Unsatisfactory Neurological Outcome in an Intramedullary Thoracic Intermediate-Grade Melanocytoma-Systematic Review and Illustrative Case

BACKGROUND

Intramedullary melanocytomas are exceedingly rare, with only twenty-four cases reported up to now. They present as local invasive tumors despite their benign biological behavior. Attempting a complete safe resection often results in severe post-operative neurological deficits, as in our case presented here.

METHODS

A systematic review was conducted across the PubMed and Scopus databases including studies published till February 2024.

RESULTS

A total of 19 studies were included, encompassing 24 cases. A similar distribution between sexes was noted (M:F 13:11), with ages ranging from 19 to 79 years. The thoracic segment was most affected, and intermediate-grade melanocytoma (19 cases) was the most common histotype. Radiographically, intramedullary melanocytomas usually appear as hyperintense hemorrhagic lesions peripheral to the central canal with focal nodular enhancement. Intraoperatively, they are black-reddish to tan and are tenaciously adherent lesions. In the sampled studies, IONM employment was uncommon, and post-operative new-onset neurological deficits were described in 16 cases. Adjuvant RT was used in four cases and its value is debatable. Recurrence is common (10 cases), and adjuvant therapies (RT or repeated surgery) seem to play a palliative role.

CASE PRESENTATION

A 68-year-old woman presented with a three-year history of worsening spastic paraparesis and loss of independence in daily activities (McCormick grade 4). An MRI revealed an intramedullary tumor from Th5 to Th7, characterized by T1-weighted hyperintensity and signs of recent intralesional hemorrhage. Multimodal neuromonitoring, comprising the D-Wave, guided the resection of a black-tan-colored tumor with hyper-vascularization and strong adherence to the white matter. During final dissection of the lesion to obtain gross total resection (GTR), a steep decline in MEPs and D-Wave signals was recorded. Post-operatively, the patient had severe hypoesthesia with Th9 level and segmental motor deficits, with some improvement during neurorehabilitation. Histopathology revealed an intermediate-grade melanocytoma (CNS WHO 2021 classification). A four-month follow-up documented the absence of relapse.

CONCLUSIONS

This literature review highlights that intramedullary T1 hyperintense hemorrhagic thoracic lesions in an adult patient should raise the suspicion of intramedullary melanocytoma. They present as locally aggressive tumors, due to local invasiveness, which often lead to post-operative neurological deficits, and frequent relapses, which overwhelm therapeutic strategies leading to palliative care after several years.

Geometry and Symmetry of Willis' Circle and Middle Cerebral Artery Aneurysms Development

Background: A relationship between the geometry and symmetry of Willis' circle and intracranial aneurysms was reported for anterior communicating and posterior communicating (PCom) aneurysms. A similar association with the middle cerebral artery (MCA) aneurysms instead appeared weaker. Methods: We reviewed 432 patients from six Italian centers with unilateral MCA aneurysms, analyzing the relationship between the caliber and symmetry of Willis' circle and the presence of ruptured and unruptured presentation. CT-angiograms were evaluated to assess Willis' circle geometrical characteristics and the MCA aneurysm side, dimension and rupture status. Results: The hypoplasia of the first segment of the anterior cerebral artery (A1) was in approximately one-quarter of patients and PCom hypoplasia was in almost 40%. About 9% had a fetal PCom ipsilaterally to the aneurysm. By comparing the aneurysmal and healthy sides, only the PCom hypoplasia appeared significantly higher in the affected side. Finally, the caliber of the internal carotid artery (ICA) and the first segment of MCA (M1) caliber were significantly greater in patients with unruptured aneurysms, and PCom hypoplasia appeared related to the incidence of an ipsilateral MCA aneurysm and its risk of rupture. Conclusions: Although according to these findings asymmetries of Willis' circle are shown to be a risk factor for MCA aneurysm formation and rupture, the indifferent association with ipsilateral or contralateral hypoplasia remains a datum of difficult hemodynamic interpretation, thereby raising the concern that this association may be more casual than causal.

Posterior cranial fossa surgery with a 3D Exoscope: a single-center survey-based analysis and a literature review

BACKGROUND

The potential advantages of exoscopy have been discussed theoretically for a long time. Such a concept holds significance, especially in the specific setting of the posterior cranial fossa (PCF), characterized by complex anatomy and long and narrow surgical corridors with relatively extreme working angles.

AIM

We aimed to: 1) analyze the institutional preliminary case-based data on the use of the Robotic 3D Exoscope AEOS Aesculap in three different PCF approaches: retrosigmoid (RSA), midline suboccipital (MSA), and supra cerebellar infratentorial (SIA) via feedbacks was collected using a 20-point questionnaire. 2) perform a comprehensive review of the literature concerning the use of EX in PCF surgery RESULTS: A total of 38 patients with neurosurgical pathologies underwent a neurosurgical procedure using the EX (Robotic 3D exoscope AEOS Aesculap) at our institution between January and March 2022. 21 surgeons were involved in the abovementioned PCF surgeries and answered the questionnaire. The main perceived advantages were in terms of ergonomics (67%) and magnification (52%) and visualization of extreme angles. The main reported disadvantage was color vision (16, 76%), followed by manual mobility (24%). Concerning the review, the search of the literature yielded a total of 177 results. Upon full-text review, 17 articles were included, including 153 patients.

CONCLUSIONS

In conclusion, our study provides a comprehensive evaluation of the advantages and challenges associated with using the exoscope in posterior fossa surgery, setting a precedent as the first to report on a questionnaire-based analysis of exoscope utilization in this specific domain.

Surgery versus endovascular treatment for spinal dural arteriovenous fistulas: a multicenter experience and systematic literature review

Surgery and endovascular therapy are the primary treatment options for spinal dural arteriovenous fistula (SDAVF). Due to the absence of a consensus regarding which therapy yields a superior outcome, we conducted a comparative analysis of the surgical and endovascular treatment of SDAVF through a multicenter case series and a systematic literature review. Patients with SDAVF, surgically or endovascularly treated at four neurosurgical centers from January 2001 to December 2021, were included in this study. Level of SDAVF, primary treatment modality, baseline and post-procedural neurological status were collected. The primary outcomes were failure, complication rates, and a newly introduced parameter named as therapeutic delay. A systematic review of the literature was performed according to PRISMA-P guidelines. The systematic review identified 511 papers, of which 18 were eligible for analysis, for a total of 814 patients, predominantly male (72%) with a median age of 61 and mainly thoracic SDAVFs (65%). The failure rate was significantly higher for endovascular therapy (20%) compared to surgery (4%) (p < 0.01). Neurological complications were generally rare, with similar rates among the two groups (endovascular 2.9%; surgery 2.6%). Endovascular treatment showed a statistically significantly higher rate of persistent neurological complications than surgical treatment (2.9% versus 0.2%; p < 0.01). Both treatments showed similar rates of clinical improvement based on Aminoff Logue scale score. The multicenter, retrospective study involved 131 patients. The thoracic region was the most frequent location (58%), followed by lumbar (37%). Paraparesis (45%) and back pain (41%) were the most common presenting symptoms, followed by bladder dysfunction (34%) and sensory disturbances (21%). The mean clinical follow-up was 21 months, with all patients followed for at least 12 months. No statistically significant differences were found in demographic and clinical data, lesion characteristics, or outcomes between the two treatment groups. Median pre-treatment Aminoff-Logue score was 2.6, decreasing to 1.4 post-treatment with both treatments. The mean therapeutic delay for surgery and endovascular treatment showed no statistically significant difference. Surgical treatment demonstrated significantly lower failure rates (5% vs. 46%, p < 0.01). In the surgical group, 2 transient neurological (1 epidural hematoma, 1 CSF leak) and 3 non-neurological (3 wound infections) complications were recorded; while 2 permanent neurological (spinal infarcts), and 5 non-neurological (inguinal hematomas) were reported in the endovascular group. According to the literature review and this multicenter clinical series, surgical treatment has a significantly lower failure rate than endovascular treatment. Although the two treatments have similar complication rates, endovascular treatment seems to have a higher rate of persistent neurological complications.

Preoperative Angiographic Protocol for the Surgical Management of Spinal Dural Arteriovenous Fistulas: A Technical Nuance for Safe Minimally Invasive Surgery

BACKGROUND

Interruption of the fistulous point is the goal of treatment of spinal dural arteriovenous fistulas (dAVFs). Microsurgery remains a highly efficient treatment in terms of complete occlusion with the lowest risk of recurrence rate. It is reported that the hardest step involves finding the fistulous site itself, potentially extending surgical access and time and increasing potential postoperative surgical-related complications. The accurate preoperative detection of the shunt and spinal level together is crucial for guiding optimal, fast, and safe microsurgical treatment.

