Extracranial Jugular Foramen Schwannomas Treated with the Extreme Lateral Juxtacondylar Approach: Surgical Technique and Our Experience

BACKGROUND

Schwannoma that arises in the jugular foramen (JF) represents an important challenge for neurosurgeons for its precise location, extension, and neurovascular relationship. Nowadays, different managements are proposed. In this study, we present our experience in the treatment of extracranial JF schwannomas (JFss) with the extreme lateral juxtacondylar approach (ELJA).

OBJECTIVE

To present our experience in the treatment of extracranial JF schwannomas (JFss) with the ELJA.

METHODS

Between January 2013 and January 2017, 12 patients with extracranial JFs underwent surgery by ELJA. All lesions were type C of the Samii classification. Indocyanine green videoangiography was used to evaluate the relationship between the internal jugular vein and the tumor and to control the presence of spasm in the vertebral artery.

RESULTS

A complete exeresis was achieved in 9 patients while in 3 patients, it was subtotal. The complete regression of symptoms was obtained in 7 patients with a total resection. The remaining cases experienced a persistence of symptoms.

CONCLUSION

The success of this surgery is achieved through a management that starts from the patient's position. We promote an accurate evaluation of JFs through the Samii classification: Type C tumors allow the use of ELJA that reduces surgical complications. Furthermore, we recommend the use of indocyanine green videoangiography to preserve the vessels and prevent vasospasm.

First documented case of intracranial falcine malignant peripheral nerve sheath tumor: illustrative case

BACKGROUND

The authors reported the first documented case of intracranial extraaxial nonneurofibromatosis type 1-related nontriton malignant peripheral nerve sheath tumor (MPNST) originating from the falx cerebri.

OBSERVATIONS

A 34-year-old man with headache, short-term memory deficit, postural instability, and blurred vision presented with a large heterogenous contrast-enhanced intraventricular cystic lesion originating from the free margin of the falx cerebri. The patient received surgery using the right posterior interhemispheric approach. Gross total resection was performed, and the inferior border of the falx cerebri was resected. The postoperative course was uneventful. Histological examination revealed hypercellular foci of neoplastic spindle cells with hyperchromatic and wavy nuclei. Hence, a diagnosis of MPNST was made based on concomitant immunochemistry findings, including mouse double minute 2 homolog focal positivity and geographic loss of H3K27me3. The patient received adjuvant radiotherapy, and recurrence was not observed.

LESSONS

Intracranial MPNSTs are extremely rare tumors, typically originating from the cranial nerves in the posterior cranial fossa. An even rarer variant of these tumors, referred to as malignant intracerebral nerve sheath tumors, may directly arise from the brain parenchyma. The authors reported the first case of an intracranial MPNST originating from the dura mater of the falx cerebri, acting as an extraaxial lesion with prevalent expansion in the right ventricle.

Transnasal endoscopic removal of a retrochiasmatic cavernoma: A case report and review of literature

Background:

Cavernomas arising in the region of the optic apparatus are extremely rare, accounting for <1% of all the central nervous system cavernomas. Most patients are affected by acute visual disturbances related to hemorrhagic events. A prompt resection of the lesion together with a decompression of the optic apparatus may lead to a functional improvement. Almost all patients reported in literature were treated by means of a craniotomy, whereas only few papers described the use of a transnasal approach.

Case Description:

We report the case of a 53-year-old woman with a hemorrhagic, cavernous malformation of the optic chiasm region and we discuss the technical nuances of the endoscopic transnasal approach we employed. We also review literature for patients with cavernomas treated with a transsphenoidal approach. In our case, the patient underwent the gross-total resection of the lesion through a fully endoscopic transnasal route and the visual disturbances improved immediately after the operation. The ventral access allowed an adequate exposure of the chiasm/anterior circulation complex, thus avoiding an excessive dissection and retraction of neurovascular structures. Moreover, with the aid of angled scopes, we were able to identify the frail vascular supply of the chiasm by employing the suprachiasmatic corridor as well as the infrachiasmatic one. We stress the need for a careful reconstruction of the skull base to avoid a postoperative cerebrospinal fluid leak.

Conclusions:

With the evolution and spreading of the neuroendoscopic techniques, in selected cases, we advocate the use of the transnasal route for the removal of cavernomas arising in the region of the anterior optic pathways.

Application of diffusion tensor imaging (DTI) and MR-tractography in the evaluation of peripheral nerve tumours: state of the art and review of the literature

Peripheral nerves can be affected by a variety of benign and malignant tumour and tumour-like lesions. Besides clinical evaluation and electrophysiologic studies, MRI is the imaging modality of choice for the assessment of these soft tissue tumours. Conventional MR sequences, however, can fail to assess the histologic features of the lesions. Moreover, the precise topographical relationship between the peripheral nerve and the tumor must be delineated preoperatively for complete tumour resection minimizing nerve damage. Using Diffusion tensor imaging (DTI) and tractography, it is possible to obtain functional information on tumour and nerve structures, allowing the assess anatomy, function and biological features. In this article, we review the technical aspects and clinical application of DTI for the evaluation of peripheral nerve tumours. (www.actabiomedica.it)

Neurosurgical issues of bariatric surgery: A systematic review of the literature and principles of diagnosis and treatment

