Background: A subset of pediatric epilepsy patients suffer from epilepsy syndromes related to mul... more Background: A subset of pediatric epilepsy patients suffer from epilepsy syndromes related to multi-lobar or hemispheric epileptogenic networks and diseases. Most of these patients are refractory to anti-seizure drug treatment, resulting in persistent disabling seizures, neurocognitive delay and impaired quality of life. In well-selected patients, hemispheric surgery is associated with excellent seizure freedom rates and relatively low complication rates. Nevertheless, 30% of patients develop seizure recurrence after cerebral hemispheric surgery. The purpose of this study was to develop and validate a model to predict seizure freedom in children undergoing cerebral hemispheric surgery for the treatment of drug-resistant epilepsy. Methods: We analyzed 1237 hemispheric surgeries performed in pediatric patients across 31 centers and 12 countries to identify predictors of seizure freedom at 12 months after surgery. A multivariate logistic regression model was developed based on the enti...
Awake surgery and intraoperative neuromonitoring represent the gold standard for surgery of lesio... more Awake surgery and intraoperative neuromonitoring represent the gold standard for surgery of lesion located in language-eloquent areas of the dominant hemisphere, enabling the maximal safe resection while preserving language function. Nevertheless, this functional mapping is invasive; it can be executed only during surgery and in selected patients. Moreover, the number of neuro-oncological bilingual patients is constantly growing, and performing awake surgery in this group of patients can be difficult. In this scenario, the application of accurate, repeatable and non-invasive preoperative mapping procedures is needed, in order to define the anatomical distribution of both languages. Repetitive navigated transcranial magnetic stimulation (rnTMS) associated with functional subcortical fiber tracking (nTMS-based DTI-FT) represents a promising and comprehensive mapping tool to display language pathway and function reorganization in neurosurgical patients. Herein we report a case of a bil...
An 8-year-old Indian boy was admitted to the pediatric emergency department with severe and progr... more An 8-year-old Indian boy was admitted to the pediatric emergency department with severe and progressive visual loss. A CT scan and a subsequent cerebral MRI showed a large intra-axial lesion in the right parieto-occipital region with a mass effect and midline shift (Fig. 1). The patient underwent surgery and a gross total removal was achieved without complication; the pathology revealed an anaplastic ependymoma with neuronal aspects (WHO III). Reviewing the preoperative imaging, we noticed a transethmoidal encephalocele of both gyri recti associated to a bony erosion in the cribriform plate region (Fig. 2, 3a). The 3-month follow-up MRI showed an ini-
(1) Background: Surgical treatment of choroid plexus tumors is challenging, burdened by a notable... more (1) Background: Surgical treatment of choroid plexus tumors is challenging, burdened by a notable risk of bleeding. Neoadjuvant chemotherapy and preoperative embolization have been attempted, with encouraging results; however, the consensus on these procedures is lacking. (2) Methods: We present a case of a 10-month-old girl who underwent preoperative embolization of a hemorrhagic choroid plexus carcinoma of the lateral ventricle via the anterior choroidal artery, followed by total resection. (3) Results: The endovascular procedure was successfully completed, despite the rectification of the anterior choroidal artery associated with the absence of flow proximal to the plexal point. Minimal bleeding was observed during resection and the patient remained neurologically intact. (4) Conclusions: The time from entrance to exit in the anterior choroidal artery should be monitored and regarded as a potential ‘occlusion time’ in this specific group of patients. Nevertheless, our case supports the feasibility and effectiveness of preoperative embolization of a choroid plexus carcinoma of the lateral ventricle via the anterior choroidal artery, without complications. Furthermore, we suggest the use of a fast-embolic agent, such as N-butyl cyanoacrylate glue, as the preferred agent for this specific pathology and patient population.
Background Primary osteosarcoma of craniovertebral junction is extremely rare and reports in paed... more Background Primary osteosarcoma of craniovertebral junction is extremely rare and reports in paediatric patients are limited. The symptoms are subtle and mostly underestimated. Case presentation We present an unusual case of a 11-years old girl affected by an extensive and metastatic osteosarcoma of the atlas presented with cervicalgia and right torticollis refractory to medical treatment. The patient underwent open biopsy confirming the malignant histology. Conclusions Cervicalgia with or without a torticollis refractory to medical treatment, in absence of history of fell or trauma, is highly suspicious and should be considered as a warning sign for a severe pathology and it should not be neglected.
