Out of a consecutive series of 1082 operations performed on head-injured patients over a 9-year period, 28 cases of acute subdural haematomas (SDHs) or epidural haematomas (EDHs) occurring in patients aged between 80 and 100 years were selected. Mortality rates in these patients (100% in 2 EDHs, 88% in 26 SDHs) were significantly higher (p less than 0.01) compared with patients under 80 years (12% in 308 EDHs, 57% in 215 SDHs). Pre-existing diseases, primary events precipitating falls, and multiple system failure complicating the postoperative course accounted for most of the deaths. None of the patients operated upon with a Glasgow Coma Scale score of 11 or less survived. A typical 'talk and die' course occurred in two cases. Three patients, all operated on for SDH, survived and returned to their pre-injury conditions. It was concluded that, whilst the question as to whether to submit very old comatose patients to life-prolonging measures remains unsettled, there is a case for the prompt evacuation of extra-axial clots in patients with minimal impairment of consciousness.

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Background: Gliomas are among the most challenging pathologies for neurosurgeons due to their infiltrative and recurrent nature in functionally relevant regions. Current knowledge confirms that gross total resection highly influence survival in patient with glioma. However, surgery performed in eloquent brain area, could seriously compromise the quality of life in patient with reduced life expectancy even more if it concerns the language function. Methods: 18 right-handed patients with perisylvian gliomas on the left hemisphere were prospectively analyzed over a period of 12 months. Standardized preoperative Diffusion-Tensor-Imaging based tractography of the five main language Tracts (Arcuate Fasciculus, Frontal Aslant Tract, Inferior Fronto-Occipital Fasciculus, Inferior Longitudinal Fasciculus, Uncinate Fasciculus) was navigated during the surgical procedure. Using a validated method, correlations were made between the pre-operative fascicles and their possible infiltration and surgical damage. The language status was assessed using the Aachen Aphasia Test. Results: In all nine patients who developed a permanent disorder there was pre-operative involvement of at least one fascicle and resection of at least one of these. In this way, areas of high risk of permanent language damage have emerged as a result of surgical injury: the temporoparietal junction, the middle portion of the FAT and the temporal stem. Conclusions: Navigated tractography has proven to be a user-friendly tool that can assess perioperative risk, guide surgical resection, and help the neurosurgeon to find that balance between tumor resection and function preservation.

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.