Bariatric surgery is gaining popularity as the treatment of choice of morbid obesity since this condition is constantly increasing over the last decades. Several complications have emerged as the number of surgeries and follow-up data increase. No systematic review of the neurosurgery-related potential complications has been performed to date. Objective of this work is to fill this gap. We reviewed the literature for bariatric surgery-related complications involving the neurosurgical practice. Moreover, we present explicative cases dealing with peri- and post-operative therapeutic precautions. Three pathological mechanisms emerged. The first is related to intracranial pressure alterations and may imply either intracranial hypertension or hypotension syndromes in the operative or post-operative periods. The second is the deficiency of macro- and micro-nutrients which are potential risk factors for neuro- or myelo-encephalopathies, fetal malformations and spine disorders. The third is a dysregulation of both autonomic and endocrine / pituitary control. Neurosurgeons must be aware of the several, multifactorial neurosurgery-related complications of bariatric surgery as their prevalence is likely to be higher in the next few years.

Outcome of elderly patients undergoing intracranial meningioma resection: a single center experience

BACKGROUND

Higher life expectancy and higher mean age in general population created growing interest in medical and surgical management of meningiomas in elderly. It is well known that, due to possible complications, pre-operative status and comorbidities, expecially in aged people, should be carefully considerated in the decision-making process. We described our experience with this kind of patients and analized the influence of complications on the outcome.

METHODS

We conducted a monocentric retrospective study to evaluate outcome and complications in elderly patients that underwent intracranial meningioma surgery in our center in a ten year period. Between January 2005 and December 2014, 107 patients - older than 70 years old - were operated for an intracranial meningioma. We excluded patients operated for a recurrent meningioma. We use the Dindo classification modified by Poon to describe complications and the Karnofsky Performance Status Scale and Glasgow Outcome Scale to evaluate the outcome at discharge and after a 6 months period.

RESULTS

84 patients did not have postoperative complications, 10 patients had mild postoperative complications, while 13 patients suffered severe postoperative complications. As a group, patients with mild complications presented, six months after surgery, an average Karnofsky Performance Status better than preoperative one.

CONCLUSIONS

Even though the fragility is considered an important risk factor, surgery for symptomatic intracranial meningiomas should be considered also in elderly patients. The presence of early postoperative mild complications do not seem to worsen the average 6 months- KSP score.

Dorsal extradural meningioma: Case report and literature review

Background:

Extradural spinal mass lesions are most commonly metastatic tumors. Extradural meningiomas are rare, accounting for approximately 2.5–3.5% of spinal meningiomas; intraoperatively, they are easily mistaken for malignant tumors, especially in the en plaque variety, resulting in inadequate surgical treatment.

Case Description:

Our case is one of the first to describe a patient with two purely extradural meningiomas, one each between D3–D4 and between D5–D6 vertebral levels. Surgical resection was radical, and pathologically both lesions were meningothelialmeningiomas.

Conclusions:

Reviewing the literature, we discuss the pathogenesis, treatment strategies, and long-term behavior of these uncommon lesions.

Dural repair using autologous fat: Our experience and review of the literature

Background:

Various materials have been proposed to obliterate dead spaces and to reconstruct dural defects during a neurosurgical approach. This study describes our technique of using the abdominal autologous fat graft and evaluates the complications and characteristics related to the use of this tissue during cranial procedures.

Methods:

Autologous fat grafts were used in 296 patients with basicranial and convexity extraaxial tumors from April 2005 to January 2015. The adipose tissue was removed from the paraumbilical abdominal region and was transformed into a thin foil. When possible, a watertight suture was made between the dural or bone edge with a fat graft. We always used fibrin glue to reinforce the dural closure.

Results:

Complications occurred between 2 days and 1 year following procedure. Cerebrospinal fluid leaks were found in 11 cases. No case of mortality, pseudomeningoceles, fistula, infections, bacterial meningitides, or lipoid meningitides was reported. No patient required removal of the graft. No adhesion was observed between the brain and the autologous fat. Other fat-related complications observed were 2 cases of fat necrosis in the abdomen and 2 cases of abdominal hemorrhage.

Conclusion:

The technique of harvesting and applying fat grafts is fairly simple, although it must be performed meticulously to be effective. Our experience has led us to believe that the use of fat grafts presents low morbidity and mortality. However, a neurosurgeon should never forget the possible late or early complications related to the use of fat grafts.

Facial functional outcome in monitored versus not-monitored patients in vestibular schwannomas surgery

Objective:

Even though advances in surgical techniques have improved facial nerve outcomes, functional preservation is still an issue because injury to the facial nerve has significant physical and psychological consequences for the patient. We retrospectively review our data in VS surgery to compare the facial outcome in intraoperative facial monitored versus not-monitored patients.

Materials and Methods:

51 consecutive patients with unilateral vestibular schwannoma in the period from 2005 to 2010 were treated in our Institution. In according to the type of neurophysiological tool used during surgical procedures, two patients groups were identified: Group 1 (facial stimulator only) and Group 2 (stimulator and facial monitoring). Statistical comparison of the two groups was made with the t- test, and facial function results were evaluated with the Fisher's exact test.

Results:

In the Group 1, of the 22 patients with anatomically preserved facial nerves, 3 (13.6%) showed excellent facial nerve function, 14 (63.6%) showed intermediate function, and 5 (22.7%) showed poor function. In the Group 2, all the 27 patients got anatomically preserved facial nerves, and 18 (66.7%) showed excellent facial nerve function, 9 (33.3%) showed intermediate function, and no one showed poor function.

