed2006

Central neurocytoma: a novel appraisal of a polymorphic pathology. Our experience and a review of the literature.

Central neurocytoma should be considered in the differential diagnosis of intraventricular tumours. The records of 20 patients operated on between 1975 and 2000 for central neurocytoma were retrospectively reviewed, and the histological gradings and clinical outcomes were compared. On the basis of our previous cases, in the latter five of this series, the following therapeutic protocol was adopted. In those cases in which total removal was achieved, no further treatment was given if the MIB-1 index was <4%; vice versa, if it was >4%, a course of conformational radiotherapy was delivered. In subtotally removed cases, radiosurgery with linac was also performed (median dose 20 Gy) as well as conformational radiotherapy whenever there was a recurrence of the lesion (median dose 45 Gy). In cases in which there was only partial cytoreduction, conformational radiotherapy was administered with the adjunct of polychemotherapy if the MIB-1 was >4%. Twenty patients were surgically treated: 11 men and nine women, with an average age of 26 years (range 17 years to 42 years).Total, subtotal and partial removals were achieved in, respectively, ten, three and seven cases. At average follow-up of 7 years, 16 patients had been cured, had significantly improved or were at least stable [Karnofsky performance status score (KPS)] >70 or more)]. On the other hand, four patients had worsened; of these, two had died and two had a KPS=50 and an unfavourable prognosis. The presence of histological atypia has proved to be a significantly negative risk factor for survival (P=0.02) while an MIB score >4% was significantly correlated with an unfavourable outcome (death or worsening of neurological status). The "atypical" neurocytoma seems to be a distinct entity, with a less favourable prognosis and a higher tendency to recur.

Adolescent↗

PubMed2006

Surgical treatment of pial cerebellar arteriovenous fistulas with aneurysm of the main feeding artery.

BACKGROUND: Intracranial pial arteriovenous fistulas (pAVFs) are rare vascular lesions only recently considered distinct from arteriovenous malformations. Conservative management was associated with a high mortality rate. The abnormality of the lesion arises from its high-flow nature. The authors present a case of a cerebellar pAVF associated with aneurysms of the main feeding artery that was surgically treated. CASE DESCRIPTION: A 54-year-old woman was referred to us after an attack of severe headache and vomiting. Computerized tomography scan visualized a hematoma of the fourth ventricle. Digital subtraction angiography (DSA) revealed a cerebellar pAVF mainly fed by the right posteroinferior cerebellar artery (PICA) and with drainage into one of the superior cerebellar veins. The PICA presented a saccular aneurysm on its fourth segment and a fusiform dilatation on its third segment. The patient underwent surgical operation via a midline suboccipital craniotomy. The fusiform dilatation was wrapped and the saccular aneurysm was clipped. The most fistulous connections were closed. The draining vein at the level of torcular herophili was closed by application of a clip. Control DSA demonstrated exclusion of both the aneurysms and the fistula from the circulation. At 1-year follow-up, the patient was neurologically intact. CONCLUSIONS: The association of a cerebellar pAVF and an aneurysm is rare. Surgical treatment of multiple-channel arteriovenous fistulas by closure of venous varix should guarantee the exclusion from the circulation and avoid recruitment of new arterial connections and recurrence. Attention must be paid to normal venous channels draining into the varix.

Angiography, Digital Subtraction↗

PubMed2006

Lumbar hemorrhagic synovial cysts: diagnosis, pathogenesis, and treatment. Report of 3 cases.

BACKGROUND: To define the etiologic, clinical, histological, and surgical features of lumbar hemorrhagic synovial cysts (LHSCs). Three personal cases are reported together with a review of the pertinent literature. METHODS: We identified 3 cases of LHSC treated in our departments and 20 cases culled from the literature. RESULTS: A total of 23 cases of LHSC were selected. All the patients underwent surgical treatment because of untreatable radicular pain and/or neurological deficits. The amount of bleeding, either massive or minor but repeated, influenced the timing of surgery. In our cases, the histological examinations showed an inflammatory reaction within the cyst and the consequent formation of neoangiogenic vessels. CONCLUSIONS: Hemorrhagic synovial cyst of the spine is rare and its most common localization is lumbar. Bleeding within the cyst leads to an increase of its volume, accompanied by neurological deficits and/or painful symptoms that are violent and generally intractable. In this event, surgical excision is the treatment of choice and, in some cases, emergency surgery is necessary. Hemorrhages are probably caused by the rupture of fragile neoangiogenic vessels.

Adult↗

PubMed2006

Neuroanatomy and cadaver dissection in Italy: History, medicolegal issues, and neurosurgical perspectives.

