Supraorbital keyhole approach: Pure endoscopic and endoscope-assisted perspective

Comparison of the Endoscopic Endonasal Approach with the Endoscopic Supraorbital Keyhole Approach to the Tuberculum Sellae Region: A Quantitatively Cadaveric Study

BACKGROUND

 The endoscopic endonasal approach (EEA) and the endoscopic supraorbital keyhole approach (eSKA) provide minimally invasive access to tuberculum sellae (TS) tumors. Evaluation of the operating maneuverability is helpful for approach selection. Herein, we compared the two approaches and aimed to provide quantitative anatomic data for surgical decision-making in the management of TS lesions.

METHODS

 Fifteen dissections were performed on five silicone-injected cadaveric heads. The EEA and eSKA (both right and left) were performed on each head. Surgical freedom and working angles in the axial and sagittal planes were calculated using the stereotactic navigation system in the selected six targets: the midpoint of the leading edge of the sphenoid sinus (leSS), the midpoint of the edge of the dorsum sellae (eDS), the ipsilateral medial opticocarotid recess (imOCR), the contralateral medial opticocarotid recess (cmOCR), the ipsilateral lateral opticocarotid recess (ilOCR), and the contralateral lateral opticocarotid recess (clOCR).

RESULTS

 The surgical freedom at the ilOCR and the axial working angles at the leSS, ilOCR, and imOCR (imOCR with excessive manipulation of the optic apparatus) were greater in the eSKA. The EEA provided greater surgical freedom and/or working angles at most targets than eSKA (the surgical freedom at the imOCR, cmOCR, clOCR, and eDS; the axial working angles at the cmOCR and clOCR; and the sagittal working angles at the leSS, imOCR, cmOCR, clOCR, and eDS).

CONCLUSION

 The EEA provides greater surgical freedom and working angles for paramedian lesions, whereas the eSKA provides better surgical maneuverability for lesions with lateral extension.

Microsurgical and endoscopic-assisted supraorbital keyhole approach for intra-suprasellar cysticercosis

Background

Treatment for intra/suprasellar cysticercosis can be challenging and may result in visual disturbances if not managed properly. Despite its limited knowledge, an effective surgical option exists to treat this condition. This article presents three cases of sellar cysticercosis, comprising one female and two male patients, managed with microsurgical supraorbital keyhole approach (mSKA) and endoscopic-assisted supraorbital keyhole approach (eaSKA).

Case Description

The first patient is a 35-year-old man with no prior medical history who suffered from memory deficits and visual disturbances due to a sellar cyst pushing the orbitofrontal gyrus treated with mSKA. The second case involved a 52-year-old man who experienced visual deficits caused by a rostral sellar cyst with posterior displacement of the pituitary gland treated with eaSKA. The third case was a 46-year-old woman who experienced decreased visual acuity and memory loss due to multifocal neurocysticercosis (NCC) with sellarsuprasellar cyst extension treated with mSKA. All case diagnoses were confirmed by neuropathology department.

Conclusion

The authors confidently suggest that the SKA is an effective surgical option and could be considered for removing sellar cystic lesions with suprasellar extension. With endoscopic assistance, it improves adequate neurovascular structure visualization.

Optic Foraminotomy versus Anterior Clinoidectomy for Small Superior-Projecting Paraclinoid Aneurysms: Visual and Angiographic Outcome Evaluation

INTRODUCTION

Optic foraminotomy (OF) has been recently proposed as an alternative to anterior clinoidectomy (AC) for selected types of paraclinoid aneurysms. In this study, OF and AC were compared for small superior-projecting paraclinoid aneurysms assuming visual and angiographic results as outcome measures. Indications for OF are also discussed.

METHODS

Data of patients who underwent surgery for a paraclinoid aneurysm in the last 10 years were collected across 3 tertiary hospitals. Small to regular-size and superior projecting aneurysms were sorted. Multiple and complex aneurysms were excluded. Records of patients who went through OF were compared with those of patients who underwent AC. Neurologic outcome was reported as a modified Rankin Scale. Aneurysm complete occlusion rate and rate of approach-related worsened vision were selected as outcome measures of efficacy and safety, respectively, of the OF versus AC. Unpaired t test and χ² test were used for numerical and categorical variables, respectively. A P value less than 0.05 was considered statistically significant.

RESULTS

OF and AC groups involved 18 and 25 patients, respectively. Complication rate, overall neurologic outcome, rate of approach-related worsened vision, and complete occlusion rate did not differ between the groups. The average follow-up was 51 ± 34 and 60 ± 41 months in the OF and AC groups, respectively.

CONCLUSIONS

Compared to AC, OF did not show either a higher rate of approach-related worsened vision or a lower aneurysm complete occlusion rate. OF can be considered a valid alternative to the AC for small superior-projecting dorsal ICA wall paraclinoid aneurysms.