Conclusions:

We found that retrosigmoid approach associated with continuous EMG facial monitoring combined with the use of bipolar stimulation is a safe and effective treatment for vestibular schwannomas.

Giant aneurysm of distal posterior inferior cerebellar artery: a case report and review of the literature

INTRODUCTION

Aneurysms in the vertebrobasilar system are rare and in the distal segment of the posterior inferior cerebellar artery they are even less frequent. Giant aneurysms are also rare in the posterior cranial fossa. Giant aneurysms of the distal posterior inferior cerebellar artery generally can have mainly compressive effects on the adjacent structures and they can be mistaken for tumors.

CASE PRESENTATION

We report the case of a 74-year-old Italian woman who presented with a complaint of dizziness. Her dizziness was found to be a result of aneurysmal dilatation arising from the distal segment of the right posterior inferior cerebellar artery. A mid-line suboccipital craniotomy was performed, and the aneurysm was clipped without post-operative deficits and with improvement in the patient's dizziness. In our present report, we also review the literature and discuss our case with regard to the clinical and radiological features and surgical procedure performed.

CONCLUSION

To the best of our knowledge, few cases of this type of aneurysm have been described in the literature. Our patient had a good outcome after surgical treatment.

Endoscope-assisted microneurosurgery for intracranial aneurysms

Background: The endovascular techniques has widely changed the treatment of intracranial aneurysms. However surgery still represent the best therapeutic option in case of broad-based and complex lesions. The combined use of endoscopic and microsurgical techniques (EAM) may improve surgical results.

Objective: The purpose of our study is to evaluate the advantages and limits of EAM for intracranial aneurysms.

Methods: Between January 2002 and December 2012, 173 patients, harboring 206 aneurysms were surgically treated in our department with the EAM technique. One hundred and fifty-seven aneurysms were located in the anterior circulation and 49 were in the posterior circulation. Standard tailored approaches, based on skull base surgery principles, were chosen. The use of the endoscope included three steps: initial inspection, true operative time, and final inspection. For each procedure, an intraoperative video and an evaluation schedule were prepared, to report surgeons’ opinions about the technique itself. In the first cases, we always used the endoscope during surgical procedures in order to get an adequate surgical training. Afterwards we became aware in selecting cases in which to apply the endoscopy, as we started to become familiar with its advantages and limits.

Results: After clipping, all patients were undergone postoperative cerebral angiography. No surgical mortality related to EAM were observed. Complications directly related to endoscopic procedures were rare.

Conclusion: Our retrospective study suggests that endoscopic efficacy for aneurysms is only scarcely influenced by the preoperative clinical condition (Hunt–Hess grade), surgical timing, presence of blood in the cisterns (Fisher grade) and/or hydrocephalus. However the most important factors contributing to the efficacy of EAM are determined by the anatomical locations and sizes of the lesions. Furthermore, the advantages are especially evident using dedicated scopes and holders, after an adequate surgical training to increase the learning curve.

Cognitive deficits in patients with low and high grade gliomas

AIM

Studies in the literature with specific information concerning the neuropsychological alterations in patients with high and low grade gliomas are poor. The aim of the present study was to investigate and compare the cognitive functioning in patients with high and low-grade glioma pre- and postoperatively.

METHODS

Between January 2009 and January 2011 27 patients with high-grade glioma (HG group) and 15 patients with low-grade glioma (LG group) were neuropsychologically assessed in the preoperative time, as well as 6 months and 1 year after surgery. During the examination, memory, visuo-constructive abilities, language and executive functions were tested. In addition in the preoperative time, the effect on cognition of lateralization, size and edema was analyzed for each group.

RESULTS

Both in the HG and LG group statistical comparisons of the pre- and postoperative assessments of cognitive abilities showed a postoperative improvement in memory functions and in processing speed (P<0.05). In particular the analysis of the significance of clinical factors in the postoperative outcome of patients with glioma showed that lesion size, edema and lateralization affect cognitive functioning in varying degree.

CONCLUSION

These findings demonstrated different levels of impairments in executive and memory domains and in processing speed in patients with low and high grade gliomas. These deficits may have a strong impact on quality of life. Psychiatric interventions may be useful for patients and their families; in particular for helping the patient to become aware of the illness, in bolstering coping strategies, and for facilitating their support at home.

The usefulness of intraoperative mobile computed tomography in severe head trauma

With modern technology, intraoperative computed tomography scans are being used in neurosurgical operative rooms. A case of severe head trauma is reported to underline how intraoperative computed tomography can improve the treatment of traumatic lesions, without changing the operative setup, with safety for patients and surgeons. The ability to perform an intraoperative computed tomography scan rapidly, at any surgical step, and with no need of any change in the operative room set or of moving the patient from the operative table improves safety both for the patient and surgeon. Intraoperative computed tomography is a very helpful tool during surgery for complex cases when a rapid evaluation of surgical manoeuvres is required.

Image-guided transoral biopsy in a boy with Grisel's syndrome

Grisel's syndrome is a disease characterized by an atlanto-axial rotatory subluxation following acute inflammation of the upper respiratory tract. The syndrome has a good prognosis as it usually heals with antibiotics, despite the delayed serious complications that have been reported. When neuroradiological investigation does not allow an accurate differential diagnosis between a tumor and osteomyelitis, an image-guided transoral biopsy is a safe, fast, minimally invasive, as well as effective, procedure.