Despite the significant Italian tradition of important anatomical studies, an outdated law historically influenced by the Catholic church restricts the use of cadavers for teaching and scientific purposes. The object of the present paper was to trace the historical evolution of the Italian anatomical tradition, particularly neuroanatomical studies, in relation to the juridical regulations on the use of cadavers today. Special attention was paid to the opportunities offered to neurosurgery by using cadavers and to the scientific and social issues in neurosurgical training in the twenty-first century. Considering the new Common European Constitution, the authors advocate a political solution from the European community to improve the quality of training in the disciplines with a social impact such as neurosurgery.

Cadaver↗

PubMed2006

Early nuclear factor-kappaB activation and inducible nitric oxide synthase expression in injured spinal cord neurons correlating with a diffuse reduction of constitutive nitric oxide synthase activity.

OBJECT: Because of toxicity at high concentrations, nitric oxide (NO) contributes to spinal cord injury (SCI) secondary lesions. At low concentrations NO modulates nuclear factor-kappaB (NF-kappaB) activation. The authors investigated the activity of neuronal and endothelial NO synthase (nNOS and eNOS) to determine correlations with NF-kappaB activation and inducible NOS (iNOS) expression soon after SCI. METHODS: In 48 adult male Wistar rats clip-based (50 g/mm2/10 seconds) SCI was induced, and spinal cords were removed at different intervals for the following evaluations: 1) assaying specific activity of nNOS and eNOS; 2) electrophoresis mobility shift assay for activated NF-kappaB; 3) Northern blotting for iNOS; 4) immunohistochemistry for iNOS and NF-kappaB; and 5) immunofluorescence for iNOS and NF-kappaB. At 15 minutes postinjury, eNOS activity decreased significantly (p < 0.001), as did nNOS activity at 1 hour compared with these levels in control animals and rats killed at 15 and 30 minutes after SCI (p < 0.001). Basal NF-kappaB levels were variable in controls and at 15 and 30 minutes after injury. One hour postinjury, NF-kappaB activation was diffuse. Inducible NOS messenger RNA localized diffusely, peaking 6 hours after injury and remaining stable until 24 hours postinjury. Immunohistochemical analysis showed diffuse iNOS and NF-kappaB staining, especially in neurons inside and around the lesion. Immunofluorescence demonstrated that injured neurons were a source of NF-kappaB and iNOS soon after injury. CONCLUSIONS: Both nNOS and eNOS exhibited different regulation and roles soon after injury: nNOS correlated with NF-kappaB activation, whereas eNOS may have participated in vascular changes of the injured spinal cord. Neurons seemed to play a pivotal role in modulating and amplifying the inflammatory response in the injured spinal cord.

Animals↗

PubMed2005

Multilevel oblique corpectomy without fusion: our experience in 48 patients.

STUDY DESIGN: The authors provide their results in performing multilevel oblique corpectomy for degenerative spondylotic myelopathy in 48 patients. OBJECTIVE: To demonstrate the efficacy and safety of the multilevel oblique corpectomy when applied in selected cases. SUMMARY OF BACKGROUND DATA: The technique of multilevel oblique corporectomies for treatment of cervical spondylogenetic myeloradiculopathies allows anterolateral access to the cervical spine so that the spinal canal and conjugate foramen can be widened at more than one level, without the need for vertebral stabilization. METHODS: During a 7-year period, multilevel oblique corpectomy was performed in 48 consecutive patients for degenerative spondylotic myelopathy. The outcomes were analyzed according to the Japanese Orthopaedic Association classification modified to Western customs, and according to Nurick's scale 1 month, 1 year, and 2 years after surgery. Spinal stability was evaluated in all patients by plain radiograph films of the cervical spine, lateral views in flexion and extension, on discharge, 1 month and 1 year after operation. RESULTS: Significant clinical improvement occurred in 29 patients with a complete functional recovery in 22; moderate improvement was achieved in 12 patients; neurological status remained stable in 5, and it worsened in 2. All patients showed spinal stability. CONCLUSIONS: Multilevel oblique corpectomy was found to be a safe technique that guarantees good results in terms of both regression of clinical symptoms and long-term spinal stability.

Adult↗

PubMed2005

Extradural spinal cavernous angiomas: report of seven cases.

