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BACKGROUND: The surgical management of pure apical tumours of the orbit may be problematic with traditional approaches. A postero-lateral approach, specifically designed for apical growths, provides a more favourable angle of vision through a relatively small bone opening. METHODS: A series of 103 consecutive cases of intraorbital tumours, operated on in a community-based institution, was retrospectively reviewed. Out of this series, 8 patients, harbouring lesions located in the posterior intraconal space, underwent a postero-lateral orbitotomy. This approach, through a small opening on the orbital and temporal portions of the greater wing of the sphenoid, with the lesser sphenoidal wing, the orbital plate of the frontal bone, the lateral rim of the orbit being maintained intact, allowed adequate exposure of the orbital apex and successful extirpation of the tumours. In four patients the histological examination disclosed a cavernoma; the other patients had, respectively, a dermoid cyst, a lymphoma, a hemangiopericytoma and a metastatic melanoma. RESULTS: No recurrences were observed in a follow-up period ranging from 1 to 7 years postoperatively (the patient with melanoma died 16 months after operation for systemic complications of her illness). One patient showed transient weakness of lateral rectus muscle due to surgical manipulation, which subsided in few months. CONCLUSIONS: The postero-lateral orbitotomy represents a reliable alternative to other traditional surgical approaches when dealing with tumours of the orbital apex, providing excellent exposure of this region with a low rate of operative morbidity.

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A case is presented in which a patient developed a complication related to the use of Silastic dural substitute. Ten years after the initial surgery, a fibrotic-haemorrhagic reaction around the graft material was found, mimicking a recurrent meningioma clinically and radiologically. A review of the literature and suggested mechanisms of these complications are reported.

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Early changes of cerebellar and cerebral blood flow, as well as subsequent infratentorial ischaemia, were evaluated in an experimental model of cerebellar haemorrhage. Eight anaesthetized male adult Sprague-Dawley rats received an injection of autologous arterial blood (50 microliters) into the right cerebellar hemisphere. Eight animals were sham-operated and served as controls. Cerebellar blood flow, measured at regular time intervals in the hemispheric cortex ipsilateral to the lesion by the hydrogen clearance method, was significantly depressed in the experimental group as compared with the control animals. This drop in cerebellar blood flow was evident 5, 30, 60, 90, and 120 min postoperatively, with a return to pre-injection values recorded 180 min after surgery. No significant difference in supratentorial blood flow was detected over the entire period examined between the two groups of animals. Enzyme histochemistry demonstrated areas of ischaemia around the clot and within the brain stem in animals with an intracerebellar haemorrhage at the end of the experiment. These results provided evidence of ischaemic damage within the infratentorial compartment after the induction of experimental cerebellar haemorrhage.

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A 25-year-old male was wounded accidentally in the neck by a metallic fragment, which penetrated his right carotid artery and migrated within the ipsilateral middle cerebral artery. Clinical and laboratory findings over a 16-month-period are reported. Problems arising from the presence of metallic emboli to the cerebral circulation are discussed on the basis of the pertinent literature.

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A case of spinal subarachnoid hematoma at T3-T7 level is reported in a 60-year-old hunter, who developed progressive spinal cord impairment after receiving the recoil of his shotgun. Both clinical and neuroradiological investigations, including the selective spinal angiography, failed to demonstrate the origin of the bleeding. The combination of an apparently trivial spinal trauma with temporary increase of the intrathoracic pressure might be considered as possible etiologic factor.

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The temporal progression of changes in blood flow within the hemispheric cerebellar cortex, following an experimental cerebellar ipsilateral haemorrhage, was investigated in rats by using the hydrogen clearance technique. Stereotactical injection of 50 microliters of fresh autologous blood into the paramedian white matter was found to produce an early drop of cerebellar blood flow, with subsequent rise toward higher values. An increase of the intracranial pressure only occurred at the time of injection of blood. Arterial blood gases, mean arterial blood pressure and blood glucose levels did not exhibit significant changes. Histochemical evaluations of glycogen phosphorylase showed a posthaemorrhagic pattern of enzyme depletion, consistent with the occurrence of an ischaemic damage in both the cerebellum and the brain stem.