Keyhole supraorbital eyebrow approach for fully endoscopic resection of tuberculum sellae meningioma

Background

The fully endoscopic supraorbital trans-eyebrow keyhole approach is a technique utilized for the transcranial resection of tuberculum sellae meningioma (TSM). Surgery is the first choice for TSM treatment. This study aimed to summarize and analyze the safety, feasibility, limitations, and technical requirements of the fully endoscopic supraorbital trans-eyebrow keyhole approach for TSM resection.

Methods

Data of 19 TSM fully endoscopic supraorbital trans-eyebrow keyhole approach resections cases (six and 13 on the left and right eyebrows, respectively) were retrospectively analyzed at the Neurosurgery Department of the First Affiliated Hospital of Bengbu Medical College (Bengbu, China) from August 2015 to March 2022.

Results

All 19 patients were diagnosed with meningioma (World Health Organization grade I), and according to the scope of tumor resection (EOR), 18 patients (94.7%) had gross total resection (GTR), and one patient (5.3%) had near-total resection (NTR). Preoperative chief complaints were symptomatic visual dysfunction (n = 12), headache and dizziness (n = 6), and accidental discovery (n = 1). Postoperative visual function improved in 83.3% of cases (10/12), and headache and dizziness were relieved in 83.3% of cases (5/6 patients). Postoperative intracranial infection occurred in one case and was cured by external drainage of the lumbar cistern and anti-infective treatment. Two cases of frontal lobe injury were discharged after conservative treatment. There was no postoperative olfactory dysfunction, eyelid ptosis, cerebrospinal fluid leakage, or death. There were no reports of disease recurrence or death during the 3-month follow-up at an outpatient clinic or by telephone.

Conclusion

Fully endoscopic TSM resection through the keyhole approach is safe and feasible. It can be used to explore angles that cannot be seen under a microscope and show the true value of endoscopy technology. The endoscopic equipment and technical skills of the surgeon and surgical team are important in this technique.

Leptomeningeal and subependymal seeding of diffuse intrinsic pontine glioma: a case report

DIPG (diffuse intrinsic pontine glioma) is a deadly cancerous tumor of the brainstem that spreads across the pons. The tumor's infiltrative nature, as well as the tumor's critical pathway and nuclei compression, contributes to the tumor's extremely poor prognosis and limited existing therapeutic options. A previous study revealed that in 40 patients with brainstem glioma, 13 (33%) patients had leptomeningeal spreading. In this paper, we reported a 7-year-old female patient who presented with a history of decreased consciousness and weakness of the right limb. Her magnetic resonance imaging (MRI) revealed a pontine mass. She was given 35 fractions of 54 Gy whole-brain radiotherapy. The post-radiotherapy MRI evaluation showed multiple nodules in periventricular region, and was suggestive of leptomeningeal and subependymal seeding of the pontine glioma in the lateral ventricles. This case report elucidated the leptomeningeal seeding in a pediatric patient with diffuse intrinsic pontine glioma.

Endoscope-assisted microneurosurgery for intracranial aneurysms: A systematic review and meta-analysis

BACKGROUND

In the surgical approach to treat deep-seated intracranial lesions, endoscopes can be used to assist microsurgical operations and improve outcomes. This technique is often called endoscope-assisted microneurosurgery (EAM). This systematic review and meta-analysis aimed to evaluate the feasibility, safety, and effectiveness of EAM.

METHODS

We performed a meta-analysis of relevant articles identified using PubMed, Embase, and the Cochrane Central Register to assess the efficacy of EAM according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. Primary outcomes were repositioning of the definitive clip, better surgical field, the overall and endoscope-related complication rates, mortality, and the rate of follow up.

RESULTS

A total of 10 studies of 1,432 patients with 1,717 aneurysms treated with EAM were included. EAM led to repositioning of the definitive clip in 13% (95% CI, 9%-17%; I₂ = 72.61%; p < 0.001); 77% of aneurysms treated with endoscopically assisted vision and information had a better outcome than that with standard surgery (95% CI, 52%-95%; I₂ = 97.63%; p < 0.001). There was an overall complication rate of 6% (95% CI, 1%-13%; I₂ = 91.39%; p < 0.001). The incidence of endoscope-related complications was 0% (95% CI, 0%-1%; I₂ = 64%; p < 0.001). The mortality was 0% (95% CI, 0-1%; I₂ = 0.0%); and 94% of patients had an excellent to good recovery and good outcome (95% CI, 88%-98%; I₂ = 88.42%; p < 0.001).

CONCLUSIONS

Our comprehensive study showed that EAM for intracranial aneurysms is feasible, the safety of the surgery is good, and the patients have a good prognosis, Therefore, we think EAM can be more widely adopted in the future.