METHODS

We describe a preoperative angiographic protocol for achieving a safe and simple resection of spinal dural arteriovenous fistulas based on a 6-year institutional experience of 42 patients who underwent minimally invasive procedures. Two illustrative cases are included to support the technical descriptions.

RESULTS

The suspected artery associated with the vascular malformation of interest is studied in our angiographic protocol through nonsubtracted selective acquisitions in lateral projection. The resulting frames are reconstructed with three-dimensional rotational angiography. The implementation of the preoperative angiographic protocol allowed 100% of intraoperative identification of the fistulous point in all cases with the use of a minimally invasive approach.

CONCLUSIONS

Nowadays, neurosurgeons advocate for minimally invasive procedures and procedures with low morbidity risk for treatment of spinal dural arteriovenous fistulas. Our preoperative approach for accurate angiographic localization of the fistulous point through nonsubtracted and three-dimensional reconstructed angiography allowed us to achieve safe and definitive occlusion of the shunt.

Navigating Complexity: A Comprehensive Approach to Middle Cerebral Artery Aneurysms

Background: The concept of aneurysm "complexity" has undergone significant changes in recent years, with advancements in endovascular treatments. However, surgical clipping remains a relevant option for middle cerebral artery (MCA) aneurysms. Hence, the classical criteria used to define surgically complex MCA aneurysms require updating. Our objective is to review our institutional series, considering the impacts of various complexity features, and provide a treatment strategy algorithm. Methods: We conducted a retrospective review of our institutional experience with "complex MCA" aneurysms and analyzed single aneurysmal-related factors influencing treatment decisions. Results: We identified 14 complex cases, each exhibiting at least two complexity criteria, including fusiform shape (57%), large size (35%), giant size (21%), vessel branching from the sac (50%), intrasaccular thrombi (35%), and previous clipping/coiling (14%). In 92% of cases, the aneurysm had a wide neck, and 28% exhibited tortuosity or stenosis of proximal vessels. Conclusions: The optimal management of complex MCA aneurysms depends on a decision-making algorithm that considers various complexity criteria. In a modern medical setting, this process helps clarify the choice of treatment strategy, which should be tailored to factors such as aneurysm morphology and patient characteristics, including a combination of endovascular and surgical techniques.

Clipping of Anterior Circulation Aneurysms: Operative Instructions and Safety Rules for Young Cerebrovascular Surgeons

INTRODUCTION

Due to the constant development of the technique, in the last 30 years, the endovascular treatment of the intracranial aneurysms (IAs) has gradually superseded the traditional surgery in the majority of centers. However, clipping still represents the best treatment for some anterior circulation IAs according to their angioarchitectural, topographical, and hemodynamic characteristics. Thus, the identification of residual indications for clipping and the maintenance of training programs in vascular neurosurgery appear nowadays more important than ever.

MATERIALS AND METHODS

We reviewed our last 10-year institutional experience of ruptured and unruptured IAs clipping. We appraised in detail all technical refinements we adopted during this time span and analyzed the difficulties we met in teaching the aneurysm clipping technique to residents and fellows. Then, we described the algorithm of safety rules we used to teach young neurosurgeons how to surgical approach anterior circulation IAs and develop a procedural memory, which may intervene in all emergency situations.

RESULTS

We identified seven pragmatic technical key points for clipping of the most frequent anterior circulation IAs and constructed a didactic approach to teach young cerebrovascular surgeons. In general, they concern craniotomy; cisternostomy; obtaining proximal control; cranial nerve, perforator, and vein preservation; necessity of specific corticectomy; aneurysm neck dissection; and clipping.

CONCLUSION

In the setting of an IA clipping, particularly when ruptured, the young cerebrovascular surgeon needs to respect an algorithm of safety rules, which are essential not only to avoid major complications, but they may intervene during the difficulties helping to manage potentially life-tethering conditions.

Relationship Between Mediterranean Diet, Cardiovascular Risk Factors, and Meningiomas: A Retrospective Study

BACKGROUND/AIM

The Mediterranean diet may be deemed as the best combination of nutrients to play a protective role against cancer. Previous studies have demonstrated how a healthy lifestyle, and the adherence to the Mediterranean diet might affect the onset of most common cancers, focusing less on their relationship with central nervous system (CNS) tumoral pathologies, especially benign ones, such as meningiomas.

PATIENTS AND METHODS

This was a retrospective multicenter study, involving 52 patients who underwent meningioma resection and a group of 100 subjects not affected by brain tumors. This preliminary study aimed to investigate whether the non-adherence to a dietary pattern, such as the Mediterranean diet, and pre-existing cardiovascular risk factors can affect the onset of cranial meningiomas.

RESULTS

Patients affected by meningioma had a significantly lower mean Mediterranean Diet Score (MDS), and a similar distribution of the main cardiovascular risk factors.

CONCLUSION

A larger patient cohort is required to corroborate our findings. However, these promising results open up a new avenue for further exploration of the role of the Mediterranean diet in the development of meningiomas.

Assessing the Training in Neurosurgery with the Implementation of VITOM-3D Exoscope: Learning Curve on Experimental Model in Neurosurgical Practice

(1) Background: Innovation and continuous demand in the field of visual enhancing technologies and video streaming have led to the discovery of new systems capable of improving visualization and illumination of the surgical field. The exoscope was brought into neurosurgical routine, and nearly ten years later, modern 3D systems have been introduced and tested, giving encouraging results. (2) Methods: In order to evaluate the surgeon's confidence with the exoscope and their increasing ability in terms of time spent and quality of the final achievement since their first encounter with the technique, an experimental trial on 18 neurosurgeons from a single Institution was performed to evaluate the learning curve for the use of the VITOM-3D exoscope in neurosurgical practice on a model of brain and dura mater. (3) Results: A significant improvement in the quality of the performance, number of errors made, and reduction in the time was found after the third iteration of the task, by when almost all the participants felt more comfortable and confident. No significant differences between senior neurosurgeons and resident neurosurgeons were reported. (4) Conclusions: Our results show that three iterations are enough to gain confidence with the exoscope from its first use, regardless of previous experience and training with an operating microscope.

Bleeding risk evaluation in cerebral cavernous malformation, the role of medications, and hemorrhagic factors: a case-control study

OBJECTIVE

Cerebral cavernous malformations (CCMs) are vascular lesions with an overall risk of rupture from 2% to 6% per year, which is associated with significant morbidity and mortality. The diagnostic incidence is increasing, so it is of paramount importance to stratify patients based on their risk of rupture. Data in the literature seem to suggest that specific medications, particularly antithrombotic and cardiovascular agents, are associated with a reduced risk of bleeding. However, the effect of the patient coagulative status on the cumulative bleeding risk remains unclear. The aim of this study was to assess the impact of different radiological, clinical, and pharmacological factors on the bleeding risk of CCMs and to assess the predictive power of an already validated scale for general bleeding risk, the HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol concomitantly).

METHOD

This was a multicenter retrospective observational study. The authors collected imaging, clinical status, and therapy data on patients with bleeding and nonbleeding CCMs. Univariate analysis and subsequent multivariate logistic regression were performed between the considered variables and bleeding or nonbleeding status to identify potential independent predictors of bleeding.

RESULTS

The authors collected data on 257 patients (46.7% male, 25.3% with bleeding CCMs). Compared with patients with nonbleeding lesions, those with bleeding CCMs were younger, less frequently had hypertension, and less frequently required antiplatelet drugs and beta-blockers (all p < 0.05). Bleeding lesions, however, had significantly higher median volumes (1050 mm3 vs 523 mm3 , p < 0.001). On multivariate analyses, after adjusting for age, history of hypertension and diabetes, and use of antiplatelet drugs or beta-blockers, lesion volume ≥ 300 mm3 was the only significant predictor of bleeding (adjusted OR 3.11, 95% CI 1.09-8.86). When the diagnostic accuracy of different volume thresholds was explored, volume ≥ 300 mm3 showed a limited sensitivity (36.7%, 95% CI 24.6%-50.0%), but a high specificity 78.2% (95% CI 71.3%-84.2%), with an area under the curve of 0.57 (95% CI 0.51-0.64).

CONCLUSIONS

This study supports previous findings that the CCM volume is the only factor influencing the bleeding risk. Antithrombotic agents and propranolol seem to have a protective role against the bleeding events. A high HAS-BLED score was not associated with an increased bleeding risk. Further studies are needed to confirm these results.

