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Liverana Lauretti, Quintino Giorgio D'Alessandris, Massimo Fantoni, Tiziana D'Inzeo, Eduardo Fernandez, Roberto Pallini and Giancarlo Scoppettuolo

The authors report on the first case of the intraventricular administration of tigecycline described in the Western literature. A 22-year-old man developed cerebrospinal fluid infection from an extremely drug-resistant strain of Acinetobacter baumannii as a complication of endoscopic transsphenoidal surgery for the removal of a giant pituitary adenoma. The patient was safely and successfully treated with the prolonged intraventricular administration of tigecycline. Here, the authors provide the schedule details that can be invaluable in treating meningitis from extremely drug-resistant bacterial strains. Intraventricular tigecycline can be a valuable tool against multidrug-resistant central nervous system infections.

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Liverana Lauretti, Quintino Giorgio D'Alessandris and Eduardo Fernandez

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Nicola Montano, Quintino Giorgio D'Alessandris, Manuela D'Ercole, Liverana Lauretti, Roberto Pallini, Rina Di Bonaventura, Giuseppe La Rocca, Federico Bianchi and Eduardo Fernandez

OBJECT

Only a few published studies of the surgical treatment of benign peripheral nerve sheath tumors (BPNSTs), malignant peripheral nerve sheath tumors (MPNSTs), and peripheral non–neural sheath tumors (PNNSTs) have analyzed the results and possible prognostic factors using multivariate analysis. The authors report on their surgical series of cases of BPNSTs, MPNSTs, and PNNSTs with long-term follow-up and analyze the role of selected factors with respect to the prognosis and risk of recurrence of these tumors using multivariate analysis. They also review the pertinent literature and discuss their results in its context.

METHODS

The authors retrospectively reviewed data from cases involving patients who underwent resection of a peripheral nerve tumor between January 1983 and December 2013 at their institution. Of a total of 200 patients, 150 patients (with 173 surgically treated tumors) had adequate follow-up data available for analysis. Pain was assessed using a visual analog scale (VAS), and motor and sensory function were assessed by means of the Louisiana State University grading system. They also analyzed the relationship between tumor recurrence and patient sex, patient age, diagnosis of neurofibromatosis (NF), tumor histopathology, tumor size, tumor location, and extent of resection (subtotal vs gross-total resection), using univariate and multivariate analyses.

RESULTS

There was a statistically significant improvement in the mean VAS pain score (preoperative 3.96 ± 2.41 vs postoperative 0.95 ± 1.6, p = 0.0001). Motor strength and sensory function were significantly improved after resection of tumors involving the brachial plexus (p = 0.0457 and p = 0.0043, respectively), tumors involving the upper limb (p = 0.0016 and p = 0.0016, respectively), BPNSTs (p = 0.0011 and p < 0.0001, respectively), and tumors with dimensions less than 5 cm (motor strength: p = 0.0187 and p = 0.0021 for ≤ 3 cm and 3–5 cm tumors, respectively; sensory function: p = 0.0003 and p = 0.0001 for ≤ 3 cm and 3–5 cm tumors, respectively). Sensory function showed a statistically significant improvement also in patients who had undergone resection of tumors involving the lower limb (p = 0.0118). Total resection was associated with statistically significant improvement of motor strength (p = 0.0251) and sensory function (p < 0.0001). In univariate analysis, a history of NF (p = 0.0034), a diagnosis of MPNST or PNNST (p < 0.0001), and subtotal resection (p = 0.0042) were associated with higher risk of tumor recurrence. In multivariate analysis (logistic regression analysis), a history of NF (OR 9.28%, 95% CI 1.62–52.94, p = 0.0121) and a diagnosis of MPNST (OR 0.03%, 95% CI 0.002–0.429, p = 0.0098) or PNNST (OR 0.081%, 95% CI 0.013–0.509, p = 0.0077) emerged as independent prognostic factors for tumor recurrence.

CONCLUSIONS

A total resection should be attempted in all cases of peripheral nervous system tumors (irrespective of the supposed diagnosis and tumor dimensions) because it is associated with better prognosis in term of functional outcome and overall survival. Moreover, a total resection predicts a lower risk of tumor recurrence. Patients with a history of NF and tumors with malignant histology remain a challenge both for neurosurgeons and oncologists due to higher recurrence rates and the lack of standardized adjuvant therapies.