Endoscope-Assisted Trans-Sphenoidal Approach for Treatment of Sternberg's Canal

We report an uncommon case of a 45-year-old woman who presented with spontaneous rhinorrhea. A computed tomography (CT) scan of the head revealed an abnormally large sphenoid sinus associated with a parasellar bony defect (Sternberg's canal) through which magnetic resonance imaging could detect an encephalocele of the right temporal lobe. An endoscope-assisted trans-sphenoidal approach was performed and, with the aid of image guided surgery, reduction of the encephalocele was obtained and followed by surgical repair of the dural and bony defects. The postoperative course was uneventful and the cerebrospinal fluid fistula was closed as confirmed by the postoperative CT scan and by the absence of rhinorrhea. After three years of monitoring the patient remained asymptomatic.

A rare case of intracranial rosai-dorfman disease mimicking multiple meningiomas. A case report and review of the literature

Rosai-Dorfman disease (RDD) was firstly described in 1969 as a benign proliferative disorder of histiocytes with systemic symptoms and lymphadenopathy. This disease is of uncertain pathogenesis and mostly occurs in children and young adults. The typical clinical features of RDD include bilateral painless cervical lymphadenopathy, but extranodal involvement may also be present. The most common extranodal sites include organs such as the respiratory tract, skin, nasal cavity, orbit and bone. Isolated central nervous system (CNS) manifestations are extremely rare. In case of CNS involvement, the commonest imaging findings are dural-based extra-axial enhancing masses. We describe a case of intracranial RDD mimicking multiple meningiomas both clinically and radiologically in a 57-year-old man presenting with a six-year history of progressive right visual and hearing loss and tinnitus. In cases of multiple extra-axial lesions it is worth bearing in mind the possible differential diagnosis for intracranial RDD and eventually propose to the patient further investigations.

Survival prognostic factors in patients with glioblastoma: our experience

AIM

Approximate survival for glioblastoma is less than 1 year. Age, histological features and performance status at presentation represent the three statistically independent factors affecting longevity. The purpose of the study was to assess the role of surgery and to analyze prognostic factors in our patients operated for glioblastoma.

METHODS

We evaluated in 56 patients operated for glioblastoma their depressive and performance status in the preoperative and postoperative time. Moreover we analyzed the extent of surgery, the site and the size of lesions.

RESULTS

Median overall survival was 17 months. An age of ≥60 years (P<0.03), a preoperative Karnofsky Performance Status KPS≤70 (P=0.04), a subtotal tumor resection (P<0.001), a tumor size >5 cm (P=0.01), and no postoperative adjuvant treatment (P=0.01) were associated with the worst prognosis. Before surgery we found the presence of depression in 10 patients with a significative reduction of mean Back Depression Inventory scores after tumor resection (P=0.03). Finally, a KPS≤70 was significantly associated with an increased incidence of depression in the postoperative time.

CONCLUSION

Tumor size, total resection and affective disorders were identified as predictors of survival in our series of patients with glioblastoma in addition to age and KPS score. In our opinion an early diagnosis and the use of specific safeguards in the operating room contribute to have an extension of the tumor progression time and median survival.

Posterior cranial fossa tumors: Results and prognostic factors in a consecutive series of 14 operated patients by occipital transtentorial approach

BACKGROUND

The objective of our study was to determine the safety and usefulness of performing surgery via occipital transtentorial approach to treat posterior cranial fossa tumors, which is well known as an approach to the pineal region (Poppen's approach).

METHODS

Fourteen patients with posterior cranial fossa tumors were successfully treated using occipital transtentorial approach between 2007 and 2012. The lesions included five meningiomas, three astrocytomas, two metastases, two hemangioblastomas, one cavernoma, and one dysgerminoma.

RESULTS

Lesions were <3 cm in 12 cases and ≥3 cm in two cases. Average Karnofsky Performance Status (KPS) scoring at admission was 88.5. Eleven patients scored ≥70 and seven patients <70. Average age was 43.1 years. All patients underwent surgical treatment by the same surgical team. All tumors were completely removed surgically without any injury to the venous complex and the adjoining structures. There was no incidence of mortality or morbidity in all patients, and all functional outcomes were good to excellent postoperatively. Postoperative computed tomography (CT) imaging revealed that none of the patients had suffered brain damage or infarction around the cerebellum, brainstem, or occipital lobe.

CONCLUSIONS

We found that the use of occipital transtentorial approach is strongly supported by the successful removal of posterior cranial fossa tumors without serious complications. Open microneurosurgery is probably still the most effective therapy in improving survival and KPS in patients with posterior cranial fossa tumors, given that the proper surgical technique is used and complications do not occur. This case study has strongly suggested that this approach is very useful, safe, and accurate for removing the tumors of posterior fossa and evaluating the surrounding anatomy, as well as for determining operative strategy.

