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Alberto Feletti and Pierluigi Longatti

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Pierluigi Longatti, Elisabetta Marton and Salima Magrini

Isolated fourth ventricle is not uncommon in complex posthemorrhagic or postinfectious hydrocephalus. When the condition is symptomatic, the current surgical treatment is endoscopic aqueductoplasty, followed by endoscope-assisted placement of a catheter in the fourth ventricle. The authors suggest a very simple method of steering the tip of standard ventricular catheters by using materials commonly available in all operating rooms. The main advantage of this method is that it permits less invasive transaqueductal drainage of trapped fourth ventricles, especially in cases of narrow third ventricle, because the scope and catheter are introduced in sequence and not in a double-barreled fashion. Two illustrative cases are reported.

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Pierluigi Longatti, Alessandro Fiorindi, Alberto Feletti and Vittorio Baratto

✓A membrane obstruction of the foramina of Magendie and Luschka is an uncommon origin of hydrocephalus characterized by unusual clinical symptoms of rhomboid fossa hypertension. Various surgical approaches have been proposed to alleviate this obstruction, including opening the obstructed foramen of Magendie using suboccipital craniectomy, shunting procedures, and more recently, endoscopic third ventriculostomy (ETV). In some cases, however, reshaping of the posterior fossa due to the collapse of the prepontine cistern could make ETV difficult for the surgeon and dangerous to the patient. In these cases, endoscopic opening of the foramen of Magendie by transaqueductal navigation of the fourth ventricle is a suitable and feasible therapeutic option.

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Endoscopic navigation of the fourth ventricle

Technical note and preliminary experience

Pierluigi Longatti, Luca Basaldella, Alberto Feletti, Alessandro Fiorindi and Domenico Billeci

Transaqueductal navigation of the fourth ventricle has long been considered dangerous and of no clinical relevance. After the refinement of the endoscopic technique and supported by the extensive experience gained at the authors' institution since 1994, endoscopic exploration of the fourth ventricle has been performed by the same surgeon in 54 patients. In all cases reviewed, endoscopic navigation of the fourth ventricle was successfully performed with no related neurological deficit. This preliminary experience shows the feasibility of transaqueductal navigation of the fourth ventricle, which is made possible by the use of small, flexible endoscopes in expert hands.

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Pierluigi Longatti, Donatella Sgubin and Francesco Di Paola

✓The authors report a case of acute subarachnoid hemorrhage due to the rupture of multiple anterior spinal artery aneurysms. In view of the clinical and radiological findings, surgery was excluded and a wait-and-see policy was followed. A magnetic resonance imaging study performed 3 months after presentation and an angiographic study performed 6 months after presentation confirmed spontaneous regression of the aneurysms and preservation of blood flow through the anterior spinal artery.

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Dumbbell-shaped C-2 psammomatous melanotic malignant schwannoma

Case report and review of the literature

Elisabetta Marton, Alberto Feletti, Enrico Orvieto and Pierluigi Longatti

✓The authors present the case of a dumbbell-shaped malignant psammomatous melanotic schwannoma of the upper cervical spine involving the C-2 sensory root. The family of the patient had a history of other malignant stromal tumors, without the Carney complex genetic pattern. The 30-year-old female patient complained of experiencing cervical pain and cervical muscle contractions for 6 months, and was admitted to the hospital. The cervical T1-weighted magnetic resonance (MR) images revealed the presence of a slightly hyperintense C2–3 intra–extradural lesion, moderately enhancing, which had eroded and enlarged the intervertebral foramen. The patient workup also included computed tomography scans and angiography. A posterior approach was used to perform a C2–3 hemilaminectomy, including opening of the dura mater and gross-total removal of the lesion. Histopathological examination of the lesion revealed it to be a malignant psammomatous melanotic schwannoma. The cerebrospinal MR image of the patient obtained at the 12-month follow-up examination demonstrated the presence of tumor progression into the subarachnoid space at the C-3 level. The strong malignancy potential of the lesion must be considered in the future management of the patient, especially due to the presence in the family of other stromal tumors such as gastrointestinalstromal tumors and malignant melanomas. The authors review all the literature concerning melanotic schwannomas and report 105 cases of melanotic schwannoma that were not related to the Carney complex. The particular focus of their review is on the characteristics of the malignant progression of melanotic schwannoma, such as local recurrences, metastasis, and survival rate.

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Luca Basaldella, Elisabetta Marton, Alessandro Fiorindi, Bruno Scarpa, Hadi Badreddine and Pierluigi Longatti


Massive intraventricular hemorrhages (IVHs) require aggressive and rapid management to decrease intracranial hypertension, because the amount of intraventricular blood is a strong negative prognostic predictor on outcome. Neuroendoscopy may offer some advantages over more traditional surgical approaches on outcome and may decrease the number of shunt procedures that need to be performed.