The authors describe seven cases of extradural spinal cavernous angioma. Although cavernoma itself is not rare, the extradural spinal localization is uncommon and makes preoperative differential diagnosis difficult. Routine MRI investigation has aided neurosurgeons in evaluating the true incidence of these vascular malformations, which was understimated in the past. The data published so far have not entirely clarified the treatment of choice for these lesions. Considering their rarity in this site, their presenting symptoms and the difficulties involved in neuroradiological diagnosis, the authors discuss the role of surgery as the principal form of treatment and review the relevant literature. Seven patients (4 male, 3 female) were admitted to our Institute of Neurosurgery between 1992 and 2004, with a 5-6 month history (range=2-365 days) of low back pain or radicular pain, sometimes associated with paresthesia. All patients had a CT scan, as well as MRI with gadolinium when possible, which detected an extradural roundish lesion: differential diagnosis was very difficult, especially between neurinoma and cavernoma. Treatment was always surgical and resection of the lesion radical. Postoperatively, all patients presented complete regression of clinical symptoms. In all cases histological diagnosis was cavernous angioma. Postoperative MRI with gadolinium or CT scan with IV contrast, performed before discharge, confirmed radical removal of the vascular malformation in all cases. Our experience confirms that surgery should be the treatment of choice for these lesions, in view of both their tendency to bleed and their straightforward surgical removal.

Adult↗

PubMed2005

Intraventricular neurocytoma with massive brain stem involvement in a 5-year-old child.

INTRODUCTION: Central neurocytoma is a tumor of neuronal origin that should be taken into consideration in the differential diagnosis of intraventricular neoplasms. Reports of neurocytomas with an extraventricular localization are rare: to our knowledge, the case described here is the first in which a neurocytoma developed within the ventricles but also invaded the brain stem. CASE REPORT: The authors describe the unusual case of a 5-year-old boy with an intraventricular neurocytoma presenting with massive involvement of the basal nuclei and the brain stem. The patient underwent first biopsy and then surgery for ventricular-peritoneal shunting and partial removal of the tumor. Histology showed the tumor to be a typical neurocytoma with Mib-1 <2%. The postoperative course was uneventful. At 3 years' follow-up, the patient's clinical condition is stable and there are no signs of disease progression. DISCUSSION: The literature is reviewed and the characteristics of this unusual tumor are discussed.

Brain Stem↗

PubMed2005

Combined intra-extracanal approach to lumbosacral disc herniations with bi-radicular involvement. Technical considerations from a surgical series of 15 cases.

Large lumbosacral disc herniations effacing both the paramedian and the foraminal area often cause double radicular compression. Surgical management of these lesions may be difficult. A traditional interlaminar approach usually brings into view only the paramedian portion of the intervertebral disc, unless the lateral bone removal is considerably increased. Conversely, the numerous far-lateral approaches proposed for removing foraminal or extraforaminal disc herniations would decompress the exiting nerve root only. Overall, these approaches share the drawback of controlling the neuroforamen on one side alone. A combined intra-extraforaminal exposure is a useful yet rarely reported approach. Over a 3-year period, 15 patients with bi-radicular symptoms due to large disc herniations of the lumbar spine underwent surgery through a combined intra-extracanal approach. A standard medial exposure with an almost complete hemilaminectomy of the upper vertebra was combined with an extraforaminal exposure, achieved by minimal drilling of the inferior facet joint, the lateral border of the pars interarticularis and the inferior margin of the superior transverse process. The herniated discs were removed using key maneuvers made feasible by working simultaneously on both operative windows. In all cases the disc herniation could be completely removed, thus decompressing both nerve roots. Radicular pain was fully relieved without procedure-related morbidity. The intra-extraforaminal exposure was particularly useful in identifying the extraforaminal nerve root early. Early identification was especially advantageous when periradicular scar tissue hid the nerve root from view, as it did in patients who had undergone previous surgery at the same site or had long-standing radicular symptoms. Controlling the foramen on both sides also reduced the risk of leaving residual disc fragments. A curved probe was used to push the disc material outside the foramen. In conclusion, specific surgical maneuvers made feasible by a simultaneous extraspinal and intraspinal exposure allow quick, safe and complete removal of lumbosacral disc herniations with paramedian and foraminal extension.

Decompression, Surgical↗

PubMed2005

Occipital condyle fractures: report of five cases and literature review.

Occipital condyle fractures (OCFs) are uncommon and potentially fatal lesions. After the advent of CT, prompt diagnosis can be readily made and consequently better prognosis of these patients is expected. Early recognition of some types of OCF is imperative to avoid fatal results. We analyzed 121 cases of OCF (116 from the literature and five of our own). Rarely patients with a deficit of the lower cranial nerves make a complete recovery. However, quoad vitam prognosis of patients with "pure OCFs" remains good. Immobilization provides good recovery of most OCFs, but delay of treatment can lead to serious morbidity. We want to emphasize that not only an OCF with instability of O-C1-C2 can be a fatal injury unless prompt surgical intervention, but a displacement and migration of the fractured condylar fragment can also result in a fatal outcome. A high level of suspicion is fundamental for the early diagnosis of these fractures, so that when a posterior basal cranial or occipital squama fracture occurs, a CT study of the occipital condyles becomes imperative.

