In response to: Collet-Sicard Syndrome After Jefferson Fracture.

We read with great interest the recent article by Shahrvini et al. concerning Collect-Sicard syndrome after Jefferson fracture.1 The authors present a detailed report of the syndrome in an aged woman after an accidental forward fall with head injury. This case is unique, as we found no geriatric patients with associated Jefferson fracture in our previous review of Collect-Sicard syndrome

Emergency decompressive craniectomy after removal of convexity meningiomas

BACKGROUND: Convexity meningiomas are benign brain tumors that are amenable to complete surgical resection and are associated with a low complication rate. The aim of this study was to identify factors that result in acute postoperative neurological worsening after the removal of convexity meningiomas. METHODS: Clinical evaluation and neuroradiological analysis of patients who underwent removal of a supratentorial convexity meningioma were reviewed. Patients were selected when their postoperative course was complicated by acute neurological deterioration requiring decompressive craniectomy. RESULTS: Six patients (mean age: 43.3 years) underwent surgical removal of a supratentorial convexity meningioma. Brain shift (mean: 9.9 mm) was evident on preoperative imaging due to lesions of varying size and perilesional edema. At various times postoperatively, patient consciousness worsened (up to decerebrate posture) with contralateral paresis and pupillary anisocoria. Computed tomography revealed no postoperative hematoma, however, did indicate increased brain edema and ventricular shift (mean: 12 mm). Emergency decompressive craniectomy and brief ventilator assistance were performed in all patients. Ischemia of the ipsilateral posterior cerebral artery occurred in 3 patients and hydrocephalus occurred in 2 patients. Outcome was good in 2, fair in 2, 1 patient had severe disability, and 1 patient died after 8 months. CONCLUSIONS: Brain shift on preoperative imaging is a substantial risk factor for postoperative neurological worsening in young adult patients after the removal of convexity meningiomas. Emergency decompressive craniectomy must be considered because it is effective in most cases. Other than consciousness impairment, there is no reliable clinical landmark to guide the decision to perform decompressive craniectomy; however, brain ischemia may have already occurred

Probabilistic Approach to Provide Scenarios of Earthquake-Induced Slope Failures (PARSIFAL) Applied to the Alcoy Basin (South Spain)

The PARSIFAL (Probabilistic Approach to pRovide Scenarios of earthquake-Induced slope FAiLures) approach was applied in the basin of Alcoy (Alicante, South Spain), to provide a comprehensive scenario of earthquake-induced landslides. The basin of Alcoy is well known for several historical landslides, mainly represented by earth-slides, that involve urban settlement as well as infrastructures (i.e., roads, bridges). The PARSIFAL overcomes several limits existing in other approaches, allowing the concomitant analyses of: (i) first-time landslides (due to both rock-slope failures and shallow earth-slides) and reactivations of existing landslides; (ii) slope stability analyses of different failure mechanisms; (iii) comprehensive mapping of earthquake-induced landslide scenarios in terms of exceedance probability of critical threshold values of co-seismic displacements. Geotechnical data were used to constrain the slope stability analysis, while specific field surveys were carried out to measure jointing and strength conditions of rock masses and to inventory already existing landslides. GIS-based susceptibility analyses were performed to assess the proneness to shallow earth-slides as well as to verify kinematic compatibility to planar or wedge rock-slides and to topples. The experienced application of PARSIFAL to the Alcoy basin: (i) confirms the suitability of the approach at a municipality scale, (ii) outputs the main role of saturation in conditioning slope instabilities in this case study, (iii) demonstrates the reliability of the obtained results respect to the historical data.This work was partially funded by Spanish MINECO and European funds under project EPILATES (CGL2015.65602-R) and by the University of Alicante, research group VIGROB-184

Total recovery from Parkinson syndrome after surgical removal of a meningioma: a clinical case.