Meningioangiomatosis Without Neurofibromatosis Type 2

Meningioangiomatosis (MA) is a rare, benign hamartomatous lesion found in cerebral cortex and leptomeninges. It occurs mostly in 5 - 15 year old children in form isolated or diffuse; the diffuse form may be associated with neurofibromatosis type 2 (NF2). The sporadic type in the adults is less common.The patient was a 37 year-old man with a long history of frontal headache. In suspected sinusitis, the patient underwent cerebral MRI that showed hypointense lesion in the right frontal lobe with heterogeneous contrast enhancement after gadolinium administration. There were no stigmata or family history of neurofibromatosis. A right pterional approach with a supraorbital craniotomy was performed. The lesion was removed with complete remission of the headache in the postoperative time. MA enters into differential diagnosis with several other diseases and a correct diagnosis is mandatory. The total surgical removal is the treatment of choice, and the prognosis after surgery is usually excellent for the absence of recurrence in sporadic cases.

Reorganization of functional connectivity of the language network in patients with brain gliomas

BACKGROUND AND PURPOSE

fcMRI measures spontaneous and synchronous fluctuations of BOLD signal between spatially remote brain regions. The present study investigated potential LN fcMRI modifications induced by left hemisphere brain gliomas.

MATERIALS AND METHODS

We retrospectively evaluated fcMRI in 39 right-handed patients with a left hemisphere brain glioma and 13 healthy controls. Patients and controls performed a verb-generation task to identify individual BOLD activity in the left IFG (Broca area); the active region was used as seed to create whole-brain background connectivity maps and to identify the LN (including bilateral regions of the IFG, STS, and TPJ) following regression of task-evoked activity. We assessed differences between patients and controls in the pattern of functional connectivity of the LN, as well as potential effects of tumor position, histopathology, and volume.

RESULTS

Global fcMRI of the LN was significantly reduced in patients with tumor compared with controls. Specifically, fcMRI was significantly reduced within seed regions of the affected hemisphere (left intrahemispheric fcMRI) and between the TPJ of the 2 hemispheres. In patients, the left TPJ node showed the greatest decrease of functional connectivity within the LN.

CONCLUSIONS

The presence of a brain tumor in the left hemisphere significantly reduced the degree of fcMRI between language-related brain regions. The pattern of fcMRI was influenced by tumor position but was not restricted to the area immediately surrounding the tumor because the connectivity between remote and contralateral areas was also affected.

Brain Metastasis From Prostate Adenocarcinoma: Case Report and Review of Literature

It is rare for prostate carcinoma to metastasize to the central nervous system. It often represents a terminal event with death in one year frequently due to the advanced systemic disease. Starting by a case report, we also reviewed the relevant literature to focus on this uncommon entity from epidemiology to clinical manifestation and therapeutic strategies. In this article, a case of multiple brain prostate metastasis is reported and a review of relevant literature is also discussed. Treatments available for intracranial metastasis include neurosurgery, external beam radiation and hormonal manipulation. Surgery associated with whole brain radiotherapy seems to be effective in the control of brain lesions both relieving neurological symptoms and prolonging survival, even if prognosis remains dismal. From this case, we concluded that brain metastasis from prostate carcinoma is a rare, terminal event with death in one year frequently due to the advanced systemic disease. A better understanding of the biology of prostate carcinoma will help clarify the basis for its metastasis to the brain.

Less invasive approaches for the treatment of cervical schwannomas: our experience

PURPOSE

The purpose of our paper is to illustrate our experience with minimally invasive approaches for the treatment of cervical schwannomas. Moreover, a brief review of the literature was conducted.

METHODS

All data regarding patients treated for cervical schwannomas were retrospectively revised. Site, size and extension of the lesions and preoperative neurological status were obtained through re-examination of neuroimaging and clinical records. Postoperative clinical examinations and radiological images were available for all patients. The clinical course was documented using the visual analog scale (VAS), Karnofsky score (KPS) and the Klekamp-Samii score system.

RESULTS

Sixteen patients harboring cervical schwannomas were treated from 2003 to 2009. Hemilaminectomy was performed in eight cases, subtotal hemilaminectomy in four cases, interlaminar fenestration in two cases, osteoplastic hemilaminotomy and laminoplasty in one case each. Postoperative neuroimaging revealed complete removal of the lesion and no signs of spinal instability. At discharge, neurological improvement was observed in 14 patients and all patients demonstrated reduction of VAS score and improvement of KPS and Klekamp-Samii's score.

CONCLUSIONS

Minimal access procedures are increasingly gaining popularity but their use is poorly described in the treatment of cervical tumors. Less invasive approaches may effectively be used instead of traditional laminectomy in the treatment of cervical tumors, especially schwannomas, providing less iatrogenic traumatism and preventing postsurgical spinal instability. Modern neuroimaging allows adequate preoperative planning and microsurgical techniques provide adequate execution of the surgical act. The procedure has to be tailored case by case considering the specific lesional features and the individual anatomical situation.

Prognostic impact of hemoglobin level and other factors in patients with high-grade gliomas treated with postoperative radiochemotherapy and sequential chemotherapy based on temozolomide: a 10-year experience at a single institution

BACKGROUND AND PURPOSE

To evaluate the influence of serum hemoglobin level prior to radiotherapy and other prognostic factors on survival in patients with high-grade gliomas.

MATERIAL AND METHODS

From 2001-2010, we retrospectively evaluated a total of 48 patients with malignant glioma treated with surgery and postoperative radiochemotherapy with temozolomide. A total of 37 of 48 patients received sequential temozolomide. Hemoglobin levels were assayed before radiotherapy in all patients. The Kaplan-Meier method was applied to estimate the overall survival, while the log-rank test was applied to evaluate the differences on survival probability between prognostic subgroups.