Role of Mediterranean diet in the development and recurrence of meningiomas: a narrative review

Several studies through the years have proven how an unhealthy nutrition, physical inactivity, sedentary lifestyle, obesity, and smoking represent relevant risk factors in cancer genesis. This study aims to provide an overview about the relationship between meningiomas and food assumption in the Mediterranean diet and whether it can be useful in meningioma prevention or it, somehow, can prevent their recurrence. The authors performed a wide literature search in PubMed and Scopus databases investigating the presence of a correlation between Mediterranean diet and meningiomas. The following MeSH and free text terms were used: "Meningiomas" AND "Diet" and "Brain tumors" AND "diet." Databases' search yielded a total of 749 articles. After duplicate removal, an abstract screening according to the eligibility criteria has been performed and 40 articles were selected. Thirty-one articles were excluded because they do not meet the inclusion criteria. Finally, a total of 9 articles were included in this review. It is widely established the key and protective role that a healthy lifestyle and a balanced diet can have against tumorigenesis. Nevertheless, studies focusing exclusively on the Mediterranean diet are still lacking. Thus, multicentric and/or prospective, randomized studies are mandatory to better assess and determine the impact of food assumptions in meningioma involvement.

Has intraoperative neuromonitoring changed the surgery for unruptured middle cerebral artery aneurysms? A retrospective comparative study

Intraoperative neurophysiological monitoring (IONM) represents one of the available technologies able to assess ischemia and aimed to improve surgical outcome reducing the treatment related morbidity in surgery for intracranial aneurysms. Many studies analyzing the impact of IONM are poised by the heterogeneity bias affecting the cohorts. We report our experience with IONM for surgery of unruptured middle cerebral artery (MCA) aneurysm in order to highlight its influence on functional and radiological outcome and surgical strategy. We retrospectively reviewed all MCA unruptured aneurysms treated between January 2013 and June 2021 by our institutional neurovascular team. Patients were divided into 2 groups according to the use of IONM. A total of 153 patients were included in the study, 52 operated on without IONM and 101 with IONM. The groups did not differ preoperatively regarding clinical status and aneurysm characteristics. Patients operated with IONM had better functional outcomes at discharge as well as at follow-up (p= 0.048, p=0.041) due to lower symptomatic ischemia and better radiological outcome due to lower rate of unexpected aneurysmal remnants (p= 0.0173). The introduction of IONM changed the use of temporary clipping (TeC), increasing its average duration (p= 0.01) improving the safety of dissecting and clipping the aneurysm. IONM in surgery for unruptured MCA aneurysm could improve the efficacy and safety of clipping strategy in the way it showed a role in changing the use of TeC and was associated to the reduction of unexpected aneurysmal remnants' rate and improvement in both short- and long-term patient's outcome.

Post-operative segmental cerebral venous sinus thrombosis: risk factors, clinical implications, and therapeutic considerations

Cerebral venous sinus thromboses (CVSTs) are rare complications of neurosurgical interventions and their management remains controversial as most of cases appear clinically silent. Here, we analyzed our institutional series of patients with CVSTs evaluating clinical and neuroradiological characteristics, risk factors, and outcome. From the analysis of our institutional PACS, we collected a total of 59 patients showing postoperative CVSTs after supratentorial or infratentorial craniotomies. For every patient, we collected demographics and relevant clinical and laboratory data. Details on thrombosis trend were retrieved and compared along the serial radiological assessment. A supratentorial craniotomy was performed in 57.6% of cases, an infratentorial in 37.3%, while the remaining were a single cases of trans-sphenoidal and neck surgery (1.7%, respectively). A sinus infiltration was present in almost a quarter of patients, and in 52.5% of cases the thrombosed sinus was exposed during the craniotomy. Radiological signs of CVST were evident in 32.2% of patients, but only 8.5% of them developed a hemorrhagic infarct. CVST-related symptoms were complained by 13 patients (22%), but these were minor symptoms in about 90%, and only 10% experienced hemiparesis or impaired consciousness. The majority of patients (78%) remained completely asymptomatic along the follow-up. Risk factors for symptoms occurrence were interruption of preoperative anticoagulants, infratentorial sinuses involvement and evidence of vasogenic edema and venous infarction. Overall, a good outcome defined mRS 0-2 was observed in about 88% of patients at follow-up. CVST is a complication of surgical approaches in proximity of dural venous sinuses. CVST usually does not show progression and courses uneventfully in the vast majority of cases. The systematic use of post-operative anticoagulants seems to not significantly influence its clinical and radiological outcome.

Analysis of Italian isolates of Pantoea stewartii subsp. stewartii and development of a real-time PCR-based diagnostic method

Pantoea stewartii subsp. stewartii (Pss) causes Stewart's vascular wilt of maize, and it is responsible for serious crop losses. Pss is indigenous to North America and spreads with maize seeds. The presence of Pss has been notified in Italy since 2015. The risk assessment of the entry of Pss in the EU from the United States through seed trade is in the order of magnitude of hundred introductions per year. Several molecular or serological tests were developed for the detection of Pss and used as official analysis for the certification of commercial seeds. However, some of these tests lack adequate specificity, not allowing to correctly discriminate Pss from P. stewartii subsp. indologenes (Psi). Psi is occasionally present in maize seeds and is avirulent for maize. In this study, several Italian isolates of Pss recovered in 2015 and 2018 have been characterized by molecular, biochemical, and pathogenicity tests; moreover, their genomes have been assembled through MinION and Illumina-sequencing procedures. Genomic analysis reveals multiple introgression events. Exploiting these results, a new primer combination has been defined and verified by real-time PCR, allowing the development of a specific molecular test able to detect the presence of Pss down to the concentration of 103  CFU/ml in spiked samples of maize seed extracts. Due to the high analytical sensitivity and specificity achieved with this test, the detection of Pss has been improved disentangling the inconclusive results in Pss maize seed diagnosis, overcoming its misidentification in place of Psi. Altogether, this test addresses the critical issue associated with maize seeds imported from regions where Stewart's disease is endemic.

Comparison between intrasylvian and intracerebral hematoma associated with ruptured middle cerebral artery aneurysms: clinical implications, technical considerations, and outcome evaluation

BACKGROUND

Subarachnoid hemorrhage (SAH) due to a middle cerebral artery (MCA) aneurysms rupture is often associated with intracerebral (ICH) or intrasylvian hematomas (ISH).

MATERIALS AND METHODS

We reviewed 163 patients with ruptured MCA aneurysms associated with pure SAH or SAH+ICH/ISH. Patients were first dichotomized according to the presence of a hematoma (ICH/ISH). Then, we performed a subgroup analysis comparing ICH versus ISH in order to explore their relationship with the most relevant demographic, clinical, and angioarchitectural features.

RESULTS

Overall, 85 patients (52%) had a pure SAH, whereas 78 (48%) presented an associated ICH/ISH. No significant differences were observed in demographics and angioarchitectural features between the two groups, but Fisher grading and Hunt-Hess score were higher in patients with hematomas. A good outcome was observed in a higher percentage of patients with pure SAH compared with the others (76% Vs 44%), although mortality rates were comparable. Age, Hunt-Hess and treatment-related complications were the main outcome predictors at multivariate analysis. Patients with ICH appeared clinically worse than those with ISH. We also found that older age, higher Hunt-Hess, larger aneurysms, decompressive craniectomy and treatment-related complications were associated with poor outcome among patients with ISH, but not with ICH, which appeared per se as a more severe clinical condition.

CONCLUSIONS

Our study confirm that age, Hunt-Hess and treatment-related complications influence the outcome of patients with ruptured MCA aneurysms. However, in the subgroup analysis of patients with SAH associated with ICH or ISH, only the Hunt-Hess at onset appeared as an independent predictor of outcome.

Safety and efficacy of propranolol for treatment of familial cerebral cavernous malformations (Treat_CCM): a randomised, open-label, blinded-endpoint, phase 2 pilot trial

BACKGROUND

Observations in people with cerebral cavernous malformations, and in preclinical models of this disorder, suggest that the β-blocker propranolol might reduce the risk of intracerebral haemorrhage. We aimed to evaluate the safety and efficacy of prolonged treatment with propranolol to reduce the incidence of symptomatic intracerebral haemorrhage or focal neurological deficit in people with familial cerebral cavernous malformations.

METHODS

We conducted a randomised, open-label, blinded-endpoint, phase 2 pilot trial (Treat_CCM) at six national reference centres for rare diseases in Italy. People aged 18 years or older with symptomatic familial cerebral cavernous malformation were eligible for enrolment. Participants were randomly assigned (2:1) to receive either oral propranolol (20-320 mg daily) plus standard care (intervention group), or standard care alone (control group), for 24 months. Participants, caregivers, and investigators were aware of treatment group assignment. Participants had clinical assessments and 3 T brain MRI at baseline and at 12 and 24 months. The primary outcome was new occurrence of symptomatic intracerebral haemorrhage or focal neurological deficit attributable to cerebral cavernous malformation over 24 months. Outcome assessors were masked to treatment group assignment. The primary analysis was done in the intention-to-treat population. Because of the pilot study design, we chose a one-sided 80% CI, which could either exclude a clinically meaningful effect or show a signal of efficacy. This trial is registered with EudraCT, 2017-003595-30, and ClinicalTrials.gov, NCT03589014, and is closed to recruitment.