Supraorbital Keyhole Craniotomy in Pediatric Neurosurgery: A Systematic Review of Clinical Outcomes and Cosmetic Outcomes

BACKGROUND

Supraorbital keyhole craniotomy is a minimally invasive approach used to access the parasellar region with advantages of decreased cortical exposure, simple closure, and decreased risk of postoperative cerebrospinal fluid leak. The incision of this approach, however, has raised cosmetic concerns, especially for pediatric patients. The aim of this study is to assess postoperative complications and cosmeses of the supraorbital keyhole approach for resection of intracranial lesions in pediatric patients.

METHODS

A literature search of PubMed, Scopus, and Web of Science databases was performed on June 1, 2021, searching for all studies of pediatric patients undergoing supraorbital keyhole craniotomy for surgical resection of lesions in the anterior fossa/sellar region.

RESULTS

Of 729 unique hits, 15 supraorbital keyhole studies reporting on 177 pediatric cases were included in the final review. Quality of all included studies was moderate. Overall, the surgery was well tolerated with a low number of severe adverse events. A wide variety of pathologies were treated with this approach. Complications of surgery included changes in vision, epidural hematoma, subdural hematoma, cerebrospinal fluid leak, and wound infection. At 6 weeks of follow-up, surgical scars in most patients were noted to be minimally detectable. At 3-6 months of follow-up, scars were no longer visible. Cosmetic complications included 5 bone defects, 1 split eyebrow, and 1 case of ptosis.

CONCLUSIONS

This study suggests that supraorbital keyhole craniotomy is a safe and effective approach to access the parasellar region in pediatric patients with excellent cosmetic outcomes reported across multiple institutions.

Cranio-Orbito-Zygomatic Approach: Core Techniques for Tailoring Target Exposure and Surgical Freedom

Background: The cranio-orbito-zygomatic (COZ) approach is a workhorse of skull base surgery, and each of its steps has a precise effect on target exposure and surgical freedom. The present study overviews the key techniques for execution and tailoring of the COZ approach, focusing on the quantitative effects resulting from removal of the orbitozygomatic (OZ) bar, orbital rim, and zygomatic arch. Methods: A PRISMA-based literature review was performed on the PubMed/Medline and Web of Science databases using the main keywords associated with the COZ approach. Articles in English without temporal restriction were included. Eligibility was limited to neurosurgical relevance. Results: A total of 78 articles were selected. The range of variants of the COZ approach involves a one-piece, two-piece, and three-piece technique, with a decreasing level of complexity and risk of complications. The two-piece technique includes an OZ and orbitopterional variant. Superolateral orbitotomy expands the subfrontal and transsylvian corridors, increasing surgical freedom to the basal forebrain, hypothalamic region, interpeduncular fossa, and basilar apex. Zygomatic osteotomy shortens the working distance of the pretemporal and subtemporal routes. Conclusion: Subtraction of the OZ bar causes a tremendous increase in angular exposure of the subfrontal, transsylvian, pretemporal, and subtemporal perspectives avoiding brain retraction, allowing for multiangled trajectories, and shortening the working distance. The COZ approach can be tailored based on the location of the lesion, thus optimizing the target exposure and surgical freedom and decreasing the risk of complications.

Resection of Tumors Located in the Anterior Skull Base and Sellar Region Through the Supraorbital Keyhole Approach via a Forehead Wrinkle Incision: Modifications and Deficiencies

OBJECTIVE

To investigate the clinical effect of the supraorbital keyhole approach (SKA) via a forehead wrinkle incision in the resection of tumors in the anterior skull base and sellar region.

METHODS

Sixty patients with tumors located in the anterior skull base and sellar region treated through the SKA in our hospital from 2017 to 2020. The skin incision and bone flap position were designed individually according to the size and growth of the tumor. The clinical data of the patients were retrospectively analyzed.

RESULTS

Based on the feasibility of this surgical approach, personalized skin incisions and bone flaps were designed for different lesions. Among the 60 patients, gross total resection was achieved in 53 cases (88.3%), for meningiomas 97.8% (46/47) and near-total resection in 7 cases (11.7%). In the survey of the patients' scale scores toward skin incision after operation, the "no pain"' level was 90.0% (54/60) and 91.7% (55/60) for the level of "very satisfactory"' of the aesthetic of the skin incision (as shown in Supplementary Digital Content, Table 2, http://links.lww.com/SCS/D742). Three patients whose satisfaction with the aesthetic of the incision excelled scale 3, suggesting that they were not completely satisfied with the wound healing. No permanent skin incision discomfort was noted during follow-up. There were no surgical deaths.

CONCLUSIONS

The SKA via forehead wrinkle incision is a flexible and feasible method for tumors near the midline of the anterior skull base and sellar region. However, this approach requires strict preoperative planning, which includes choosing appropriate tumors and applicable forehead wrinkles.