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Analysis of 314 cases of penetrating craniocerebral missile injuries in civilians revealed a high rate of early mortality, with 228 victims having died at the scene and a further 38 dead within 3 hours. Surgery was performed in 44 patients who had a preoperative Glasgow Coma Score of at least 4. Out of the 26 survivors, all operated upon, 19 had an adequate recovery (score of 0-3 on the expanded Glasgow Outcome Scale). Vigorous resuscitation and early surgery often resulted in useful survivals and occasionally in spectacular recoveries. However, the high mortality rate on the scene or soon after the injury restricted the possibility of effective management to a minority of cases.

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A case of chronic subdural hematoma associated with contralateral upper monoballism is reported. Intracranial midline shift and transtentorial herniation of the ipsilateral temporal lobe were the only demonstrated CT abnormalities. Complete neurological recovery followed the evacuation of the hematoma. Direct mechanical injury caused by the marked brain compression and distortion, and transient ischemic changes within cerebral areas whose damages may result in ballism, may be considered important causative factors of such an unusual neurological complication.

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In order to assess the actual incidence of gas bubbles trapped within acute intracranial epidural haematomas, as revealed by computed tomography (CT) of the skull, a series of 204 patients with surgically verified epidural haematomas was retrospectively reviewed. Gas bubbles were observed on CT scan in 22.5% of the cases, with the incidence rising to 37% when CT scanners of the last generation were employed. The available data failed to demonstrate the actual source of intracranial gas. No correlation was found between the presence of gas bubbles and outcome. No patient in the whole series showed any sign of intracranial infection.

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Bilateral Parkinsonism has been observed in a 60-year-old female with a chronic subdural intracranial haematoma. Scattered, poorly marginated, hypodense areas within the ipsilateral pallidus and putamen were evident on the preoperative CT scans. The rapid neurological improvement following the surgical drainage of the subdural clot and the evolution of the densitometric features of the nuclear lesions, which became clear-cut, though smaller, in the following months, suggest a cause-and-effect relation between the haematoma and the clinical symptomatology. To the best of our knowledge this is the first case in which anatomical lesions within the basal ganglia could be detected neuroradiologically.

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A consecutive series of 178 civilians with gunshot wounds of the brain was retrospectively analyzed. The overall mortality was 93%, with 88% of the victims having succumbed within 3 hours. Surgery was performed in 21 cases, all with a Glasgow Coma Score of 6 or more. Out of the 12 survivors, 9 exhibited minor neurological signs at the time of discharge. Good outcome occasionally resulted in patients with lesions crossing the midline, or affecting two lobes of a single hemisphere. Although spectacular recoveries in individual patients with apparently devastating injuries can be regarded as a sufficient basis for an aggressive approach, including vigorous resuscitation and early surgery, bleak possibilities still exist as to the management of civilian gunshot wounds, owing to the high mortality rate on the scene, or soon after the injury.

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After destruction of the thalamocortical projections of one side in 12 adult rats, the ipsilateral thalamic ventrobasal nucleus was connected with the contralateral somatosensory cortex through an autologous peripheral nerve graft. Three months after the implanting procedure, horseradish peroxidase was applied to the transected nerve. Retrograde labeling of cells occurred in all examined animals. Evidence of newly formed thalamocortical connections provides the experimental basis to a model suitable for functional evaluations.

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21 patients with hydatid disease of the spine were operated on upon a 30-year period. The follow-up ranged up to 24 years. 12 cases underwent one or more reoperations, due to recurrences. 8 patients died between 1 and 21 years after the first operation. The surgical treatment usually allows only a transient remission and does not avoid recurrence or progression of the illness. Although the parasite cannot be wholly eradicated surgically, a prolonged and acceptable life with the disease can result from repeat surgical interference.

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Seventeen patients with minor cerebral contusion were selected from a series of patients with head injuries of various severity, who had undergone repeat evaluations of the regional cerebral blood flow. The mean global flow (expressed as mean global initial slope index) on early examination was found to be significantly lower, compared with that recorded in healthy volunteers. A tendency towards the recovery of higher flow values was apparent in repeat evaluations that were performed several weeks after the injury. Interhemispheric asymmetries of flow were a common occurrence, with lower perfusion and reduced attenuation values on computed tomography scans being, however, in good agreement only in approximately half of the cases.

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In a series of 88 cases of chronic subdural haematoma, the occurrence of dilatation of the posterior portion of the contralateral ventricle was found to be unrelated to any major neurological variable. There was, however, a prevalence of recurrences of the subdural effusions in the patients with partial hydrocephalus, compared with patients without ventricular dilatation.

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