FINDINGS

Between April 11, 2018, and Dec 5, 2019, 95 people were assessed for eligibility and 83 were enrolled, of whom 57 were assigned to the propranolol plus standard care group and 26 to the standard care alone group. The mean age of participants was 46 years (SD 15); 48 (58%) were female and 35 (42%) were male. The incidence of symptomatic intracerebral haemorrhage or focal neurological deficit was 1·7 (95% CI 1·4-2·0) cases per 100 person-years (two [4%] of 57 participants) in the propranolol plus standard care group and 3·9 (3·1-4·7) per 100 person-years (two [8%] of 26) in the standard care alone group (univariable hazard ratio [HR] 0·43, 80% CI 0·18-0·98). The univariable HR showed a signal of efficacy, according to predefined criteria. The incidence of hospitalisation did not differ between groups (8·2 cases [95% CI 7·5-8·9] per 100 person-years in the propranolol plus standard care group vs 8·2 [95% CI 7·1-9·3] per 100 person-years in the standard care alone group). One participant in the standard care alone group died of sepsis. Three participants in the propranolol plus standard care group discontinued propranolol due to side-effects (two reported hypotension and one reported weakness).

INTERPRETATION

Propranolol was safe and well tolerated in this population. Propranolol might be beneficial for reducing the incidence of clinical events in people with symptomatic familial cerebral cavernous malformations, although this trial was not designed to be adequately powered to investigate efficacy. A definitive phase 3 trial of propranolol in people with symptomatic familial cerebral cavernous malformations is justified.

FUNDING

Italian Medicines Agency, Associazione Italiana per la Ricerca sul Cancro, Swedish Science Council, Knut and Alice Wallenberg Foundation, CARIPLO Foundation, Italian Ministry of Health.

Spinal Dural Arteriovenous Fistulas: A Retrospective Analysis of Prognostic Factors and Long-Term Clinical Outcomes in the Light of the Recent Diagnostic and Technical Refinements

Spinal dural arteriovenous fistulas (dAVFs) are abnormal connections between the meningeal branches of segmental arteries and a radiculomedullary veins that result in a progressive myelopathy thanks to perimedullary coronal venous plexus congestion. Usually, dAVFs show nonspecific symptoms, thus leading to late clinical suspicion and a difficult MRI diagnosis.Several authors have tried to identify prognostic factors before treatment, but published studies results are often inconsistent and sometimes contradictory.In this study, we reviewed our recent experience of 30 dAVF patients where we collected all demographic, clinical and angioarchitectural features as well as radiological and treatment-related characteristics. The thoracic spine was the most common location, constituting 53.3% of cases, followed by the lumbar roots, comprising 30%. About 83% of patients showed motor deficits, urinary disturbances were present in 70%, and bowel symptoms in 50%.We treated 86.7% of patients with microsurgery and 13.3% with endovascular occlusion with a mean interval between clinical onset and intervention of 10.8 ± 14.2 months.A significant clinical improvement was observed at follow-up in 80% of patients, with a significant reduction in mean G-score, U-score and F-score at a mean follow-up of 105.89 ± 191.9 months.However, none among the principal demographic, clinical and radiological characteristics showed significant prognostic value to the clinical improvement observed at follow-up.

Brain tissue oxygenation monitoring in subarachnoid hemorrhage for the detection of delayed ischemia: a systematic review and meta-analysis

INTRODUCTION

Subarachnoid hemorrhage (SAH) is a severe subtype of stroke which can be caused by the rupture of an intracranial aneurysm. Following SAH, about 30% of patients develop a late neurologic deterioration due to a delayed cerebral ischemia (DCI). This is a metanalysis and systematic review on the association between values of brain tissue oxygenation (PbtO2) and DCI in patients with SAH.

EVIDENCE ACQUISITION

The protocol was written according to the PRISMA-P (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and approved by the International Prospective Register of Systematic Reviews (PROSPERO registration number CRD42021229338). Relevant literature published up to August 1, 2022 was systematically searched throughout the databases MEDLINE, WEB OF SCIENCE, SCOPUS. A systematic review and metanalysis was carried out. The studies considered eligible were those published in English; that enrolled adult patients (≥18years) admitted to neurointensive care units with aneurysmal SAH (aSAH); that reported presence of multimodality monitoring including PbtO2 and detection of DCI during the period of monitoring.

EVIDENCE SYNTHESIS

We founded 286 studies, of which six considered eligible. The cumulative mean of PbtO2 was 19.5 mmHg in the ischemic group and 24.1mmHg in the non ischemic group. The overall mean difference of the values of PbtO2 between the patients with or without DCI resulted significantly different (-4.32 mmHg [IC 95%: -5.70, -2.94], without heterogeneity, I² = 0%, and a test for overall effect with P<0.00001).

CONCLUSIONS

PbtO2 values were significantly lower in patients with DCI. Waiting for definitive results, monitoring of PbtO2 should be considered as a complementary parameter for multimodal monitoring of the risk of DCI in patients with SAH.

BIOM-57. DISSECTING STEMNESS IN AGGRESSIVE MENINGIOMAS: PROGNOSTIC ROLE OF SOX2 EXPRESSION

Aggressive meningiomas are prone to recur despite GTR and eventually progress: they represent a challenge and are difficult to recognize at first diagnosis. SOX2 (Sex-determining region Y-box2) is a transcription regulator whose role is crucial for cell’s fate and maintenance of progenitor’s identity during embryogenesis, and homeostasis and regeneration in adult tissue through stem cell activity preservation. We reviewed meningioma cases surgically treated at Gemelli Hospital, Rome between 2014 and 2019. We included all patients with diagnosis of grade 3 meningiomas, both progressive and de novo, grade 2 with at least one surgical recurrence after GTR and benign grade 1 and grade 2 without recurrence at 10 and 5 years long follow-up respectively. SOX2 expression was evaluated through IHC and RT-PCR. Its role in predicting progression, recurrence, OS and PFS was investigated. 87 patients were included: 16 de novo grade 3 meningioma, 7 progressive grade 1, 13 progressive grade 2, 12 recurrent grade 2, 20 benign grade 1, 19 benign grade 2. The IHC method for SOX2 was validated by correlation between IHC score and mRNA levels (Spearman R=0.0398, p=0.001, AUC 0.87). Although SOX2 expression is related to WHO grade in the series, its status doesn’t change with progression. SOX2 expression at first surgery is related to risk of progression (p&lt; 0,0001) and represents a grade independent prognostic factor for PFS and OS (PFS 38,41 months in positive cases vs not reached in negative cases; p&lt; 0,0001; OS 173,9 months in positive cases vs not reached in negative cases; p=0,0001) and both in grade 1 and grade 2. Histomorphological criteria, cornerstone of the current WHO classification, are inadequate to predict aggressiveness. SOX2 expression since first diagnosis is able to point out meningiomas prone to recur and progress. SOX2 status could integrate current classification as molecular biomarker of stemness and aggressiveness.

Intraoperative Evaluation of Brain-Tumor Microvascularization through MicroV IOUS: A Protocol for Image Acquisition and Analysis of Radiomic Features

Microvascular Doppler (MicroV) is a new-generation Doppler technique developed by Esaote (Esaote s.p.a., Genova, Italy), which is able to visualize small and low-flow vessels through a suppression of interfering signals. MicroV uses advanced filters that are able to differentiate tissue artifacts from low-speed blood flows; by exploiting the space-time coherence information, these filters can selectively suppress tissue components, preserving the signal coming from the microvascular flow. This technique is clinically applied to the study of the vascularization of parenchymatous lesions, often with better diagnostic accuracy than color/power Doppler techniques. The aim of this paper is to develop a reproducible protocol for the recording and collection of MicroV intraoperative ultrasound images by the use of a capable intraoperative ultrasound machine and post-processing aimed at evaluation of brain-tumor microvascularization through the analysis of radiomic features. The proposed protocol has been internally validated on eight patients and will be firstly applied to patients affected by WHO grade IV astrocytoma (glioblastoma-GBM) candidates for craniotomy and lesion removal. In a further stage, it will be generally applied to patients with primary or metastatic brain tumors. IOUS is performed before durotomy. Tumor microvascularization is evaluated using the MicroV Doppler technique and IOUS images are recorded, stored, and post-processed. IOUS images are remotely stored on the BraTIoUS database, which will promote international cooperation and multicentric analysis. Processed images and texture radiomic features are analyzed post-operatively using ImageJ, a free scientific image-analysis software based on the Sun-Java platform. Post-processing protocol is further described in-depth. The study of tumor microvascularization through advanced IOUS techniques such as MicroV could represent, in the future, a non-invasive and real-time method for intraoperative predictive evaluation of the tumor features. This evaluation could finally result in a deeper knowledge of brain-tumor behavior and in the on-going adaptation of the surgery with the improvement of surgical outcomes.