RESULTS

Results were assessed in 43 patients. The median overall survival time was 18 months (95% confidence interval: 12-40 months). The 1- and 2-year survival rates were 62.2% and 36.3%, respectively. The prognostic factors analyzed were gender, age, extent of surgery, performance status before and after radiotherapy, sequential chemotherapy, hemoglobin level, and methylation of the O-6-methylguanine-DNA methyltransferase gene (MGMT). In univariate analysis, the variables significantly related to survival were performance status before and after radiotherapy, sequential chemotherapy, and hemoglobin level. The median overall survival in patients with a hemoglobin level ≤ 12 g/dl was 12 months and 23 months in patients with a hemoglobin level > 12 g/dl. The 1- and 2-year survival rates were 46.7% and 20.0%, respectively, for patients with a hemoglobin level ≤ 12 mg/dl and 69.6% and 45.7%, respectively, for patients with a hemoglobin level > 12 g/dl.

CONCLUSION

Our results confirm the impact of well-known prognostic factors on survival. In this research, it was found that a low hemoglobin level before radiotherapy can adversely influence the prognosis of patients with malignant gliomas.

Endovascular stenting of an extracranial-intracranial saphenous vein high-flow bypass graft: Technical case report

Background:

The authors describe a case of endovascular stenting of an extracranial–intracranial saphenous vein high-flow bypass graft in the management of a complex bilateral carotid aneurysm case.

Case Description:

A 43-year-old woman was admitted with progressive visual field restriction and headache. Imaging studies revealed bilateral supraclinoid carotid aneurysms. The right carotid aneurysm was clipped and the left one was treated by an endovascular procedure, after performing an internal carotid artery–middle cerebral artery (ICA-MCA) saphenous vein bypass graft. A few months following the bypass procedure, a 70–80% stenosis of the graft was discovered and treated endovascularly with a stenting procedure. Follow-up at 36 months after the first operation showed the patency of the venous graft and no neurological deficits.

Conclusions:

Endovascular stenting of the extracranial–intracranial saphenous vein high-flow bypass graft is technically feasible when postoperative graft occlusion is discovered.

Arteriovenous malformations and intraoperative indocyanine green videoangiography: preliminary experience

We report our preliminary clinical experience with microscope-integrated intraoperative indocyanine green (ICG) videoangiography in the treatment of arteriovenous malformations (AVMs). Nine patients underwent surgical procedures for AVMs. All patients had preoperative and early postoperative digital subtraction angiography (DSA). In all the procedures, ICG was injected intravenously during AVM occlusion and the removal of the nidus were directly analized into the microscope-integrated video, and they were compared with early postoperative angiography images. A total of 16 intraoperative ICG angiographies were performed. In all the patients the image quality was excellent, allowing intraoperative real-time evaluation of the completeness of the removal of the nidus. ICG videoangiography is easily performed during surgery for AVM and can confirm the completeness of the removal and may detect residual nidus, thus improving outcomes.

A rare case of greater petrosal nerve schwannoma

Background:

Facial nerve schwannomas include only 0.8% of all intrapetrous mass lesions, and schwannomas originating exclusively from the greater petrosal nerve (GPN) are extremely rare. To date, only 13 reports have been described. In this case, the tumor was thought to originate from the GPN on the basis of clinical, radiological, and operative findings.

Case Description:

A 23-year-old girl presented an acute left facial palsy, a disturbance in tear secretion of the ipsilateral eye, and a left-sided conductive hypoacusia. Computed tomography (CT) scan and magnetic resonance imaging (MRI) showed an extradural mass in the left middle fossa. A subtemporal approach was performed and the lesion, originating from the proximal portion of the GPN, was excised. The post-operative course was satisfactory, except for a xerophtalmia, which was treated with artificial teardrops.

Conclusion:

GPN schwannomas can originate anywhere alongside the course of the nerve, from its proximal segment near the facial hiatus to its distal segment near the foramen lacerum. For these reasons, it requires differential diagnosis with trigeminal nerve schwannomas or with injuries arising from the geniculate ganglion, because it can be easily confused with those lesions. However, in less severe cases, an early diagnosis can be able to preserve the function of the facial nerve by reducing iatrogenic injuries caused by surgical maneuvers.

Laparoscopy-assisted ventriculoperitoneal shunt surgery: personal experience and review of the literature

Ventriculoperitoneal shunting is a widely accepted technique for the treatment of hydrocephalus. The standard procedure to insert the peritoneal catheter requires an abdominal incision, muscle dissection, and opening of the peritoneum. A number of complications related to the abdominal surgical phase have been reported. Laparoscopy-assisted ventriculoperitoneal shunting is a valid alternative procedure that reduces surgical trauma. We describe our experience and review the literature. A total of 30 laparoscopically guided ventriculoperitoneal shunting procedures were performed between January 2007 and June 2008, in collaboration with a general surgeon experienced in laparoscopy. Of these procedures, 25 were new shunt placements and 5 were revisions. Data about operative time, outcome, and complications were registered and compared with a group of 30 patients treated by means of standard laparotomy in the period 2005-2007. Laparoscopic shunt placement was successful in all patients. Operative duration, complications, and postoperative pain were all lower in patients treated by laparoscopy as compared to the laparotomy. In the laparoscopic group, an earlier peristalsis, quicker mobilization, and better cosmetic results were also noted. Laparoscopy in both ventriculoperitoneal shunt placement and revision is a safe, effective, and minimally invasive technique. It ensures proper abdominal placement of the distal catheter under direct vision allowing confirmation of its patency.