Signs of parkinsonism, such as resting tremors, rigidity, bradykynesia, and gait disturbance, tipically have a unilateral onset and result from a malfunction in the extrapyramial system involving the basal ganglia. Here we describe a patient who developed a pure bilateral parkinsonism that completely regressed after neurosurgical removal of the patient's tumour

Factor XI deficiency and delayed hemorrhages after resection of choroid plexus papilloma: illustrative case

BACKGROUND Factor XI deficiency, also known as hemophilia C, is a rare inherited bleeding disorder that may leave routine coagulation parameters within normal range. Depending on the mutation subtype, prolonged activated partial thromboplastin time may occasionally be found. The disease has an autosomal transmission, with an estimated prevalence in the general population of approximately 1 in 1 million. Heterozygosis accounts for partial deficits, but the tendency to bleed is unrelated to the measured activity of factor XI. Diagnosis usually follows unexpected hemorrhages occurring spontaneously or after trauma or surgical procedures. OBSERVATIONS Few cases have been reported in the neurosurgical literature, all occurring spontaneously or after head trauma. Owing to its subtle features, the true incidence of the disease is probably underestimated. The authors report a case of a patient with previously undiagnosed factor XI deficiency who underwent uncomplicated resection of a fourth-ventricle papilloma and experienced delayed, severe hemorrhagic complications. LESSONS The known association between choroid plexus tumors and intracranial bleeding raised differential diagnosis issues. This report may serve to help to investigate delayed hemorrhages after cranial surgery

Interhemispheric contralateral approach: the falx as a retractor

The contralateral transfalcine approach is a valuable option to access lesions around the mesial surface of the brain hemispheres. Despite a favourable perspective, surgical manoeuvres within the interhemispheric fissure carry a risk of inadvertent injury to the healthy cortex on the craniotomy side. To overcome this drawback, a new method of brain retraction was developed. After dissecting the interhemispheric fissure, the falx was incised in an upside-down U-shaped manner and hinged inferiorly, taking care not to violate the inferior sagittal sinus. The falcine flap was reflected laterally and fixed to the lateral edge of the craniotomy, providing homogeneous retraction of the ipsilateral mesial cortex. Surgery proceeded with the brain surface hidden from the surgeon's view and protected by the flap. The absence of retractor devices hindering the surgeon's movements further simplified the procedure

Post-traumatic Collet-Sicard syndrome: personal observation and review of the pertinent literature with clinical, radiologic and anatomic considerations

Study design The lesion of the lower four cranial nerves, commonly called Collet–Sicard syndrome, can be caused by a blunt head and neck trauma. It may be associated to an isolated fracture of the occipital condyle or of the atlas. Objective The aim of this report is to assess the modality of the trauma, the type of fracture, the anatomic characteristics, the treatment and clinical results of this syndrome. Summary of background data We discuss 14 cases of fracture of occipital condyle and of atlas and 1 personal case. Methods We analyzed 14 cases collected from the literature between 1925 and 2013, reported a further personal case and performed an anatomical study of the paracondylar, atlas and styloid process region. The anatomical dissection was performed to assess the anatomic relationships in the site of transit in which the nerves IX, X, XI and XII are injured. Results A total of 14 cases of p-CSS were collected: 9 caused by a condyle fracture and 5 by an atlas fracture. The patients were 13 males and only 1 female, 10 of them had a blunt trauma due to the result of axial loading (force directed through the top of the head and through the spine) falling on the head. The nine cases with a condyle fracture were associated to the dislocation of part of it, while those with atlas fractures showed the fracture and/or disjunction of the articular mass. The anatomical evaluations reveal that the lower four cranial nerves, at their emergency, pass through a close osteo-ligamentous space in relationship to the condyle. Below they run through a little wider channel between the articular mass of C1 and the styloid process. Two cases underwent surgical procedure. All the other cases were treated conservatively with immobilization of the cervical spine. During follow-up three cases with condylar fractures were found to be clinically unchanged and six showed modest improvements while one case with atlas fracture had a complete recovery and four improved significantly. Conclusions The p-CSS is caused by force directed through the top of the head.Wesuppose that the nerve injuries are due to their laceration caused by a displacement of a condyle fragment or to their compression and stretching when they pass between the lateral mass of the atlas and the styloid process. Thesemodalities of traumaexplain the better clinical results in patients affected by C1 fractures. Conservative treatment is the option of choice. Surgical option, when choosed, is not considered to fix nerve damages

Intracranial meningioma and concomitant cavernous malformation: a series description and review of the literature