Supraorbital Keyhole Craniotomy via Eyebrow Incision: A Systematic Review and Meta-Analysis

BACKGROUND

Supraorbital eyebrow keyhole craniotomy is a minimally invasive alternative to a frontotemporal craniotomy and is often used for tumor resection and aneurysm clipping. The purpose of this study is to provide a contemporary review on the outcomes related to this approach and to determine whether they vary with the type of pathology and the addition of an endoscope.

METHODS

PubMed, Embase, and Scopus databases were systematically searched, and results were reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. For the meta-analysis portion, the DerSimonian-Laird random effects model was used.

RESULTS

A total of 2629 manuscripts were identified. of those, 124 studies (8241 surgical cases) met the inclusion criteria. Mean total complication rate was 26.7 ± 25.7% and the mean approach-related mortality rate was 1.3 ± 2.8%. Technical success, defined as gross total tumor resection or complete aneurysm clipping, was achieved in 83.6 ± 21.5% of the cases. Vascular pathologies were associated with greater technical success, lower total complications, and longer length of hospital stay compared with tumor cases (P < 0.05 for all). For vascular cases, addition of the endoscope yielded lower technical success (P = 0.001) and lower complication rate (P = 0.041). The use of the endoscope for tumor pathologies did not affect technical success, complications, mortality, length of hospital stay, operative time, or reoperation rate (P > 0.05).

CONCLUSIONS

The supraorbital craniotomy via an eyebrow incision is a feasible minimally invasive approach with an overall high technical success rate for both vascular and tumor pathologies.

Comparative Anatomical Study of Fronto-Orbito-Zygomatic and Fronto-Temporal Approach to the Central Skull Base

ABSTRACT

Despite the advances in microsurgery and neuroanatomy, surgery of the central skull base still represents a challenge. Fronto-temporal approach has represented the mainstay of surgical approaches to this region. With advances in skull base surgery, orbital and zygomatic extensions were added to fronto-temporal approach to improve exposure minimizing brain retraction.The authors compared fronto-temporal and fronto-orbitozygomatic approaches to the central skull base by using the previously described operability score, to three different anatomical targets: the ipsilateral anterior clinoid process, the contralateral anterior clinoid process, and the ipsilateral posterior clinoid process.Based on the measurements taken, fronto-orbitozygomatic approache showed higher values at all 3 targets. The reported values were critically discussed.The operability score has been reported as an effective method to compare surgical approaches. The present study demonstrated the maximal possibility of exposure of the two approaches. Based on the strong variability of this anatomical region, especially because of the different pathologies, the authors suggest considering the operability score as a further tool to better define the best surgical approach to this anatomical region.

The Preoperative Functional Downgrading of Brain AVMs

The actual role of preoperative embolization of brain arteriovenous malformations (AVMs) is undervalued.The present study aims to describe the effectiveness, safety, technics, and results of the endovascular-based functional downgrading of brain AVMs.Data regarding 31 Spetzler-Martin (SM) grade III AVMs that consecutively underwent a combined endovascular-surgical treatment were reviewed. Clinical and radiological outcomes were evaluated according to modified Ranking Scale score (mRS) and postoperative angiography, respectively.Low-density Onyx was used in all cases, and the timeframe between the embolizations was 10-15 days. Procedures were 1.6 (±0.6) on average. Superselective nidal catheterization was essential to reach the deepest parts of the AVMs, which were the targets. Onyx made the nidus compact and easier to dissect. The Average obliteration rate was 29.6%, with negligible morbidity. Surgery was performed after 3.7 days on average and the AVM exclusion was complete in 83.4% of cases. An mRS score between 0 and 2 was reported in 77.5% of patients, while the best outcome was achieved in small and medium-deep malformations.An effective and safe functional downgrading of brain AVMs must be based upon specific technical key aspects, which make surgery easier and, ultimately, allow for the achievement of the best outcome.

Microsurgical Clipping of Carotid-Ophthalmic Tandem Aneurysms: Case Report and Surgical Nuances

Tandem intracranial aneurysms (TandIAs) are rare but inherently complex, and special technical considerations are required for their surgical management. The present case highlights the key surgical aspects of two carotid-ophthalmic TandIAs incidentally found in a 60-year-old female. Both the aneurysms were superiorly projecting, regular in size, and involved the left ophthalmic segment of the internal carotid artery (ICA). The minimum distance between the necks was 3 mm. The patient underwent microsurgery because of the reported major complications rate of the endovascular treatment in the case of a very short minimum distance between the TandIAs. After cervical ICA exposure, both the aneurysms were excluded through a pterional approach. Intradural anterior clinoidectomy and unroofing of the optic canal allowed the mobilization of the left optic nerve. The more distal aneurysm was clipped before the opening of the distal dural ring of the ICA. The proximal aneurysm was clipped with two straight clips stacked perpendicular to the ICA. A small remnant was intentionally left to avoid the stenosis of the ophthalmic artery. Postoperative angiography showed the exclusion of both the aneurysms with a small dog-ear of the more proximal one. The patient was discharged neurologically intact and, after one year, the remnant remained stable. Microsurgical clipping is a definitive and durable treatment for carotid-ophthalmic TandIAs. In the case of a very short minimum distance between the aneurysms, the distal one should be clipped first to make the anterior clinoidectomy, opening of the distal dural ring of the ICA, and clipping of the more proximal aneurysm easier.