Nutrient regulation of lipochitooligosaccharide recognition in plants via NSP1 and NSP2

Many plants associate with arbuscular mycorrhizal fungi for nutrient acquisition, while legumes also associate with nitrogen-fixing rhizobial bacteria. Both associations rely on symbiosis signaling and here we show that cereals can perceive lipochitooligosaccharides (LCOs) for activation of symbiosis signaling, surprisingly including Nod factors produced by nitrogen-fixing bacteria. However, legumes show stringent perception of specifically decorated LCOs, that is absent in cereals. LCO perception in plants is activated by nutrient starvation, through transcriptional regulation of Nodulation Signaling Pathway (NSP)1 and NSP2. These transcription factors induce expression of an LCO receptor and act through the control of strigolactone biosynthesis and the karrikin-like receptor DWARF14-LIKE. We conclude that LCO production and perception is coordinately regulated by nutrient starvation to promote engagement with mycorrhizal fungi. Our work has implications for the use of both mycorrhizal and rhizobial associations for sustainable productivity in cereals.

Widening or narrowing inequalities? The equity implications of digital tools to support COVID-19 contact tracing: A qualitative study

Background

As digital tools are increasingly used to support COVID‐19 contact tracing, the equity implications must be considered. As part of a study to understand the public's views of digital contact tracing tools developed for the national ‘Test and Protect’ programme in Scotland, we aimed to explore the views of groups often excluded from such discussions. This paper reports on their views about the potential for contact tracing to exacerbate inequalities.

Methods

A qualitative study was carried out; interviews were conducted with key informants from organizations supporting people in marginalized situations, followed by interviews and focus groups with people recruited from these groups. Participants included, or represented, minority ethnic groups, asylum seekers and refugees and those experiencing multiple disadvantage including severe and enduring poverty.

Results

A total of 42 people participated: 13 key informants and 29 members of the public. While public participants were supportive of contact tracing, key informants raised concerns. Both sets of participants spoke about how contact tracing, and its associated digital tools, might increase inequalities. Barriers included finances (inability to afford smartphones or the data to ensure access to the internet); language (digital tools were available only in English and required a degree of literacy, even for English speakers); and trust (many marginalized groups distrusted statutory organizations and there were concerns that data may be passed to other organizations). One strength was that NHS Scotland, the data guardian, is seen as a generally trustworthy organization. Poverty was recognized as a barrier to people's ability to self‐isolate. Some participants were concerned about giving contact details of individuals who might struggle to self‐isolate for financial reasons.

Conclusions

The impact of contact tracing and associated digital tools on marginalized populations needs careful monitoring. This should include the contact tracing process and the ability of people to self‐isolate. Regular clear messaging from trusted groups and community members could help maintain trust and participation in the programme.

Patient and Public Contribution

Our patient and public involvement coapplicant, L. L., was involved in all aspects of the study including coauthorship. Interim results were presented to our local Public and Patient Involvement and Engagement Group, who commented on interpretation and made suggestions about further recruitment.

Updated Systematic Review on the Role of Brain Invasion in Intracranial Meningiomas: What, When, Why?

Simple Summary

Meningioma is still the most common adult tumor of the CNS, most of which are slow-growing, benign tumors and could even be accidentally diagnosed; nonetheless, they sometimes show more aggressive behavior with higher recurrence rates and relatively reduced overall survival. Assuming this, in recent years, scientific research has been accelerated, looking for new insights and applications that could improve preoperative investigation, tailor surgical planning, and strongly impact meningioma patients’ prognosis. Many fields have been developed, and the detection of brain invasion has firmly gained its potential role, leading to the revised version of WHO for CNS tumors in 2016 as a further criterion for defining atypia. Further studies are still ongoing to assess a widely accepted application of BI evaluation in intracranial meningioma management.

Abstract

Several recent studies are providing increasing insights into reliable markers to improve the diagnostic and prognostic assessment of meningioma patients. The evidence of brain invasion (BI) signs and its associated variables has been focused on, and currently, scientific research is investing in the study of key aspects, different methods, and approaches to recognize and evaluate BI. This paradigm shift may have significant repercussions for the diagnostic, prognostic, and therapeutic approach to higher-grade meningioma, as long as the evidence of BI may influence patients’ prognosis and inclusion in clinical trials and indirectly impact adjuvant therapy. We intended to review the current knowledge about the impact of BI in meningioma in the most updated literature and explore the most recent implications on both clinical practice and trials and future directions. According to the PRISMA guidelines, systematic research in the most updated platform was performed in order to provide a complete overview of characteristics, preoperative applications, and potential implications of BI in meningiomas. Nineteen articles were included in the present paper and analyzed according to specific research areas. The detection of brain invasion could represent a crucial factor in meningioma patients’ management, and research is flourishing and promising.

The Long and Winding Road: An Overview of the Immunological Landscape of Intracranial Meningiomas

Simple Summary

The tumor microenvironment represents the essential basis for characterizing oncological cells and supporting their growth. Along with genomic sequencing, the study of the tumor microenvironment represents a big step forward in oncological research and in the customization of treatments. Compared to gliomas, for which research has discovered greater results, the correlation between the microenvironment and tumor phenotype, and consequent prognostic implications, are still incompletely understood for intracranial meningioma. Recently, studies about the immunogenetic landscape of meningiomas have been promoted, and it is now clear that understanding the multifactorial pathogenesis of meningioma and its correlation with other specific signs (i.e., PTBE) could lead to the development of new targeted therapies, and significantly affect meningioma patients’ prognosis.

Abstract

The role of immunotherapy is gaining ever-increasing interest in the neuro-oncological field, and this is also expanding to the management of intracranial meningioma. Meningiomas are still the most common primary adult tumor of the CNS, and even though surgery and/or radiotherapy still represent cornerstones of their treatment, recent findings strongly support the potential role of specific immune infiltrate cells, their features and genomics, for the application of personalized treatments and prognostic implications. According to the PRISMA guidelines, systematic research in the most updated platform was performed in order to provide a descriptive and complete overview about the characteristics, role and potential implications of immunology in meningioma tumors. Seventy articles were included and analyzed in the present paper. The meningioma microenvironment reveals complex immune tumor-immune cells interactions that may definitely influence tumor progression, as well as offering unexpected opportunities for treatment.

Machine learning model prediction of 6-month functional outcome in elderly patients with intracerebral hemorrhage

Spontaneous intracerebral hemorrhage (ICH) has an increasing incidence and a worse outcome in elderly patients. The ability to predict the functional outcome in these patients can be helpful in supporting treatment decisions and establishing prognostic expectations. We evaluated the performance of a machine learning (ML) model to predict the 6-month functional status in elderly patients with ICH leveraging the predictive value of the clinical characteristics at hospital admission. Data were extracted by a retrospective multicentric database of patients ≥ 70 years of age consecutively admitted for the management of spontaneous ICH between January 1, 2014 and December 31, 2019. Relevant demographic, clinical, and radiological variables were selected by a feature selection algorithm (Boruta) and used to build a ML model. Outcome was determined according to the Glasgow Outcome Scale (GOS) at 6 months from ICH: dead (GOS 1), poor outcome (GOS 2–3: vegetative status/severe disability), and good outcome (GOS 4–5: moderate disability/good recovery). Ten features were selected by Boruta with the following relative importance order in the ML model: Glasgow Coma Scale, Charlson Comorbidity Index, ICH score, ICH volume, pupillary status, brainstem location, age, anticoagulant/antiplatelet agents, intraventricular hemorrhage, and cerebellar location. Random forest prediction model, evaluated on the hold-out test set, achieved an AUC of 0.96 (0.94–0.98), 0.89 (0.86–0.93), and 0.93 (0.90–0.95) for dead, poor, and good outcome classes, respectively, demonstrating high discriminative ability. A random forest classifier was successfully trained and internally validated to stratify elderly patients with spontaneous ICH into prognostic subclasses. The predictive value is enhanced by the ability of ML model to identify synergy among variables.