Background: Radiological parameters predicting the postoperative neurological outcome after resec... more Background: Radiological parameters predicting the postoperative neurological outcome after resection of a spinal meningioma (SM) are poorly studied, with controversial results. Methods: Observational multicenter cohort (2011–2018) of adult patients undergoing surgery for resection of SM. Tumor-canal volume ratio (TCR), the areas related to the cord and tumor occupancy at maximum compression, the presence of dural tail, calcifications, signs of myelopathy, and postoperative cord expansion were compared with the modified McCormick scale (mMCS) preoperative and at follow-up. Results: In the cohort (n = 90 patients), cord and tumor occupancy as well as cord compression and tumor volume showed a correlation with preoperative mMCS (p < 0.05, R −0.23; p < 0.001, R 0.35; p < 0.005, R −0.29; p < 0.001, R 0.42). Cord occupancy had a strong correlation with cord compression (p < 0.001, R 0.72). Tumor occupancy and TCR were correlated with relative outcome at follow-up (p < 0...
OBJECTIVE This study was undertaken to determine whether the vertical parasagittal approach or th... more OBJECTIVE This study was undertaken to determine whether the vertical parasagittal approach or the lateral peri-insular/peri-Sylvian approach to hemispheric surgery is the superior technique in achieving long-term seizure freedom. METHODS We conducted a post hoc subgroup analysis of the HOPS (Hemispheric Surgery Outcome Prediction Scale) study, an international, multicenter, retrospective cohort study that identified predictors of seizure freedom through logistic regression modeling. Only patients undergoing vertical parasagittal, lateral peri-insular/peri-Sylvian, or lateral trans-Sylvian hemispherotomy were included in this post hoc analysis. Differences in seizure freedom rates were assessed using a time-to-event method and calculated using the Kaplan-Meier survival method. RESULTS Data for 672 participants across 23 centers were collected on the specific hemispherotomy approach. Of these, 72 (10.7%) underwent vertical parasagittal hemispherotomy and 600 (89.3%) underwent lateral peri-insular/peri-Sylvian or trans-Sylvian hemispherotomy. Seizure freedom was obtained in 62.4% (95% confidence interval [CI] = 53.5%-70.2%) of the entire cohort at 10-year follow-up. Seizure freedom was 88.8% (95% CI = 78.9%-94.3%) at 1-year follow-up and persisted at 85.5% (95% CI = 74.7%-92.0%) across 5- and 10-year follow-up in the vertical subgroup. In contrast, seizure freedom decreased from 89.2% (95% CI = 86.3%-91.5%) at 1-year to 72.1% (95% CI = 66.9%-76.7%) at 5-year to 57.2% (95% CI = 46.6%-66.4%) at 10-year follow-up for the lateral subgroup. Log-rank test found that vertical hemispherotomy was associated with durable seizure-free progression compared to the lateral approach (p = .01). Patients undergoing the lateral hemispherotomy technique had a shorter time-to-seizure recurrence (hazard ratio = 2.56, 95% CI = 1.08-6.04, p = .03) and increased seizure recurrence odds (odds ratio = 3.67, 95% CI = 1.05-12.86, p = .04) compared to those undergoing the vertical hemispherotomy technique. SIGNIFICANCE This pilot study demonstrated more durable seizure freedom of the vertical technique compared to lateral hemispherotomy techniques. Further studies, such as prospective expertise-based observational studies or a randomized clinical trial, are required to determine whether a vertical approach to hemispheric surgery provides superior long-term seizure outcomes.
As far as the ventriculoatrial shunt placement in children is concerned, the percutaneous approac... more As far as the ventriculoatrial shunt placement in children is concerned, the percutaneous approach to the internal jugular vein under ultrasonographic control has been hitherto strongly recommended. Unfortunately, children still represent a challenge, having them peculiar characteristics for which the internal jugular vein cannulation shows some disadvantages. In this manuscript, we describe a percutaneous placement of ventriculoatrial shunt via right brachiocephalic vein under intraoperative ultrasonographic control. Brachiocephalic vein cannulation in surgery provides notable advantages in paediatric population and it may be considered as the first choice in younger children.
BACKGROUND The optimal treatment for posthemorrhagic hydrocephalus in newborns has not been estab... more BACKGROUND The optimal treatment for posthemorrhagic hydrocephalus in newborns has not been established yet. Moreover, despite many valid therapeutic alternatives, unfavorable neurodevelopmental outcomes are frequent. According to recent literature, these discouraging results could be related to secondary inflammatory damage of the white matter due to the gradual dissolution of the intraventricular hematoma, which should be removed. OBSERVATIONS Neuroendoscopic lavage (NEL) has proven to be a safe and reliable procedure, able to adequately remove the intraventricular clots and the products of blood degradation. To increase surgical control of the entire ventricular system, the authors illustrated a case in which they associated real-time transfontanellar ultrasound monitoring with NEL. LESSONS Coupling these two techniques, the authors performed a rapid ventricular wash and obtained intraoperative confirmation of complete and accurate clot removal.