Adult↗

PubMed2005

Gliosarcomas: analysis of 11 cases do two subtypes exist?

There are conflicting reports regarding gliosarcomas. The goal of this study is to examine clinical, radiological, surgical and therapeutic aspects of 11 patients with gliosarcoma. Between 1993 and 2001, 11 patients with cerebral gliosarcoma were treated at our Institute. Ten patients underwent surgery and one patient had stereotactic biopsy. Four patients received whole brain radiotherapy with (60)Co, five underwent radiotherapy with LINAC extended 2 cm beyond the edema margins. One patient refused any additional treatment after surgery and one patient was not treated postoperatively for poor clinical conditions (KPS 40). Chemotherapy (temozolomide) was administered to four patients. Four patients had a prevalence of sarcomatous component that corresponded to surgical and radiological aspects similar to meningioma while six patients showed a prevalence of gliomatous component and radiological and surgical aspects similar to those of glioblastomas. Surgical resection was total in six and subtotal in four patients. Patients with prevalent sarcomatous component showed median survival time more prolonged than patients with prevalent gliomatous component (71 +/- 6 weeks vs. 63 +/- 6; P=0.0417). Moreover, the survival rate differed in relation to the therapy: patients treated with multimodality therapy (surgery, radiotherapy and chemotherapy) had a longer survival time than patients treated in single or bimodality. Despite prognosis of gliosarcomas remains poor, a multidisciplinary approach (surgery, radiotherapy and chemotherapy) seems to be associated with slight more prolonged survival times.

Adult↗

PubMed2005

Severe craniofacial fractures with frontobasal involvement and cerebrospinal fluid fistula: indications for surgical repair.

BACKGROUND: The management of posttraumatic cerebrospinal fluid (CSF) fistulae is a controversial topic. Although recent literature shows that endoscopic repair of CSF fistula is efficacious and minimally invasive, in specific conditions open operative approach remains imperative. METHODS: A series of 36 patients underwent surgery for posttraumatic CSF fistula according to specific selection criteria. These criteria included: bone displacement more than 1 cm (5 cases), location of fracture in proximity to the midline (6 cases), involvement of cribriform plate (12 cases), presence of encephalocele (3 cases), and failure of the conservative treatment (10 cases). The dural defect was closed using vascularized pericranium and fibrin glue. Closure of the basal bone defect was necessary in very large fractures or in special localization of the fistula, such as near the optic nerve. Mean clinical follow-up was 5.7 years. RESULTS: Two patients presented meningitis without sequelae, and 12 with hyposmia. One patient died of the severity of the primary brain injury and associated extracranial lesions. None of the patients had recurrence. CONCLUSIONS: Our results indicate that surgical dural repair in selected cases is related to low morbidity and mortality preserving from delayed risks such as recurrence and infections.

Adolescent↗

PubMed2005

Traumatic epidural hematoma in children.

The purpose of this study was to investigate the characteristics of childhood acute epidural hematoma and to report our experience in recent years. A series of 35 patients below the age of 15 years treated for acute epidural hematoma at our institution between June 1991 and December 2000 was analyzed in detail. Pediatric epidural hematoma presents both age-related and atypical features when compared with epidural hematoma in adults. In selected cases, prompt surgical evacuation of the hematoma results in an excellent outcome. Outcomes seem to be directly related to the patient's preoperative neurologic status and the presence of associated intracranial lesions.

Accidental Falls↗

PubMed2005

Cerebral oxidative stress and depression of energy metabolism correlate with severity of diffuse brain injury in rats.

