We found 128 cases of extra CNS metastases in the English literature. The main features of the patients of the previous reports and of those of the present series were analyzed. The main modalities of glioblastoma multiforme spread, the few theories about the rarity of metastasis, and the probable biological, histological and immunogenetic mechanisms involved in the pathogenesis are described. Although several studies have reported a poor outcome in elderly patients, they affirm that the treatment of those with a Karnofsky performance status >60 should be just as aggressive as in younger patients. This allows them to obtain a longer survival time and to also treat metastases, which are uncommon particularly in the elderly.

Object In this paper, the authors' goal was to evaluate the prognostic value of YKL-40 expression as a prognostic factor for glioblastomas and to compare its validity to the already known MGMT. Methods Between January 2002 and January 2007, 105 patients were treated for cerebral glioblastoma. The extent of removal was classified in 4 groups. YKL-40 expression was evaluated by a semiquantitative immunohistochemical staining scale (0, no staining; 1, mild expression; and 2, strong expression). MGMT promoter methylation status was analyzed with methylation-specific polymerase chain reaction. All patients received adjuvant radiotherapy and chemotherapy. Kaplan-Meier curves were used to analyze progression-free survival (PFS) and overall survival (OS), and to compare these parameters between the subgroups stratified by extent of surgical removal, MGMT methylation, and YKL-40 expression. The log-rank test was used to determine statistical significance. A multivariate regression analysis was applied to extent of removal, YKL-40 expression, and MGMT status to check their specific statistical power and to test the independence of the variables. Results There were 55 men and 50 women with a mean age of 58 years. Extent of surgical removal is reported. The MGMT promoter was methylated in 48 patients and nonmethylated in 57. Analysis of YKL-40 expression is reported. The median PFS was 10.7 months (14.9 months in the gross-total removal subgroup) (p < 0.0001), and the median OS was 12.5 months (17.4 months in the gross-total removal group) (p < 0.0001). In the univariate analysis, OS was significantly correlated to the extent of resection (p < 0.0001), MGMT status (p < 0.0001), and YKL-40 (p < 0.0001). Multivariate analysis showed that all 3 factors reached statistical significance with respect to patient survival. In particular, surgical removal contributed more than the 2 other factors to the survival prediction (β = −0.6254). Interestingly, YKL-40 (β = −0.3867) contributed more than MGMT (β = −0.1705) to the predicted survival. Conclusions The extent of removal is the most important factor influencing the OS of patients harboring glioblastomas. When biological aggressiveness is taken into account, YKL-40 expression was found to be an independent prognostic factor that predicts OS better than MGMT status.

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The rarity of the pediatric intramedullary cavernoma, the familial occurrence, and the spontaneous regression of the pontine cavernoma make this case very peculiar.

The purpose of this article was to trace the historical origin of the inserted cannula during tracheotomy. Tracheotomy is mentioned in most ancient medical texts, but the origin of cannula insertion into the windpipe is unclear. We reviewed the incunabula and Renaissance texts reporting the utilization of surgical cannulas and tracheotomy. The incunabula disclosed extended use of surgical cannulas during the middle ages and Renaissance. Although tracheotomy was advocated in acutely suffocating patients for a disease of the throat termed squinantia or angina, the first report of the procedure was found only at the end of the middle ages and a second during the middle Renaissance. The introduction of cannula use in tracheotomy was supported by a semantic misinterpretation by Antonio Musa Brasavola. The historical origin for tracheotomy in the middle ages and Renaissance is conflicting. Antonio Brasavola wrongly interpreted Avicenna's oral cannula introduced into the windpipe for angina. This misinterpretation allowed Giulio Casserio to draw the first curved cannula introduced for used during tracheotomy.