IL-31 a Th2 cytokine involved in immunity and inflammation

Cytokines are immunal regulatory proteins, however they also play a relevant role in inflammatory diseases. IL-31 is a newly discovered cytokine expressed primarily in TH2 cells, introduced by activated CD4+ T cells. IL-31 is capable of inducing chemokines and other cytokines in several inflammatory diseases via its surface receptor. This cytokine is also produced by mast cells and mast cell line, suggesting a role in allergic diseases. In this editorial we revisit the biological role of IL-31 in immunity and inflammation.

VEGF, substance P and stress, new aspects: a revisited study

Mast cells play an essential role in diverse physiological and pathological processes, such as atherosclerosis, malignancy, asthma, pulmonary fibrosis and arthritis, directly interact with bacteria, and appear to play a vital role in host defense against pathogens. Mast cells could be recruited in the inflammatory site, by MCP-1, RANTES and SCF, to selectively secrete proinflammatory molecules; these could include growth factors, histamine, which is mitogenic (H1) and an immunosuppressant (H2), neovascularization agents, such as heparin, IL-8, and VEGF, as well as proteases that could permit new blood vessel formation. Neurogenic inflammation involves vasodilation and plasma protein extravasation in response to neural stimulation. Upon stimulation, sensory neurons release Substance P and other neuropeptides and activate neurokinin-1 receptors leading to plasma protein extravasation from post-capillary venules. Substance P is a neuropeptide that is released from nerve endings in many tissues and plays an important role in immunological and inflammatory states, and it is also a mediator of tissue injury, asthma, arthritis, allergy and autoimmune diseases. SP-positive nerve fibers and mast cell contacts are increased by acute stress in mice leading to dermal mast cell degranulation. VEGF is produced by flammatory cells. IL-33 is the newest inflammatory member of the IL-1 cytokine family and we show here that SP can induce VEGF secretion from mast cells and IL-33 augments the effect of SP in VEGF transcription and translation protein.

Supratentorial cavernomas in eloquent brain areas: application of neuronavigation and functional MRI in operative planning

AIM

Cavernomas located in eloquent areas of cerebral hemispheres represent a challenge for the neurosurgeon. An accurate surgical approach is essential to completely remove the lesion with function preservation. Aim of this study was to evaluate the usefulness of integration between standard magnetic resonance imaging (MRI) for neuronavigation and functional MRI (fMRI) in preoperative planning and intraoperative removal of cavernomas.

METHODS

Between June 2000 and December 2002, 21 patients underwent surgery for supratentorial subcortical cavernomas. Eleven lesions were located adjacent to eloquent brain areas. All the patients in the series underwent MRI for neuronavigation and, since January 2002, in 6 cases of lesions located in eloquent areas, fMRI was also performed, with subsequent images fusion. The surgical approach was performed via the transgyral route under conventional and ultrasound-guided neuronavigation.

RESULTS

All the lesions were totally removed. No morbidity was seen in patients harbouring lesions in non eloquent areas. Four patients with lesions in critical areas suffered transient focal deficits, but only one patient of this series was operated on by the auxilium of image fusion. In 7 patients operated on by conventional image-guided surgery and affected by preoperative seizures, no further seizures were observed after surgery. In 3 patients more hosting lesions neighbouring critical areas, the perilesional ring was not removed, observing persistence of seizures pharmacologically treated. In 4 of the 6 patients (all affected by seizures), operated on by fMRI auxilium, lesion removal was associated to the removal of the perilesional ring. No further epilepsy was seen in these patients.

CONCLUSIONS

In all the cases the use of neuronavigation allowed minimally invasive approaches and radical excision of the lesions. Moreover, fMRI seemed to provide important additional information in patients with lesions in eloquent brain areas, allowing a more aggressive approach on the perilesional tissue to the aim of resolving seizures, in absence of an increase in the morbidity rate.

Combined endovascular and microsurgical approach in the treatment of giant paraclinoid and vertebrobasilar aneurysms

AIM

The aim of this study is to present the application of endovascular intraoperative occlusion of the parent artery during the microsurgical treatment of giant paraclinoidal internal carotid artery aneurysms (ICA) and of complex vertebrobasilar junction aneurysms .

METHODS

Five cases of giant paraclinoidal ICA aneury-sms were treated by direct surgical approach. In the operatory room any patient underwent angiography and balloon occlusion test using a mobile digital subtraction angiograph. Thereafter the catheter was left in the aortic arch. Through an extended pterional craniotomy, it was possible to evidentiate the aneurismal sac. The proximal control of the vessel was achieved inflating a double-lumen balloon; clipping of the aneurysm was achieved, because of pressure lowering inside the aneurysm. Also a giant vertebrobasilar junction aneurysm was treated by this combined technique: using a posterolateral approach the control of the omolateral vertebral artery was obtained by temporary clipping above PICA's origin; the control of controlateral artery was obtained inflating a balloon introduced through the femoral artery. These combined manoeuvres determined sac deflation, allowing an easier clipping.

RESULTS

Aneurysm obliteration was achieved with preservation of the circulation without complications in all cases.