OBJECTIVE: The combined effect of traumatic brain injury (TBI) and secondary insult on biochemical changes of cerebral tissue is not well known. For this purpose, we studied the time-course changes of parameters reflecting ROS-mediated oxidative stress and modifications of cell energy metabolism determined in rats subjected to cerebral insult of increasing severity. METHODS: Rats were divided into four groups: 1) sham-operated, 2) subjected to 10 minutes of hypoxia and hypotension (HH), 3) subjected to severe diffuse TBI, and 4) subjected to severe diffuse TBI + HH. Rats were killed at different times after injury, and analyses of malondialdehyde, ascorbate, high-energy phosphates, nicotinic coenzymes, oxypurines, nucleosides, and N-acetylaspartate (NAA) were made by high-performance liquid chromatography on whole-brain tissue extracts. RESULTS: Data indicated a close relationship between degree of oxidative stress and severity of brain insult, as evidenced by the highest malondialdehyde values and lowest ascorbate levels in rats subjected to TBI + HH. Similarly, modifications of parameters related to cell energy metabolism were modulated by increasing severity of brain injury, as demonstrated by the lowest values of energy charge potential, nicotinic coenzymes, and NAA and the highest levels of oxypurines and nucleosides recorded in TBI + HH rats. Both the intensity of oxidative stress-mediated cerebral damage and perturbation of energy metabolism were minimally affected in rats subjected to HH only. CONCLUSION: These results showed that the severity of brain insult can be graded by measuring biochemical modifications, specifically, reactive oxygen species-mediated damage, energy metabolism depression, and NAA, thereby validating the rodent model of closed-head diffuse TBI coupled with HH and proposing NAA as a marker with diagnostic relevance to monitor the metabolic state of postinjured brain.

Animals↗

PubMed2005

Hypothesis of the postconcussive vulnerable brain: experimental evidence of its metabolic occurrence.

OBJECTIVE: We evaluated the effects of two consecutive concussive injuries on brain energy metabolism and N-acetylaspartate (NAA) to investigate how the temporal interval between traumatic events influences overall injury severity. METHODS: Rats were injured to induce diffuse traumatic brain injury (TBI) (mild, 450 g/1 m; severe, 450 g/2 m). In two groups, two mild TBIs were delivered in 3- or 5-day intervals. Three additional animal groups were used: single mild TBI, single severe TBI, and sham. All animals were killed 48 hours postinjury. Adenosine 5'-triphosphate (ATP), adenosine diphosphate, and NAA concentrations were analyzed with high-performance liquid chromatography on deproteinized whole brain extracts. RESULTS: In control animals, the NAA concentration was 9.17 +/- 0.38 micromol/g wet weight, the ATP concentration was 2.25 +/- 0.21 micromol/g wet weight, and the ATP-to-adenosine diphosphate ratio was 9.38 +/- 1.23. These concentrations decreased to 6.68 +/- 1.12 micromol/g wet weight, 1.68 +/- 0.24 micromol/g wet weight, and 6.10 +/- 1.21 micromol/g wet weight, respectively, in rats that received two mild TBIs at a 5-day interval (P < 0.01; not different from results in rats with single mild TBI). When a second TBI was delivered after 3 days, the NAA concentration was 3.86 +/- 0.53 micromol/g wet weight, the ATP concentration was 1.11 +/- 0.18 micromol/g wet weight, and the ATP-to-adenosine diphosphate ratio was 2.64 +/- 0.43 (P < 0.001 versus both controls and 3-day interval; not different from rats receiving a single severe TBI). CONCLUSION: The biochemical modification severity in double TBI is dependent on the interval between traumatic events, which demonstrates the metabolic state of the vulnerable brain after mild TBI. These data support the hypothesis of the application of proton magnetic resonance spectroscopy to measure NAA as a possible tool to monitor the full recovery of brain metabolic functions in the clinical setting, particularly in sports medicine.

Adenosine Triphosphate↗

PubMed2005

Brain metastasis from cutaneous squamous cell carcinoma of the dorsum. Case report.

The majority of cutaneous squamous cell carcinoma (SCC) are diagnosed early and cured using local treatment, although a minority of cases metastasize to regional structures. In this report the authors describe an unknown feature of skin SCC, namely, distant brain metastasis. This 54-year-old man, who had undergone surgery for moderately differentiated SCC of the dorsum (T2NOM0 stage), was admitted to our institution 11 months later with headache, vomiting, and ataxia. A magnetic resonance image documented a cerebellar lesion, which was totally removed. Results of histological studies revealed SCC. The patient received whole-brain radiotherapy (30 Gy over 2 weeks using a linear accelerator). A metastatic work-up showed enlarged inguinal and para-aortic lymph nodes that were histologically examined using excisional biopsy. Inguinal lymph nodes were tumor-positive and were dissected. The patient was subjected to two cycles of chemotherapy with cisplatin (75 mg/m2). After 3 months, a significant reduction in the size of the para-aortic lymph nodes was documented on control computerized tomography studies. Although the described case is unique, knowledge of the potential for this uncommon behavior in cutaneous SCC may be useful, especially because of its increasing incidence.

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