Clipping versus coiling for treatment of middle cerebral artery aneurysms: a retrospective Italian multicenter experience

Endovascular treatment has emerged as the predominant approach in intracranial aneurysms. However, surgical clipping is still considered the best treatment for middle cerebral artery (MCA) aneurysms in referral centers. Here we compared short- and long-term clinical and neuroradiological outcomes in patients with MCA aneurysms undergoing clipping or coiling in 5 Italian referral centers for cerebrovascular surgery. We retrospectively reviewed 411 consecutive patients admitted between 2015 and 2019 for ruptured and unruptured MCA aneurysm. Univariate and multivariate analyses of the association between demographic, clinical, and radiological parameters and ruptured status, type of surgical treatment, and clinical outcome at discharge and follow-up were performed. Clipping was performed in 340 (83%) cases, coiling in 71 (17%). Clipping was preferred in unruptured aneurysms and in those showing collateral branches originating from neck/dome. Surgery achieved a higher rate of complete occlusion at discharge and follow-up. Clipping and coiling showed no difference in clinical outcome in both ruptured and unruptured cases. In ruptured aneurysms age, presenting clinical status, intracerebral hematoma at onset, and treatment-related complications were significantly associated with outcome at both short- and long-term follow-up. The presence of collaterals/perforators originating from dome/neck of the aneurysms also worsened the short-term clinical outcome. In unruptured cases, only treatment-related complications such as ischemia and hydrocephalus were associated with poor outcome. Clipping still seems superior to coiling in providing better short- and long-term occlusion rates in MCA aneurysms, and at the same time, it appears as safe as coiling in terms of clinical outcome.

The clinical challenge of subarachnoid hemorrhage associated with multiple aneurysms when the bleeding source is not certainly identifiable

BACKGROUND

Multiple intracranial aneurysms (IAs) are encountered in 20-30% of the subarachnoid hemorrhages (SAH). Neuroimaging and clinical examination are usually sufficient to detect the bleeding source, but sometimes it can be misdiagnosed with catastrophic consequences.

METHODS

We reviewed our diagnostic work-up for all patients admitted from January 2016 to December 2020 for SAH with multiple IAs accounting for our rate of diagnostic failure. Then, we grouped the patients into 4 categories according to aneurysms topography and described our operative protocol in case of uncertain bleeding origin.

RESULTS

Sixty-two patients harboring 161 IAs were included. The bleeding source was identified in 56 patients (90.3%), who harbored other 81 bystander aneurysms. In 6 cases (9.7%) with a total of 24 aneurysms we failed the bleeding source identification. According to IAs topography, we grouped the IAs multiplicity in: a) anterior plus posterior circulation IAs; b) multiple posterior circulation IAs; c) bilateral anterior circulation IAs; d) multiple ipsilateral anterior circulation IAs. In case of unidentified bleeding source, key-elements favoring the simultaneous multiple IAs treatment were their number, morphology, topography, clinicians' experience, and management modality as endovascular treatment allows a faster exclusion of multiple IAs distant one each other compared with surgery. MCA involvement represented the more frequent reason to prefer multiple clipping rather than multiple coiling.

CONCLUSIONS

In a small percentage of patients with SAH with multiple IAs, bleeding source identification can be difficult. Until the routinely availability of new tools such as vessel wall imaging or computational fluid dynamics, an experienced neurovascular team and strategies aiming to simultaneously exclude multiple IAs remain mandatory.

Intracranial germ cell tumors in Adolescents and Young Adults: European and North American consensus review, current management and future development

The incidence of intracranial germ cell tumors (iGCT) is much lower in European and North American (E&NA) than in Asian population. However, E&NA cooperative groups have simultaneously developed with success treatment strategies with specific attention paid to long-term sequelae. Neurological sequelae may be reduced by establishing a diagnosis with an endoscopic biopsy and/or cerebrospinal fluid (CSF) and/or serum analysis, deferring the need to perform a radical surgery. Depending on markers and/or histological characteristics, patients are treated as either germinoma or non-germinomatous germ cell tumors (NGGCT). Metastatic disease is defined by a positive CSF cytology and/or distant drops in craniospinal MRI. The combination of surgery and/or chemotherapy and radiation therapy is tailored according to grouping and staging. With more than 90% 5-year event-free survival (EFS), localized germinomas can be managed without aggressive surgery, and benefit from chemotherapy followed by whole ventricular irradiation with local boost. Bifocal germinomas are treated as non-metastatic entities. Metastatic germinomas may be cured with craniospinal irradiation. With a 5-year EFS over 70%, NGGCT benefit from chemotherapy followed by delayed surgery in case of residual disease, and some form of radiotherapy. Future strategies will aim at decreasing long-term side effects while preserving high cure rates.

The use of Mixed Reality for the treatment planning of unruptured intracranial aneurysms

BACKGROUND

A thorough comprehension of topographic neuroanatomy is paramount in neurosurgery. In recent years, great attention has been raised towards extended reality, which comprises virtual, augmented, and mixed reality (MR) as an aid for surgery. In this paper, we describe our preliminary experience with the use of a new MR platform, aiming to assess its reliability and usefulness in the planning of surgical treatment of unruptured intracranial aneurysms.

METHODS

We prospectively enrolled 5 patients, harboring a total of 8 intracranial unruptured aneurysms, undergoing elective surgical clipping. A wearable mixed-reality device (HoloLens) was used to display and interact with a holographic model during surgical planning. Afterward, a total of 10 among surgeons and residents filled in a 5-point Likert-scale evaluation questionnaire.

RESULTS

According to the participants' feedback, the main MR platform advantages were considered the educational value, its utility during patients positioning and craniotomy planning, as well as the anatomical and imaging interpretation during surgery. The graphic performance was also deemed very satisfactory. On the other hand, the device was evaluated as not easy to use and pretty uncomfortable when worn for a long time.

CONCLUSIONS

We demonstrated that MR could play important role in planning the surgical treatment of intracranial aneurysms by enhancing the visualization and understanding of the patient-specific anatomy.

Strategies for Optic Pathways Decompression for Extra-Axial Tumors or Intracranial Aneurysms: A Technical Note

BACKGROUND

 Different types of skull base tumors and intracranial aneurysms may lead to compression of the optic pathways. Since most of them are biologically benign conditions, the first aim of surgery is preservation of optic nerves rather than the oncologic radicality.

MATERIALS AND METHODS

 Based on the progressive technical refinements coming from our institutional experience of optic nerve compression from aneurysms and extra-axial tumors, we analyzed the surgical steps to release nerves and chiasm during tumor debulking and aneurysm clipping.

RESULTS

 We distinguished vascular and tumor lesions according to the main direction of optic nerve compression: lateral to medial, medial to lateral, inferior to superior, and anterior to posterior. We also identified four fundamental sequential maneuvers to release the optic nerve, which are (1) falciform ligament (FL) section, (2) optic canal unroofing, (3) anterior clinoid process drilling, and (4) optic strut removal. The FL section is always recommended when a gentle manipulation of the optic nerve is required. Optic canal unroofing is suggested in case of lateral-to-medial compression (i.e., clinoid meningiomas), medial-to-lateral compression (i.e., tuberculum sellae meningiomas), and inferior-to-superior compression (i.e., suprasellar lesions). Anterior clinoidectomy and optic strut removal may be necessary in case of lateral-to-medial compression from paraclinoid aneurysms or meningiomas.

CONCLUSIONS

 Preservation of the visual function is the main goal of surgery for tumors and aneurysms causing optic nerve compression. This mandatory principle guides the approach, the timing, and the technical strategy to release the optic nerve, and is principally based on the direction of the compression vector.

Surgical Treatment of Middle Cerebral Artery Aneurysms: Hints and Precautions for Young Cerebrovascular Surgeons

BACKGROUND AND OBJECTIVE

 Clipping is still considered the treatment of choice for middle cerebral artery (MCA) aneurysms due to their angioarchitectural characteristics as they are often bifurcation dysplasias, needing a complex reconstruction rather than a simple exclusion. Thus, maintaining this surgical expertise is of paramount importance to train of young cerebrovascular surgeons. To balance for the increasingly limited experience due the worldwide general inclination toward the endovascular approaches, it is important to provide to the young neurosurgeons rules and operative nuances to guide this complex surgery. We describe the technical algorithm we use to teach our residents to approach ruptured and unruptured MCA aneurysms, which may help to develop a procedural memory useful to perform an effective and safe surgery.

MATERIALS AND METHODS

 We reviewed our last 10 years' institutional experience of about 400 cases of ruptured and unruptured MCA aneurysms clipping, analyzing our technical refinements and the difficulties in residents and young neurosurgeons teaching, to establish fundamental key-points and design a didactic algorithm that includes operative instructions and safety rules.

RESULTS

 We recognized seven pragmatic technical key points regarding craniotomy, sylvian fissure opening, basal cisternostomy, proximal vessel control, lenticulostriate arteries preservation, aneurysm neck microdissection, and clipping to use as a didactic algorithm for teaching residents, and as operative instructions for inexperienced neurosurgeons.

CONCLUSION

 In the setting of clipping MCA aneurysms, respect for surgical rules is of paramount importance to perform an effective and safe procedure, ensure the best aneurysm exclusion, and preserve the flow in collaterals and perforators.