CONCLUSIONS

The endovascular procedure allows safer and reliable proximal control of paraclinoidal ICA and vertebral artery during the microsurgical treatment of paraclinoid and vertebrobasilar junction aneurysms.

The interhemispheric transcallosal-transversal approach to the lesions of the anterior and middle third ventricle: Surgical validity and neuropsychological evaluation of the outcome

Based on the observation of the course of callosal fibres and of their artero-venous support as appearing in a microanatomic study, the Authors propose a variant of standard callosotomy procedure by the introduction of the transverse section of callosal fibres. This technique would allow the surgeon to spare a larger number of callosal fibres by the combined effect of a lower direct mechanical traction on fibres and a lower impact on artero-venous microcircle. The neuropsychological outcome of the patients who underwent this kind of procedure was evaluated. Fourteen patients affected by occupying-space lesions involving the anterior and middle third ventricle were included in the study. Ten patients underwent transverse callosotomy, four subjects received standard sagittal callosotomy. A control group was also included in the study. All patients underwent a pre-operative and six months post-operative neuropsychological evaluation focused on performance at cognitive and attentional tasks. No disturbances in executive function were observed in either group. Patients receiving transverse callosotomy performed as well as control group subjects in attentive tasks, which is not the case of patients undergoing sagittal callosotomy who show a marked deficit in selective attention for left side visual field. The observed more favourable neuropsychological outcome supports transverse callosotomy as a valid alternative method to standard longitudinal callosotomy in third ventricle surgery.

[Combined surgical treatment of pulmonary neoplasms with single brain metastasis]

The combined surgical treatment of primitive lung cancer with single brain metastasis is a frequently debated but still controversial problem. Up to day several therapeutic approaches are generally integrated (surgery, radiotherapy, chemotherapy) according to the clinical patterns and the technical possibilities. In general, the combined surgical operation (thoracotomy + craniotomy) when it is possible to be done, followed or proceeded by chemo-radiotherapy, has allowed to achieve a prolonged survival in these patients, maintaining an acceptable quality of life. The authors analyze 10 cases treated by thoracotomy and craniotomy at the Chair of Thoracic Surgery of University of L'Aquila. Although consisting of a small number of cases, this experience allows to detect the particular problems concerning these patients. The indications to the combined surgical treatment are considered, evaluating the surgical operation which is to be performed as first on the basis of lung cancer staging and of the location and size of the brain metastases. Finally the patients survival and their quality of life are considered.

Parailiac ectopic bone complicating the removal of a bone graft for cervical disc surgery

A case of symptomatic parailiac ectopic bone neoformation, following the removal of a bone plug for cervical disc surgery, is reported. The pathogenesis of this rare complication is discussed and some technical hints to avoid it are given.

Cerebral abscesses: topic treatment with antibiotics

The Authors, after a brief discussion of current therapies used in the treatment of cerebral abscesses, present a series of 10 cases treated topically with antibiotics (through drill-hole and puncturing of the abscess). The determining role of CT scan in this technique is emphasised.

Bilateral anomalous course of the ulnar nerve at the wrist causing ulnar and median nerve compression syndrome. Case report

The case of a patient with a bilateral compression syndrome of the ulnar and median nerves at the wrist is described. Both ulnar nerves, which were surgically explored at different times, followed an anomalous course and passed into the canalis carpi side by side with the median nerve. This variation in the course of the ulnar nerve is extremely rare and causes a unique syndrome with characteristic electromyographic patterns.

Spontaneous intraorbital hemorrhage caused by cavernous angioma of the orbit

The authors present three cases of orbital angioma (two with serious spontaneous hemorrhage) and discuss the symptomatology, the diagnostic procedures and operability. The pertinent literature is reviewed.

Giant anterior lumbosacral meningocele associated with intracranial meningiomas and multiple congenital malformations

A case of anterior meningocele arising through a thin fistulous tract in the intervertebral disk space of L5-S1 is described. This lesion was giant, and almost completely filled the abdominal and pelvic cavities. Furthermore, it was associated with two separate intracranial meningiomas, a pleuropericardial cyst, and numerous developmental malformations. Pathogenetic factors, clinical and radiological features, and surgical treatment are discussed.

Spinal intradural arachnoid cyst

A case of spinal intradural arachnoid cyst is presented, and the literature dealing with this rare lesion is surveyed. The etiological and pathological features are discussed; emphasis is placed on the importance of correct interpretation of clinical and radiological findings that may be diagnostically misleading.

Hemangioma calcificans

Two cases of intraparenchymal hemangioma calcificans, an extremely rare variety of cavernous angioma, are reported. These lesions, well demonstrated on roentgenographic films of the skull and on computerized tomography scans, appeared avascular during the course of cerebral angiography. Clinical features, as well as macroscopic and microscopic evaluation, are discussed. The differential diagnosis from other intracranial calcified lesions is difficult. The literature describing this rare lesion is briefly reviewed, with special regard to the surgical indications.

Spontaneous spinal epidural hematoma: report of a case with complete recovery

Spontaneous epidural spinal hematoma is a rare entity. Only a correct diagnosis and prompt surgical treatment permit full recovery in patients affected by this lesion. The authors report the case of an elderly patient who was successfully treated and in whom histological examination of the surgical specimens revealed a subperiosteal vascular malformation as a probable cause of the lesion.