Major Trauma in Elderly Patients: Worse Mortality and Outcomes in an Italian Trauma Center

Introduction:

Major trauma is the leading cause of mortality in the world in patients younger than 40 years. However, the proportion of elderly people who suffer trauma has increased significantly. The purpose of this study is to assess the correlation of old age with mortality and other unfavorable outcomes.

Methods:

We assessed on one hand, anatomical criteria such as ISS values and the number of body regions affected, on the other hand, hemodynamic instability criteria, various shock indices, and Glasgow Coma Scale. Finally, we also evaluated biochemical parameters, such as lactate, BE, and pH values. We conducted a prospective and monocentric observational study of all the patients referred to the Emergency Department of the IRCCS Fondazione Policlinico S. Matteo in Pavia for major trauma in 13 consecutive months: January 1, 2018–January 30, 2019. We compared the elderly population (>75 years) and the younger population (≤75).

Results:

We included 501 patients, among which 10% were over the age of 75 years. The mortality rate was higher among the older patients than among the younger (4% vs. 1.33%; P = 0.050). Hemodynamic instability was more common in the older patients than in the younger (26% vs. 9%; P < 0.001). More older patients (44%) had an ISS >16, in comparison with 32% of younger patients (P = 0.01).

Conclusions:

The elderly showed worse outcomes in terms of mortality, hospitalization rate, hemodynamic instability criteria, and anatomical and biochemical parameters.

Endoscopic Assistance in the Deep and Narrow Spaces of the Brain-Microscopic Tumor Surgery Supported by the New Micro-Inspection Tool QEVO® (Technical Note)

Introduction: To evaluate the feasibility and efficacy of the innovative micro-inspection tool QEVO® (Carl Zeiss Meditec, Oberkochen, Germany) as an endoscopic adjunct to microscopes for better visualization of the surgical field in complex deep-seated intracranial tumors in infants and adults.

Materials and Methods: We retrospectively assessed the surgical videos of 25 consecutive patients with 26 complex intracranial lesions (time frame 2018–2020). Lesions were classified according to their anatomical area: 1 = sellar region (n = 6), 2 = intra-ventricular (except IV.ventricle, n = 9), 3 = IV.ventricle and rhomboid fossa (n = 4), and 4 = cerebellopontine angle (CPA) and foramen magnum (n = 7). Indications to use the QEVO® tool were divided into five “QEVO® categories”: A = target localization, B = tailoring of the approach, C = looking beyond the lesion, D = resection control, and E = inspection of remote areas.

Results: Overall, the most frequent indications for using the QEVO® tool were categories D (n = 19), C (n = 17), and E (n = 16). QEVO® categories B (n = 8) and A (n = 5) were mainly applied to intra-ventricular procedures (anatomical area 2).

Discussion: The new micro-inspection tool QEVO® is a powerful endoscopic device to support the comprehensive visualization of complex intracranial lesions and thus instantly increases intraoperative morphological understanding. However, its use is restricted to the specific properties of the respective anatomical area.

Posterior Circulation Aneurysms: A Critical Appraisal of a Surgical Series in Endovascular Era

The advent of the endovascular era has apparently decreased the role of microneurosurgery for many of the posterior circulation aneurysms. This study consists of a critical appraisal of a retrospective surgical series regarding posterior circulation aneurysms, targeted to define whether microneurosurgery still has a role for some of these. In 28 years, 157 aneurysms were surgically treated, 98 of which ruptured. The Average patient age was 56.7 ± 14.2 years, while in hemorrhagic cases, the mean Hunt-Hess score was 2.17 ± 0.8. Basilar tip, vertebral artery and proximal posterior inferior cerebellar artery were the most frequently involved sites. The treatment consisted of 128 clippings, 19 trappings, 7 wrappings, and 3 bypasses. A total exclusion was achieved in 88.5% of the aneurysms. An average follow-up of 67.1 ± 61.3 months proved no recurrences. The best results were observed in patients <65 years old who harbored small-to-regular aneurysms of the basilar tip, distal cerebellar arteries, or vertebral artery.Clipping proved to be a definitive and durable treatment for a large part of posterior circulation aneurysms, whereas bypass allows for treating aneurysms not amenable for coiling, stenting, or clipping. The present study confirms that microneurosurgery continues to have a paramount role within neurovascular pathology.