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Quintino Giorgio D'Alessandris, Corrado Lucantoni, Francesco Signorelli and Liverana Lauretti

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Nicola Montano, Quintino Giorgio D'Alessandris, Federico Bianchi, Liverana Lauretti, Francesco Doglietto, Eduardo Fernandez, Giulio Maira and Roberto Pallini

Object

Communicating hydrocephalus is an uncommon complication in patients treated for glioblastoma multiforme (GBM). Its pathogenesis remains unclear. The authors evaluated the clinical and radiological factors associated with the onset of communicating hydrocephalus and the impact of ventriculoperitoneal (VP) shunt surgery on the outcome of these patients.

Methods

One hundred twenty-four patients harboring GBM, who had undergone craniotomy for tumor resection and adjuvant radiochemotherapy, were retrospectively assessed. Seven of them developed communicating hydrocephalus and were treated with VP shunt surgery. Clinical and radiological estimates included Karnofsky Performance Scale (KPS) score, previous surgery, overall survival (OS), CSF pressure and components, tumor location, and leptomeningeal dissemination.

Results

All 7 patients who developed communicating hydrocephalus had undergone at least 2 craniotomies for tumor resection before the onset of hydrocephalus (p = 0.0006; Fisher exact test). Six cases showed high levels of CSF proteins. There was a highly significant relationship between ventricular opening at surgery for tumor recurrence and onset of hydrocephalus (p = 0.0002; Fisher exact test). In these patients, VP shunt surgery was followed by a significant improvement of KPS score (p = 0.0180; Wilcoxon signed-rank test). The median OS after VP shunt insertion was 5 ± 2.9 months.

Conclusions

Ventricular opening after radiochemotherapy and high CSF protein levels are significant predictors of communicating hydrocephalus in patients with GBM. The VP shunt surgery improves quality of life in these patients.

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Nicola Montano, Francesco Doglietto, Alessandro Pedicelli, Alessio Albanese, Liverana Lauretti, Roberto Pallini, Libero Lauriola, Eduardo Fernandez and Giulio Maira

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Eduardo Fernandez, Francesco Doglietto, Alessandro Ciampini and Liverana Lauretti

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.

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Massimo Miscusi, Florian Ebner, Sabrina Ceccariglia, Marta Menegazzi, Sofia Mariotto, Luigi Berra, Aurora Del Fa, Carlo Gangitano, Liverana Lauretti, Paolo Missori, Roberto Delfini and Hisanori Suzuki

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–κB (NF-κB) activation. The authors investigated the activity of neuronal and endothelial NO synthase (nNOS and eNOS) to determine correlations with NF-κB 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-κB; 3) Northern blotting for iNOS; 4) immunohistochemistry for iNOS and NF-κB; and 5) immunofluorescence for iNOS and NF-κB.

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-κB levels were variable in controls and at 15 and 30 minutes after injury. One hour postinjury, NF-κB 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-κB staining, especially in neurons inside and around the lesion. Immunofluorescence demonstrated that injured neurons were a source of NF-κB and iNOS soon after injury.

Conclusions

Both nNOS and eNOS exhibited different regulation and roles soon after injury: nNOS correlated with NF-κB 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.

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Luca Denaro, Federico Di Rocco, Marco Gessi, Libero Lauriola, Liverana Lauretti, Roberto Pallini, Eduardo Fernandez and Giulio Maira

✓ Chordoid meningioma is a rare meningothelial tumor characterized by chordoma-like histological features with lymphoplasmacellular infiltration. This tumor is often seen in children, but not in adults, with a systemic inflammatory syndrome (iron-resistant microcytic anemia and/or dysgammaglobulinemia) and very rarely with a persistent moderate hyperthermia.

In the present report the authors describe a temporal chordoid meningioma in a 30-year-old woman who presented with fever, headache, and a serological inflammatory syndrome. The clinical symptomatology, chiefly the fever, disappeared immediately after removal of the tumor. To the authors' knowledge, only one similar patient with such clinical presentation and response to surgery has been mentioned in the literature. Interestingly, at immunohistochemical examination, the neoplasm showed focal positivity for the pyrogenic cytokine interleukin-6. The capacity of the tumor to produce this pyrogenic cytokine could explain both the patient's clinical presentation and her response to the surgical management.

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Eduardo Fernandez, Alessandro Di Rienzo, Enrico Marchese, Luca Massimi, Liverana Lauretti and Roberto Pallini

✓ An 18-year-old man presented with a spontaneously occurring radial nerve palsy that spared the triceps muscle. At surgery, the portion of the radial nerve located at the midarm level had an hourglass-like appearance. Under magnification, an external—internal neurolysis of the narrowed portion of the hourglass-shaped portion revealed nerve torsion. Straightening of the twisted nerve and fixation accomplished using epiperineurium—fascia stitches to avoid a new torsion resulted in complete functional recovery of the radial nerve.