Objectives: Intracranial meningioma with concomitant cavernous malformation has been rarely described in the literature. This study aimed to investigate the correct neurosurgical conduct. Patients and Methods: We retrieved clinical and radiological data for 39 outpatients or patients that underwent surgery (mean age: 60 years; n = 25 females) for a single or multiple meningiomas and concomitant single or multiple cavernous malformations. Cavernous malformations were classified according to Zabramski’s type scale. Our results were compared to results published in the literature. Results: All patients had at least one meningioma and at least one concomitant cavernous malformation. Most meningiomas and cavernous malformations were located in the supratentorial region. Nine patients (23 %) had multiple meningiomas and nine had concomitant multiple cavernous malformations. Cavernous malformations were classified as type I (n = 0), type II (n = 9), type III (n = 11), or type IV (n = 19). The surgical priority was meningioma removal. A single patient underwent simultaneous removal of a meningioma and a contiguous cavernous malformation. In the postoperative period and long term follow-up, no complications occurred related to cavernous malformations, intra- or extra-lesional bleeding, or morphology/size changes. Years after surgical treatment, a new type IV cavernous malformation occurred in two patients. Conclusion: Our findings corroborate that meningioma removal should take priority in patients with intracranial meningioma and concomitant cavernous malformation. Concomitant cavernous malformations showed no change in morphology or size; therefore, they should merely be observed during follow-up. In patients that harbor a single meningioma, a type IV cavernous malformation should preferably be considered a concomitant cerebral microbleed

Temporal horn enlargements predict secondary hydrocephalus diagnosis earlier than Evans’ Index

Lo scopo di questo studio era di identificare i primi segni radiologici di idrocefalo secondario. Abbiamo recuperato dati neuroradiologici da scansioni eseguite in vari momenti in pazienti che hanno subito un intervento chirurgico per idrocefalo secondario a causa di grave lesione cerebrale traumatica (TBI), emorragia subaracnoidea (SAH) o tumore al cervello (BT). Le misurazioni di base, eseguite sulle prime immagini acquisite dopo l'evento neurologico (T0), includevano l'indice di Evans, la distanza tra le corna frontali e le larghezze di entrambe le corna temporali. La successiva neuroimmagine che ha mostrato un aumento di almeno uno di questi quattro parametri - e che ha portato il chirurgo ad agire - è stata selezionata come indicazione dell'allargamento ventricolare (T1). I confronti delle neuroimmagini T0 e T1 hanno mostrato aumenti nell'indice di Evans, nella distanza media del corno frontale e nelle larghezze medie del corno temporale destro e sinistro. È interessante notare che nelle scansioni T1, i punteggi dell'indice medio di Evans >0,30 sono stati osservati solo nei pazienti con BT. Tuttavia, le larghezze del corno temporale sono aumentate fino a dieci volte nella maggior parte dei pazienti, indipendentemente dai punteggi dell'indice di Evans. In conclusione, gli ingrandimenti del corno temporale sono stati i primi risultati più sensibili nel predire l'allargamento ventricolare secondario a trauma cranico, SAH o BT. Per anticipare una diagnosi radiologica di idrocefalo secondario, i medici dovrebbero misurare sia l'indice di Evans che l'ampiezza del corno temporale, per evitare gravi disabilità e scarsi risultati correlati al danno del lobo temporale.The aim of this study was to identify early radiological signs of secondary hydrocephalus. We retrieved neuroradiological data from scans performed at various times in patients who under-went surgery for secondary hydrocephalus due to severe traumatic brain injury (TBI), subarach-noid haemorrhage (SAH), or brain tumour (BT). Baseline measurements, performed on the ear-liest images acquired after the neurological event (T0), included Evans’ index, the distance be-tween frontal horns, and the widths of both temporal horns. The next neuroimage that showed an increase in at least one of these four parameters - and that lead the surgeon to act - was se-lected as an indication of ventricular enlargement (T1). Comparisons of T0 and T1 neuroimages showed increases in Evans’ index, in the mean frontal horn distance, and in the mean right and left temporal horn widths. Interestingly, in T1 scans, mean Evans’ index scores >0.30 were only observed in patients with BT. However, the temporal horn widths increased up to ten-fold in most patients, independent of Evans’ index scores. In conclusion temporal horn enlargements were the earliest, most sensitive findings in predicting ventricular enlargement secondary to TBI, SAH, or BT. To anticipate a secondary hydrocephalus radiological diagnosis, clinicians should measure both Evans’ index and the temporal horn widths, to avoid severe disability and poor outcome related to temporal lobe damage