Microneurosurgical Management of Posterior Inferior Cerebellar Artery Aneurysms: Results of a Consecutive Series

Aneurysms of the posterior inferior cerebellar artery (PICA) are uncommon. The complex anatomy of PICA and its intimate relationships with medulla, lower cranial nerves, and jugular tubercle makes the surgical treatment of these aneurysms fascinating. The reported is study aimed at a critical review of the overall results of a personal series of PICA aneurysms, treated by the senior author, R. Galzio. Demographics, charts, videos, outcome, and follow-up of a cohort of PICA aneurysms managed in the last 10 years were retrospectively analyzed, focusing only upon those treated with microneurosurgery. Twenty-five patients, harboring a single aneurysm, were operated on. Fifteen aneurysms were ruptured. Nineteen were proximal, all of these being been treated through a far-lateral approach. Trans-condylar or trans-tubercular variants were rarely necessary and however reserved to peculiar cases. Twenty-three aneurysms underwent direct treatment consisting of clip ligation. At 6-month follow-up, 60% of patients had a modified Rankin Score (mRS) of 0-2. Given the high anatomical variability of both PICA and patients' bony anatomy, a case-by-case meticulous preoperative imaging evaluation is mandatory for the choice of the most suitable and tailored surgical corridor which, in turn, is pivotal to achieve the best outcome.

Microneurosurgery for Paraclinoid Aneurysms in the Context of Flow Diverters

The advent of flow diverter (FD) stents has apparently reduced the role of microneurosurgery for paraclinoid aneurysms despite sparse high-quality evidence about their long-term effects.The present study critically reviews the overall results of a microneurosurgical series of 57 paraclinoid aneurysms.Of these aneurysms, 47.4% were regular in size while 19.3 were giant. Barami type I was predominant. In 21 aneurysms a hemorrhagic onset occurred. Pterional approach with intradural anterior clinoidectomy was preferred by far. Clipping was possible in 91.2% of aneurysms and a high-flow bypass was the choice in five cases. An mRS of 0-2 was achieved in 77.3% of patients, typically <50 years old.Visual field appeared improved or unchanged in 36.3% and 63.6% of the symptomatic patients, respectively. In 76.1% of incidental aneurysms, campimetry was unaffected by surgery.A complete aneurysm exclusion was achieved in 93% of cases using a single procedure. No recurrences were documented on an average follow-up of 54.1 ± 34 months.Microneurosurgery is still a valuable, definitive, and durable option for Barami type Ia, Ib, or II paraclinoid aneurysm, especially in patients <50 years old and visually symptomatic. Conditions other than these are ideal candidates for FD stents.

Surgical Management of Giant Intracranial Aneurysms: Overall Results of a Large Series

OBJECTIVE

To review and discuss surgical treatment options for giant intracranial aneurysms (GIAs), focusing on indications, technical aspects, and results, along with some illustrative cases.

METHODS

We reviewed the data of 82 consecutive patients surgically managed between January 2000 and December 2019 for treatment of a GIA.

RESULTS

Male sex and hemorrhage at presentation were prevalent. The average follow-up was 81.2 ± 45 months. The anterior circulation was involved in 76.8% of GIAs. If the GIA showed a clear neck, minimal atherosclerosis, or intrasaccular thrombosis, and ≤2 branches arising from the neck, it was reconstructed. This procedure was possible in 78% of cases. The technique also involved temporary clipping, remodeling, and thrombectomy, as well as fragmentation techniques. Angioarchitectural features other than these techniques underwent bypass and aneurysm trapping. Most bypasses were extracranial to intracranial and high flow. Flow capacity, collateral circulation, and availability of the donor vessel mainly affected the choice of the type of bypass. Overall, successful exclusion of the GIA was 91.4%. The need for retreatment and complication rate were 3.6% and 19.5%, respectively. A good overall outcome (modified Rankin Scale score 0-3) was achieved in 84.2% of patients, and mortality was 10%.

CONCLUSIONS

Microneurosurgical techniques still maintain a significant role for most GIAs, with a high durability and acceptable rate of morbidity and mortality. Clip reconstruction is the first-line surgical treatment option, whereas bypass is indicated in cases of planned or unplanned sacrifice of the parent artery to prevent long-term ischemic complications.

Potential roads for reaching the summit: an overview on target therapies for high-grade gliomas

Background:

The tailored targeting of specific oncogenes represents a new frontier in the treatment of high-grade glioma in the pursuit of innovative and personalized approaches. The present study consists in a wide-ranging overview of the target therapies and related translational challenges in neuro-oncology.

Methods:

A review of the literature on PubMed/MEDLINE on recent advances concerning the target therapies for treatment of central nervous system malignancies was carried out. In the Medical Subject Headings, the terms “Target Therapy”, “Target drug” and “Tailored Therapy” were combined with the terms “High-grade gliomas”, “Malignant brain tumor” and “Glioblastoma”. Articles published in the last five years were further sorted, based on the best match and relevance. The ClinicalTrials.gov website was used as a source of the main trials, where the search terms were “Central Nervous System Tumor”, “Malignant Brain Tumor”, “Brain Cancer”, “Brain Neoplasms” and “High-grade gliomas”.