Combined Use of Color Doppler Ultrasound and Contrast-Enhanced Ultrasound in the Intraoperative Armamentarium for Arteriovenous Malformation Surgery

BACKGROUND

Safety and efficacy in surgical treatment of cerebral arteriovenous malformations (AVMs) are dictated by thorough understanding of angioarchitectural features, intraoperative identification of feeding vessels, and appreciation of surrounding eloquent areas. Our aim was to describe the preliminary results of combined application of color Doppler ultrasound (CDUS) and contrast-enhanced ultrasound (CEUS) in a consecutive surgical series of AVM. We pointed out the tool's efficacy in distinguishing feeding from bystander vessels and in identifying pattern of venous drainage. We examined its role as an adjunct for semiquantitative evaluation of the nidus inflow.

METHODS

We used combined CDUS and CEUS in patients surgically treated for cerebral AVMs. We adopted these techniques following a designed protocol to guide safer AVM resection as an adjunct to indocyanine green videoangiography. Intraoperative assessment by ultrasound was performed before, during, and following nidus resection.

RESULTS

Four surgically treated cerebral AVMs availed of the ultrasound protocol. Postoperative conventional angiography showed complete resection of the AVMs. CDUS and CEUS proved to be valuable adjunctive tools to indocyanine green videoangiography and micro-Doppler in properly navigating and discerning vascular structures, especially vessel feeders from bystanders. The protocol allows us to identify flow direction, estimate blood velocity within the nidus, and appreciate flow modifications following temporary clipping. Ultimately, it allows us to evaluate the degree of nidus deafferentation, residual flow, restoration of venous drainage and absence of arteriovenous shunts.

CONCLUSIONS

The CDUS and CEUS protocol is safe and repeatable and works as real-time imaging, further supporting complete surgical resection of AVMs.

Comparison Between Minipterional Craniotomy Associated With Focused Sylvian Fissure Opening and Standard Pterional Approach With Extended Sylvian Fissure Dissection for Treatment of Unruptured Middle Cerebral Artery Aneurysms

BACKGROUND

In our institution, standard pterional craniotomy (PC) with an extended Sylvian fissure opening (ESFO) represented the standard approach for unruptured middle cerebral artery (MCA) aneurysm clipping until 2014, when we progressively started to prefer minipterional craniotomy (MPC) associated with a focused Sylvian fissure opening (FSFO). In the present study, we compared our results in terms of the efficacy of clipping and the rate of complications with these 2 different techniques.

METHODS

We included patients with small- and medium-size unruptured MCA aneurysms from January 2008 to December 2018 with follow-up of >12 months. The clinical and radiologic data were reviewed from the medical records. The outcomes were measured in terms of efficacy (aneurysmal exclusion rate) and safety (intracranial complication rate).

RESULTS

Overall, 134 patients who had presented with unruptured MCA aneurysms <1.5 cm were treated at our institution from January 2007 to December 2018: PC and ESFO were used in 73 patients and MPC and FSFO in 61. The demographics and angioarchitectural features were comparable between the 2 groups, except for age, which was older in the FSFO group. The aneurysm exclusion rate was not different between the 2 groups. The intracranial complication rate was, overall, significantly lower in the FSFO group (P < 0.001), especially for the rate of postoperative seizures. Finally, the FSFO group had had shorter postoperative hospitalization and better short- and long-term clinical outcomes.

CONCLUSIONS

The association between MPC and FSFO should represent the standard of treatment of unruptured MCA aneurysms in all referral cerebrovascular centers, allowing for the achievement of the same efficacy of standard PC with ESFO and minimizing the complications.

Computational Tools for the Reliability Assessment and the Engineering Design of Procedures and Devices in Bariatric Surgery

Obesity is one of the main health concerns worldwide. Bariatric Surgery (BS) is the gold standard treatment for severe obesity. Nevertheless, unsatisfactory weight loss and complications can occur. The efficacy of BS is mainly defined on experiential bases; therefore, a more rational approach is required. The here reported activities aim to show the strength of experimental and computational biomechanics in evaluating stomach functionality depending on bariatric procedure. The experimental activities consisted in insufflation tests on samples of swine stomach to assess the pressure-volume behaviour both in pre- and post-surgical configurations. The investigation pertained to two main bariatric procedures: adjustable gastric banding (AGB) and laparoscopic sleeve gastrectomy (LSG). Subsequently, a computational model of the stomach was exploited to validate and to integrate results from experimental activities, as well as to broad the investigation to a wider scenario of surgical procedures and techniques. Furthermore, the computational approach allowed analysing stress and strain fields within stomach tissues because of food ingestion. Such fields elicit mechanical stimulation of gastric receptors, contributing to release satiety signals. Pressure-volume curves assessed stomach capacity and stiffness according to the surgical procedure. Both AGB and LSG proved to reduce stomach capacity and to increase stiffness, with markedly greater effect for LSG. At an internal pressure of 5 kPa, outcomes showed that in pre-surgical configuration the inflated volume was about 1000 mL, after AGB the inflated volume was slightly lower, while after LSG it fell significantly, reaching 100 mL. Computational modelling techniques showed the influence of bariatric intervention on mechanical stimulation of gastric receptors due to food ingestion. AGB markedly enhanced the mechanical stimulation within the fundus region, while LSG significantly reduced stress and strain intensities. Further computational investigations revealed the potentialities of hybrid endoscopic procedures to induce both reduction of stomach capacity and enhancement of gastric receptors mechanical stimulation. In conclusion, biomechanics proved to be useful for the investigation of BS effects. Future exploitations of the biomechanical methods may largely improve BS reliability, efficacy and penetration rate.

Trans-sulcal versus trans-parenchymal approach in supratentorial cavernomas. A multicentric experience

OBJECTIVES

Cavernous malformations (CM) are low-flow vascular lesions that can cause significant symptoms and neurological deficits. Different intraoperative surgical approaches have been developed. Aim of the present investigation is the comparison between the trans-sulcal approach (TS) and the trans-parenchymal neuronavigation-assisted approach (TPN) in a surgical series from two neurosurgical centers. The technique and clinical outcomes are discussed, with a specific focus on seizure outcome.

PATIENTS AND METHODS

Clinical and radiological data from two neurosurgical centers ("A. Gemelli" Hospital in Rome and A.O.U. Città della Salute e della Scienza in Turin) were retrospectively reviewed in order to evaluate the different outcome of TS and TPN approach for cavernous malformation treatment.

RESULTS

A total of 177 patients underwent surgical intervention for supratentorial CM, 130 patients with TPN approach and 47 with TS approach. TS approach was associated with higher rate of seizure in early post-operative period both in epileptic patients (p < 0,001) and in patients without history of seizures before surgery (p = 0,002). Moreover, length of incision (p < 0,001), area of craniotomy (p < 0,001) and corticectomy (p < 0,001) were bigger in TS than in TPN approach. Brain contusion (p < 0,001) and fluid collection (p < 0,001) were more likely to be discovered after TS approach.

CONCLUSIONS

TPN is a valuable approach for resection of CM. Minor complications are significantly lower in TPN approach when compared with TS approach. In addition, it is associated with lower rate of early post-operative seizure and shorter length of stay.

Retrospective application of risk scores to ruptured intracranial aneurysms: would they have predicted the risk of bleeding?

As the incidental diagnosis of unruptured intracranial aneurysms has been increasing, several scores were developed to predict risk of rupture and growth to guide the management choice. We retrospectively applied these scores to a multicenter series of patients with subarachnoid hemorrhage to test whether they would have predicted the risk of bleeding in the event of aneurysm discovery previous to its rupture. Demographical, clinical, and radiological information of 245 adults were retrieved from two neurovascular centers' database. Data were pooled and PHASES, UCAS, and ELAPSS scores were retrospectively calculated for the whole population and their performances in identifying aneurysms at risk of rupture were compared. Mean PHASES, UCAS, and ELAPSS scores were 5.12 ± 3.08, 5.09 ± 2.62, and 15.88 ± 8.07, respectively. Around half (46%) of patients would have been assigned to the low- or very low-risk class (5-year rupture risk < 1%) in PHASES. Around 28% of patients would have been in a low-risk class, with a probability of 3-year rupture risk < 1% according to UCAS. Finally, ELAPSS score application showed a wider distribution among the risk classes, but a significant proportion of patients (45.5%) lie in the low- or intermediate-risk class for aneurysm growth. A high percentage of patients with ruptured aneurysms in this multicenter cohort would have been assigned to the lower risk categories for aneurysm growth and rupture with all the tested scores if they had been discovered before the rupture. Based on these observations, physicians should be careful about drawing therapeutic conclusions solely based on application of these scores.

