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Alberto Delitala, Roberto Delfini, Roberto Vagnozzi and Stefano Esposito

✓ A patient is reported in whom enlargement of a cerebral arteriovenous malformation (AVM) over 27 years was documented by angiography. The authors discuss the different theories about the growth of AVM's.

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Intramedullary spinal neurinomas

Report of two cases

Giampaolo Cantore, Pasquale Ciappetta, Roberto Delfini, Roberto Vagnozzi and Albino Nolletti

✓ Two cases of intramedullary neurinoma are presented in patients with no signs of von Recklinghausen's disease. Only 16 similar cases have been published so far. The relevant literature is reviewed.

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Nontraumatic acute spinal subdural hematoma

Report of five cases and review of the literature

Maurizio Domenicucci, Alessandro Ramieri, Pasquale Ciappetta and Roberto Delfini

✓ Acute subdural spinal hematoma occurs rarely; however, when it does occur, it may have disastrous consequences. The authors assessed the outcome of surgery for this lesion in relation to causative factors and diagnostic imaging (computerized tomography [CT], CT myelography), as well as eventual preservation of the subarachnoid space.

The authors reviewed 106 cases of nontraumatic acute subdural spinal hematoma (101 published cases and five of their own) in terms of cause, diagnosis, treatment, and long-term outcome.

Fifty-one patients (49%) were men and 55 (51%) were women. In 70% of patients the spinal segment involved was in the lumbar or thoracolumbar spine. In 57 cases (54%) there was a defect in the hemostatic mechanism. Spinal puncture was performed in 50 patients (47%). Late surgical treatment was performed in 59 cases (56%): outcome was good in 25 cases (42%) (in 20 of these patients preoperative neurological evaluation had shown mild deficits or paraparesis, and three patients had presented with subarachnoid hemorrhage [SAH]). The outcome was poor in 34 cases (58%; 23 patients with paraplegia and 11 with SAH).

The formation of nontraumatic acute spinal subdural hematomas may result from coagulation abnormalities and iatrogenic causes such as spinal puncture. Their effect on the spinal cord and/or nerve roots may be limited to a mere compressive mechanism when the subarachnoid space is preserved and the hematoma is confined between the dura and the arachnoid. It seems likely that the theory regarding the opening of the dural compartment, verified at the cerebral level, is applicable to the spinal level too. Early surgical treatment is always indicated when the patient's neurological status progressively deteriorates. The best results can be obtained in patients who do not experience SAH.

In a few selected patients in whom neurological impairment is minimal, conservative treatment is possible.

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Giampaolo Cantore, Pasquale Ciappetta and Roberto Delfini

✓ A new steel device for occipitocervical fixation is described. The system is easily and quickly applied, and affords a stronger and more secure means of attachment of the steel wires than using the occipital bone alone.

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Giampaolo Cantore, Beniamino Guidetti and Roberto Delfini

✓ Surgical experience with grafts of human dura mater sterilized by gamma rays and preserved in alcohol is reported in 804 cases. The method of graft preparation is a simple, cheap, and practical technique for making available a plentiful quantity of large and small pieces of dura to use for plastic reconstruction in everyday neurosurgical practice. Annual inspection for sterility and immunogenicity over an 18-year period indicates that this system of preservation is valid for an unlimited period of time.

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Emiliano Passacantilli, Antonio Santoro, Angelo Pichierri, Roberto Delfini and Giampaolo Cantore

Object

The authors present the surgical results obtained using the anterolateral approach to the craniocervical junction (CCJ) to resect a lesion with an extradural component located anterolateral to the foramen magnum and upper cervical spine.

Methods

The anterolateral approach, which is a presternomastoid retrojugular route to the CCJ, was performed in 14 patients. The skin incision follows the anterior edge of the sternomastoid muscle. The vertebral artery (VA) was exposed at C-1. This approach was extended either down to the cervical spine or anteriorly to the jugular foramen, according to specific requirements. Two patients had previously undergone other surgical procedures.

The follow-up period ranged from 4 months to 6.2 years. The tumor resection was complete in 11 cases and subtotal in two. In a case of vertebral coiling, a vein graft was interposed between the V1 and the V3 segments of the VA, and the bypass was still patent at the 2-year follow-up examination. In two cases involving a glomus tumor, there was a transitory postoperative seventh cranial nerve deficit.

Conclusions

The aforementioned technique allows for sufficient access to lesions located anterolateral to the CCJ. It is indicated in cases in which lesions exhibit a significant extradural component, and it provides good control of the VA, the cervical portion of the internal carotid artery, sigmoid—jugular complex, and lower cranial nerves. This approach can easily be combined with a posterolateral approach and can be extended anteriorly toward the jugular foramen and inferiorly toward the lower cervical spine.

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Roberto Delfini, Antonino Raco, Marco Aritco, Maurizio Salvati and Pasquale Ciappetta

✓ A two-step supraorbital approach to lesions of the orbital apex is described. This technique is easy and allows a satisfactory exposure of the region. In addition, the reconstruction resulting from the procedure is anatomically perfect. The authors report the operative results obtained in 20 patients and compare this two-step supraorbital procedure with similar surgical techniques described previously.