Results:

A total of 137 relevant articles and 79 trials were selected. Target therapies entailed inhibitors of tyrosine kinases, PI3K/AKT/mTOR pathway, farnesyl transferase enzymes, p53 and pRB proteins, isocitrate dehydrogenases, histone deacetylases, integrins and proteasome complexes. The clinical trials mostly involved combined approaches. They were phase I, II, I/II and III in 33%, 42%, 16%, and 9% of the cases, respectively.

Conclusion:

Tyrosine kinase and angiogenesis inhibitors, in combination with standard of care, have shown most evidence of the effectiveness in glioblastoma. Resistance remains an issue. A deeper understanding of the molecular pathways involved in gliomagenesis is the key aspect on which the translational research is focusing, in order to optimize the target therapies of newly diagnosed and recurrent brain gliomas. (www.actabiomedica.it)

Targeting the medulloblastoma: a molecular-based approach

BACKGROUND

The lack of success of standard therapies for medulloblastoma has highlighted the need to plan a new therapeutic approach. The purpose of this article is to provide an overview of the novel treatment strategies based on the molecular characterization and risk categories of the medulloblastoma, also focusing on up-to-date relevant clinical trials and the challenges in translating tailored approaches into clinical practice.

METHODS

An online search of the literature was carried out on the PubMed/MEDLINE and ClinicalTrials.gov websites about molecular classification of medulloblastomas, ongoing clinical trials and new treatment strategies. Only articles in the English language and published in the last five years were selected. The research was refined based on the best match and relevance.

RESULTS

A total 58 articles and 51 clinical trials were analyzed. Trials were of phase I, II, and I/II in 55%, 33% and 12% of the cases, respectively. Target and adoptive immunotherapies were the treatment strategies for newly diagnosed and recurrent medulloblastoma in 71% and 29% of the cases, respectively.

CONCLUSION

Efforts are focused on the fine-tuning of target therapies and immunotherapies, including agents directed to specific pathways, engineered T-cells and oncoviruses. The blood-brain barrier, chemoresistance, the tumor microenvironment and cancer stem cells are the main translational challenges to be overcome in order to optimize medulloblastoma treatment, reduce the long-term morbidity and increase the overall survival.

Rates of Intracranial Hemorrhage in Mild Head Trauma Patients Presenting to Emergency Department and Their Management: A Comparison of Direct Oral Anticoagulant Drugs with Vitamin K Antagonists

Background and objectives: Anticoagulants are thought to increase the risks of traumatic intracranial injury and poor clinical outcomes after blunt head trauma. The safety of using direct oral anticoagulants (DOACs) compared to vitamin K antagonists (VKAs) after intracranial hemorrhage (ICH) is unclear. This study aims to compare the incidence of post-traumatic ICH following mild head injury (MHI) and to assess the need for surgery, mortality rates, emergency department (ED) revisit rates, and the volume of ICH. Materials and Methods: This is a retrospective, single-center observational study on all patients admitted to our emergency department for mild head trauma from 1 January 2016, to 31 December 2018. We enrolled 234 anticoagulated patients, of which 156 were on VKAs and 78 on DOACs. Patients underwent computed tomography (CT) scans on arrival (T0) and after 24 h (T24). The control group consisted of patients not taking anticoagulants, had no clotting disorders, and who reported an MHI in the same period. About 54% in the control group had CTs performed. Results: The anticoagulated groups were comparable in baseline parameters. Patients on VKA developed ICH more frequently than patients on DOACs and the control group at 17%, 5.13%, and 7.5%, respectively. No significant difference between the two groups was noted in terms of surgery, intrahospital mortality rates, ED revisit rates, and the volume of ICH. Conclusions: Patients with mild head trauma on DOAC therapy had a similar prevalence of ICH to that of the control group. Meanwhile, patients on VKA therapy had about twice the ICH prevalence than that on the control group or patients on DOAC, which remained after correcting for age. No significant difference in the need for surgery was determined; however, this result must take into account the very small number of patients needing surgery.

Minimal Invasive Piezoelectric Osteotomy in Neurosurgery: Technic, Applications, and Clinical Outcomes of a Retrospective Case Series

Objective: To report the physical and technical principles, clinical applications, and outcomes of the minimal invasive piezoelectric osteotomy in a consecutive veterinary neurosurgical series.

METHODS

A series of 292 dogs and 32 cats underwent an osteotomy because a neurosurgical pathology performed with a Mectron Piezosurgery^® bone scalpel (Mectron Medical Technology, Genoa, Italy) was retrospectively reviewed. Efficacy, precision, safety, and blood loss were evaluated intraoperatively by two different surgeons, on a case-by-case basis. Postoperative Rx and CT scans were used to assess the selectivity and precision of the osteotomy. A histological study on bony specimens at the osteotomized surface was carried out to evaluate the effects of piezoelectric cutting on the osteocytes and osteoblasts. All the patients underwent a six-months follow-up. A series of illustrative cases was reported.