Surgical Treatment of Anterior Communicating Artery Aneurysms: Hints and Precautions for Young Cerebrovascular Surgeons

Background Anterior communicating artery (AComA) aneurysms are the most common intracranial aneurysm, accounting for 25 to 38% of all cases. In spite of the advent of modern neurointerventional treatments, they still represent a strong indication for clipping in certain anatomical and clinical conditions. However, AComA aneurysms are the deepest located aneurysms of the anastomotic circle of Willis, with a complex spatial orientation, and they are fed by bilateral branches of the anterior circulations. Although, on one hand, these aneurysms represent the most complex ones of the anterior circulation, on the other hand, the experience of young neurosurgeons is increasingly limited. Therefore, respecting operative guidelines is crucial to achieve the best aneurysm exclusion and avoid fatal intraoperative complications.

Study Objective We describe the technical algorithm we use to teach young neurosurgeons how to approach AComA aneurysms and help them to develop a procedural memory needed to perform an efficient and safe surgery.

Materials and Methods We reviewed our last 10 years of institutional experience of > 200 cases of clipping ruptured and unruptured AComA aneurysms, analyzing our technical refinements and the difficulties in teaching residents and young neurosurgeons how to establish fundamental key points and design a didactic algorithm that includes operative instructions and safety rules.

Results We identified seven pragmatic technical key points regarding craniotomy, cisternostomy, gyrus rectus corticectomy, proximal control, perforators and Heubner preservation, aneurysm neck dissection, and clipping to use in a didactic algorithm for teaching residents and as operative instructions for inexperienced neurosurgeons.

Conclusion In the setting of clipping AComA aneurysms, respect for surgical rules is of paramount importance to perform an efficacious and safe procedure and ensure the best aneurysm exclusion and preservation of neurovascular structures.

Final height in growth hormone-deficient childhood cancer survivors after growth hormone therapy

PURPOSE

Growth hormone deficiency (GHD) is the most prevalent hypothalamic-pituitary (HP) disorder found in childhood cancer survivors (CCS). The published studies assessing GHD in CCS concluded that recombinant human GH (rhGH) does not restore final height (FH) to that predicted from mid-parental height (MPH). Thus, wider analyses on final height outcomes after rhGH in CCS are needed.

METHODS

Retrospective study on final height (FH) in 87 CCS treated with rhGH. Patients were divided into: Group A (n =48) who underwent cranial radiotherapy or had non-irradiated tumours of HP area, and B (n =39) who were treated with craniospinal or total body irradiation (TBI). 19/87 patients with central precocious/early puberty also received GnRH analogues.

RESULTS

Height (HT) gain after 1 and 2 years of rhGH was 0.38 ± 0.35 SDS and 0.18 ± 0.30 SDS, respectively (P < 0.0001); mean FH was in the normal range (- 0.85 ± 1.34 SDS), though not significantly different from HT SDS at baseline. 67% overall failed to reach MPH especially in Group B (P < 0.0001). However, height loss (HT SDS-MPH SDS) at FH improved or remained stable compared to baseline in 26/45 patients (58%). On stepwise regression analysis, major determinants of FH were HT at baseline (P < 0.0001) and delay before start of rhGH (P = 0.012). There was no significant difference in FH when GnRHa was added to rhGH.

CONCLUSION

rhGH and GnRH analogues therapy, when indicated, though failing to induce catch-up growth, prevented further height loss leading to a FH within the normal range but still below MPH, this latter being statistically significant in children who received craniospinal and TBI.

Improving the Accuracy of Neuronavigation in Cerebral Cavernous Malformation: A Technical Note on 68 Cases

Cavernous malformations (CM) are benign, low-flow vascular lesions that account for 5% - 13% of all cerebrovascular malformations. Surgery remains the most important treatment strategy, and many different approaches have been developed. We present here our institutional experience with 68 cases using a transcortical neuronavigation approach with some technical nuances to improve navigation accuracy during resection. The technique and clinical outcomes are discussed, with a specific focus on seizure sequels. Demographic data were collected, along with information on clinical and seizure characteristics at presentation, localization and size of CM, presence of multiple localizations, evidence of recent CM-related bleeding on MRI, intervention features, postoperative complications, prescription of anti-epileptic drugs at discharge and seizure outcome. We assume that surgery through a narrow well-defined working corridor would limit brain exposure and manipulation, and hence could significantly affect not only general complications, but also seizure control. The technique is feasible and associated with relatively low rates of minor and major procedure-related complications. It is also a valid method for surgeons in training since the trajectory is planned preoperatively with a senior consultant and the working corridor always follows the catheter, which directly leads to the cavernoma.

Application of indocyanine green video angiography in vascular neurosurgery

Indocyanine green video angiography (ICG-VA) is a non-invasive, easy to use and very useful tool for various neurosurgical procedures. The first application was in neurovascular surgery, because it was born as an intravascular tracer for vessels visualization; this has been really useful in aneurysms, atero-venous malformations (AVMs) and dural fistulas surgery where identification, obliteration or patency of vessels is essential. Introduced in vascular neurosurgery since 2003, ICG-VA applications have broadened over time, both in vascular and in other neurosurgical fields. In 2003 Raabe et al. have been the first to describe the use of ICG-VA for intraoperative assessment of cerebral vascular flow, enabling visualization of vessel patency and aneurysm occlusion during aneurysm surgery. ICG-VA applications in vascular neurosurgery have significantly increased over time including complex aneurysms, bypass, atero-venous malformations (AVM) artero-venous fistulas (AVF), evaluation of cortical perfusion. The procedure can be easily repeated after 5-10 minutes. Adverse reactions are comparable to those of other types of contrast media, with frequencies of 0.05% (hypotension, arrhythmia, or, more rarely, anaphylactic shock) to 0.2% (nausea, pruritus, syncope, or skin eruptions. The aim of the present study was to systematically analyze ICG-VA applications in vascular neurosurgery, highlighting the reported advantages and disadvantages, and discussing future perspectives.

Surgical Treatment of Posterior Communicating Artery Aneurysms: Hints and Precautions for Young Cerebrovascular Surgeons

Background In spite of the advent of neurointerventional treatment, different clinical and anatomical features are still strong indications for clipping of posterior communicating artery (PComA) aneurysms. But the experience of young neurosurgeons is increasingly limited, and therefore providing technical operative guidelines is a fundamental prerequisite to achieve the best aneurysm exclusion and avoid perioperative complications.

Study Objective We describe a technical algorithm we use to teach young neurosurgeons how to approach carotid aneurysms that may help them develop a procedural memory and thus perform an efficient and safe surgery.

Material and Methods We reviewed our last 10 years of institutional experience of > 150 cases of clipping ruptured and unruptured PComA aneurysms, analyzing our technical refinements and the difficulties in teaching residents and young neurosurgeons how to establish fundamental key points and design a didactic algorithm that includes operative instructions and safety rules.

Results We recognized seven pragmatic technical key points regarding craniotomy, cisternostomy, proximal and distal control, aneurysm neck dissection, preservation of neurovascular structures, and clipping to use in a didactic algorithm for teaching residents and as operative instructions for inexperienced neurosurgeons.

Conclusion In the setting of clipping PComA aneurysms, respect for surgical rules is of paramount importance to perform an efficacious and safe procedure and ensure the best aneurysm exclusion and preservation of neurovascular structures.

Antithrombotic therapy and intracranial bleeding in subjects with sporadic brain arteriovenous malformations: preliminary results from a retrospective study

Whether antithrombotic treatment is safe and/or affects the risk of intracranial bleeding in subjects with sporadic brain arteriovenous malformations (AVMs) is unknown. We conducted a retrospective analysis on the use of antithrombotics among patients affected by brain AVMs in follow-up at our institution. Attention was paid to the type of antithrombotic drug (either antiplatelets or anticoagulants), current or past use, dosage, and duration of treatment. Several clinical and angioarchitectural features of brain AVMs were also taken into consideration. The association between the use of antithrombotics and haemorrhagic onset was analyzed. A total of 77 patients were included in this study. Among them, ten patients were taking antithrombotic drugs at the time of AVM diagnosis. The rate of haemorrhagic onset was not significantly different between subjects who were and were not taking antithrombotic drugs (40 vs 55.2%, p = ns). Among the many clinical and angioarchitectural features analyzed, the only parameter that showed a statistically significant association with haemorrhagic onset was the size of the nidus. Patients who took antithrombotic treatments after being diagnosed with a brain AVM did not show an increased rate of intracranial haemorrhage over time considering a mean follow-up 4 years. In our study, antithrombotic treatment was not associated with increased intracranial bleeding among subjects with brain AVMs. In the presence of a strong clinical indication, antiplatelet and anticoagulant medications should not be denied a priori to patients with brain AVMs. Studies on larger populations are necessary to confirm these data.