The authors retrospectively reviewed the clinical and radiological data in 96 patients treated for massive IVH who were admitted between January 1996 and June 2008 to the neurosurgery unit after undergoing emergency CT scanning. Forty-eight patients (Group A) were treated with endoscopic aspiration surgery using a flexible endoscope with a “freehand” technique. A historical group of 48 patients (Group B) treated using external ventricular drain (EVD) placement alone was used as a comparison. The authors compared the radiological results with the clinical outcomes at 1 year according to the modified Rankin Scale and the need for internal CSF shunt treatment in the 2 groups.


Endoscopic aspiration did not significantly affect the outcome at 1 year as determined using the modified Rankin Scale. Patients who underwent endoscopy had an EVD in place for 0.18 days fewer than patients treated with an EVD alone. Patients undergoing external ventricular drainage alone had a 5 times greater chance of requiring a shunting procedure than those treated using neuroendoscopy and external ventricular drainage. Neuroendoscopy plus external drainage reduces shunting rates by 34% when compared with external drainage alone.


The reduction in internal shunt surgery encourages the adoption of neuroendoscopic aspiration of severe IVH as a therapeutic tool to decrease shunt dependency.

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Alberto Feletti, Giannantonio Zanata Santi, Francesco Sammartino, Marzio Bevilacqua, Piero Cisotto and Pierluigi Longatti


Peripheral nerve field stimulation has been successfully used for many neuropathic syndromes. However, it has been reported as a treatment for trigeminal neuropathic pain or persistent idiopathic facial pain only in the recent years.


The authors present a review of the literature and their own series of 6 patients who were treated with peripheral nerve stimulation for facial neuropathic pain, reporting excellent pain relief and subsequent better social relations and quality of life.


On average, pain scores in these patients decreased from 10 to 2.7 on the visual analog scale during a 17-month follow-up (range 0–32 months). The authors also observed the ability to decrease trigeminal pain with occipital nerve stimulation, clinically confirming the previously reported existence of a close anatomical connection between the trigeminal and occipital nerves (trigeminocervical nucleus).


Peripheral nerve field stimulation of the trigeminal and occipital nerves is a safe and effective treatment for trigeminal neuropathic pain and persistent idiopathic facial pain, when patients are strictly selected and electrodes are correctly placed under the hyperalgesia strip at the periphery of the allodynia region.

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Pierluigi Longatti, Andrea Porzionato, Luca Basaldella, Alessandro Fiorindi, Pietro De Caro and Alberto Feletti


The human area postrema (AP) is a circumventricular organ that has only been described in cadaveric specimens and animals. Because of its position in the calamus scriptorius and the absence of surface markers on the floor of the fourth ventricle, the AP cannot be clearly localized during surgical procedures.


The authors intravenously administered 500 mg fluorescein sodium to 25 patients during neuroendoscopic procedures; in 12 of these patients they explored the fourth ventricle. A flexible endoscope equipped with dual observation modes for both white light and fluorescence was used. The intraoperative fluorescent images were reviewed and compared with anatomical specimens and 3D reconstructions.


Because the blood-brain barrier does not cover the AP, it was visualized in all cases after fluorescein sodium injection. The AP is seen as 2 coupled leaves on the floor of the fourth ventricle, diverging from the canalis centralis medullaris upward. Although the leaves normally appear short and thick, there can be different morphological patterns. Exploration using the endoscope's fluorescent mode allowed precise localization of the AP in all cases.


Fluorescence-enhanced inspection of the fourth ventricle accurately identifies the position of the AP, which is an important landmark during surgical procedures on the brainstem. A better understanding of the AP can also be valuable for neurologists, considering its functional role in the regulation of homeostasis, emesis, and cardiovascular and electrolyte balance. Despite the limited number of cases in this report, evidence indicates that the normal anatomical appearance of the AP is that of 2 short and thick leaves that are joined at the midline. However, there can be great variability in terms of the structure's shape and size.

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Alberto Feletti, Elisabetta Marton, Grazia Marina Mazzucco, Shanna Fang and Pierluigi Longatti

Since children may not be able to complain of progressive reduction in optic acuity, visual assessment in infancy may present practical difficulties. The authors report a case of craniopharyngioma, which led a young child to early blindness before the correct diagnosis could be made. Similar to other reported cases, the authors found that surgery did not substantially modify the preoperative visual deficit. They conclude that minimal improvement in visual acuity can be expected despite successful microsurgical removal of the tumor.