RESULTS

All the osteotomies were clear-cut and precise. A complete sparing of soft and nervous tissues and vasculature was observed. The operative field was blood- and heat-free in all cases. A range of inserts, largely different in shape and length, were allowed to treat deep and difficult-to-reach sites. Two mechanical complications occurred. Average blood loss in dogs' group was 52, 47, and 56 mL for traumatic, degenerative, and neoplastic lesions, respectively, whereas it was 25 mL for traumatized cats. A fast recovery of functions was observed in most of the treated cases, early on, at the first sixth-month evaluation. Histology on bone flaps showed the presence of live osteocytes and osteoblasts at the osteotomized surface in 92% of cases.

CONCLUSIONS

Piezosurgery is based on the physical principle of the indirect piezo effect. Piezoelectric osteotomy is selective, effective, and safe in bone cutting during neurosurgical veterinary procedures. It can be considered a minimal invasive technique, as it is able to spare the neighboring soft tissues and neurovascular structures.

Trauma Coagulopathy and Its Outcomes

Background and Objectives: Trauma coagulopathy begins at the moment of trauma. This study investigated whether coagulopathy upon arrival in the emergency room (ER) is correlated with increased hemotransfusion requirement, more hemodynamic instability, more severe anatomical damage, a greater need for hospitalization, and hospitalization in the intensive care unit (ICU). We also analyzed whether trauma coagulopathy is correlated with unfavorable indices, such as acidemia, lactate increase, and base excess (BE) increase. Material and Methods: We conducted a prospective, monocentric, observational study of all patients (n = 503) referred to the Department of Emergency and Acceptance, IRCCS Fondazione Policlinico San Matteo, Pavia, for major trauma from 1 January 2018 to 30 January 2019. Results: Of the 503 patients, 204 had trauma coagulopathy (group 1), whereas 299 patients (group 2) did not. Group 1 had a higher hemotransfusion rate than group 2. In group 1, 15% of patients showed hemodynamic instability compared with only 8% of group 2. The shock index (SI) distribution was worse in group 1 than in group 2. Group 1 was more often hypotensive, tachycardic, and with low oxygen saturation, and had a more severe injury severity score than group 2. In addition, 47% of group 1 had three or more body districts involved compared with 23% of group 2. The hospitalization rate was higher in group 1 than in group 2 (76% vs. 58%). The length of hospitalization was >10 days for 45% of group 1 compared with 28% of group 2. The hospitalization rate in the ICU was higher in group 1 than in group 2 (22% vs. 14.8%). The average duration of ICU hospitalization was longer in group 1 than in group 2 (12.5 vs. 9.78 days). Mortality was higher in group 1 than in group 2 (3.92% vs. 0.98%). Group 1 more often had acidemia and high lactates than group 2. Group 1 also more often had BE <−6. Conclusions: Trauma coagulopathy patients, upon arrival in the ER, have greater hemotransfusion (p = 0.016) requirements and need hospitalization (p = 0.032) more frequently than patients without trauma coagulopathy. Trauma coagulopathy seems to be more present in patients with a higher injury severity score (ISS) (p = 0.000) and a greater number of anatomical districts involved (p = 0.000). Head trauma (p = 0.000) and abdominal trauma (p = 0.057) seem related to the development of trauma coagulopathy. Males seem more exposed than females in developing trauma coagulopathy (p = 0.018). Upon arrival in the ER, the presence of tachycardia or alteration of SI and its derivatives can allow early detection of patients with trauma coagulopathy.

Pai syndrome: a review

BACKGROUND

Pai syndrome is a rare idiopathic developmental condition characterized by midline craniofacial abnormalities. It was originally described as the presence of a median cleft lip, cutaneous polyps of the nasal mucosa and face, and midline lipomas of the central nervous system, mostly at the corpus callosum. However, there is great phenotypical variability and these characteristics are rarely all present at once.

OBJECTIVE

The aim of this review was to analyze the available evidence regarding Pai syndrome in order to better delineate this rare condition and its features.

METHODS

We analyzed the PubMed database using the words "Pai syndrome", "frontonasal dysplasia", "cleft lip", "nasal polyp", "facial polyp", and "corpus callosum lipoma", including reviews, case reports and case series.

CONCLUSION

There is no consensus regarding the diagnostic criteria of Pai syndrome up to date. It is usually diagnosed at birth, and its incidence is often underestimated. At present, the etiology of Pai syndrome is unknown. Several hypotheses regarding its genetic background have been made; however, there are not enough data yet to elucidate this point. An improved awareness could help in diagnosing the condition and performing the necessary investigations. These patients should have a multidisciplinary follow-up.