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Massimo Caldarelli, Federica Novegno, Luca Massimi, Rossana Romani, Gianpiero Tamburrini, and Concezio Di Rocco

Object

Despite progress in the understanding of the causes and pathophysiology of Chiari malformation Type I (CM-I), definitive surgical treatment remains unresolved. Various techniques have been propounded over the years, but there is no general consensus on the most appropriate surgical management for this condition. The authors report their experience with the surgical treatment of 30 pediatric patients with CM-I.

Methods

The results obtained in 30 patients who underwent surgery for symptomatic CM-I with a purely extradural procedure were retrospectively reviewed. The patient age at operation ranged from 2 months to 16 years (mean 68 months). In 26 patients the CM-I occurred as an isolated disease, whereas in four a recognized bone anomaly involving the cranial base (achondroplasia) was observed. All patients underwent suboccipital craniectomy, which was accompanied by C-l laminectomy in 22. In all cases a thick fibrous band at the level of foramen magnum was resected; in 11 children serial incisions of the outer layer of the dura mater were performed as well to expand the posterior fossa volume. The follow-up duration varied from a minimum of 12 months to 12.6 years (mean 4.7 years).

The most frequent symptoms and signs were head and/or neck pain (56.7%), followed by vertigo (27.7%), upper-and lower-extremity weakness (20.0%), and ataxia (20.0%). Syringomyelia was noted in 12 patients (40.0%) on magnetic resonance (MR) images. Improvement in or resolution of clinical symptoms and signs was observed in all patients. However, only minimal or no modifications could be found in the position of cerebellar tonsils on postoperative MR images in most patients (only occasional improvement in tonsillar herniation), whereas syringomyelic cavitations reduced in size in half of the cases. Nevertheless, in only two patients was a reoperation necessary.

Conclusions

In the authors' experience, suboccipital craniectomy and C-l laminectomy (eventually integrated by dural delamination) can represent an effective treatment for symptoms associated with CM-I.

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W. Jerry Oakes

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Hector E. James

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Stephanie M. Casillo, Anisha Venkatesh, Nallammai Muthiah, Nitin Agarwal, Teresa Scott, Rossana Romani, Laura L. Fernández, Sarita Aristizabal, Elizabeth E. Ginalis, Ahmad Ozair, Vivek Bhat, Arjumand Faruqi, Ankur Bajaj, Abhinav Arun Sonkar, Daniel S. Ikeda, E. Antonio Chiocca, Russell R. Lonser, Tracy E. Sutton, John M. McGregor, Gary L. Rea, Victoria A. Schunemann, Laura B. Ngwenya, Evan S. Marlin, Paul N. Porensky, Ammar Shaikhouni, Kristin Huntoon, David Dornbos III, Andrew B. Shaw, Ciarán J. Powers, Jacob M. Gluski, Lauren G. Culver, Alyssa M. Goodwin, Steven Ham, Neena I. Marupudi, Dhananjaya I. Bhat, Katherine M. Berry, Eva M. Wu, and Michael Y. Wang

We received so many biographies of women neurosurgery leaders for this issue that only a selection could be condensed here. In all of them, the essence of a leader shines through. Many are included as “first” of their country or color or other achievement. All of them are included as outstanding—in clinical, academic, and organized neurosurgery. Two defining features are tenacity and service. When faced with shocking discrimination, or numbing indifference, they ignored it or fought valiantly. When choosing their life’s work, they chose service, often of the most neglected—those with pain, trauma, and disability. These women inspire and point the way to a time when the term “women leaders” as an exception is unnecessary.

—Katharine J. Drummond, MD, on behalf of this month’s topic editors