BACKGROUND AND PURPOSE: Tractography of the facial nerve based on single-shell diffusion MR imagi... more BACKGROUND AND PURPOSE: Tractography of the facial nerve based on single-shell diffusion MR imaging is thought to be helpful before surgery for resection of vestibular schwannoma. However, this paradigm can be vitiated by the isotropic diffusion of the CSF, the convoluted path of the facial nerve, and its crossing with other bundles. Here we propose a multishell diffusion MR imaging acquisition scheme combined with probabilistic tractography that has the potential to provide a presurgical facial nerve reconstruction uncontaminated by such effects. MATERIALS AND METHODS: Five patients scheduled for vestibular schwannoma resection underwent multishell diffusion MR imaging (bvalues ¼ 0, 300, 1000, 2000 s/mm 2). Facial nerve tractography was performed with a probabilistic algorithm and anatomic seeds located in the brain stem, cerebellopontine cistern, and internal auditory canal. A single-shell diffusion MR imaging (b-value ¼ 0, 1000 s/mm 2) subset was extrapolated from the multishell diffusion MR imaging data. The quality of the facial nerve reconstruction based on both multishell diffusion MR imaging and single-shell diffusion MR imaging sequences was assessed against intraoperative videos recorded during the operation.
To develop and validate a model to predict seizure freedom in children undergoing cerebral hemisp... more To develop and validate a model to predict seizure freedom in children undergoing cerebral hemispheric surgery for the treatment of drug‐resistant epilepsy.
The favorable outcome generally associated with spinal meningioma surgery is the result of the co... more The favorable outcome generally associated with spinal meningioma surgery is the result of the continuing refinement of the surgical technique, the use of intraoperative neuromonitoring, and a better understanding of the tumor biological behavior. Among all the technological advancements, visualization tools are the keys to any successful surgical procedure. The operating microscope is the gold standard in all neurosurgical procedures. In recent years, high-definition exoscope systems have entered the field of neurosurgery, as another tool in the armamentarium of the contemporary neurosurgeon. After initial experiences and technical improvements, the exoscope has proven to be best suited for spinal procedures. This study aims to briefly review the exoscope journey in neurosurgery, with a special focus on spinal meningioma surgery. Benefits and limitations are analyzed and an illustrative case is reported. Spinal meningiomas removal under exoscope visualization has proven to be feasi...
Background Neurocysticercosis is the most frequent parasitic disease of the central nervous syste... more Background Neurocysticercosis is the most frequent parasitic disease of the central nervous system, and its incidence in the developed countries is increasing due to immigration and travels from endemic areas. The intraventricular location has been found to involve up to 61.3% of the patients; moreover, only 22 cases of migrating intraventricular cyst have been reported so far. Despite the rarity of the condition in western countries, its occurrence generates some concerns and the aim of this paper is to update the information concerning pathogenesis, clinical presentation, diagnosis and management of this entity. Methods and results All the pertinent literature was analysed, focused on the cases of migrating intraventricular neurocysticercosis and its peculiar features. An illustrative case regarding a 14-year-old girl is also presented. Conclusions Migrating intraventricular neurocysticercosis is a pathognomonic entity usually presenting with hydrocephalus, and its treatment is mainly surgical, preferring an endoscopic approach. When the resection of the intraventricular cyst is not performed, an accurate follow-up is mandatory to detect clinical changes due to a recurrent hydrocephalus or to the effect of the dying cyst on the surrounding area. In case of permanent shunt placement, the cysticidal and steroid treatment is recommended to reduce the risk of shunt failure.
Objective Ventriculopleural shunt is still considered a third-line option for CSF diversion, when... more Objective Ventriculopleural shunt is still considered a third-line option for CSF diversion, when both peritoneal and atrial cavity are contraindicated. Different approaches have been used and in modern surgery, lesser invasive techniques are predominant. The goal of this manuscript is to present a minimally invasive placement of a pleural catheter. Methods We describe a minimally invasive approach to the pleural space using an a-traumatic peel-away introducer under ultrasonographic intraoperative control. Furthermore, consideration about complications, follow-up and advantages of the abovementioned technique will be discussed. Conclusions Percutaneous US guided placement for pleural catheter is a safer and modern minimally invasive approach to the pleural space. Pleural effusion is the predominant complication, encountered especially in younger children.
Cerebrospinal fluid (CSF) rhinorrhea can lead to CNS infections, carrying significant moribidity ... more Cerebrospinal fluid (CSF) rhinorrhea can lead to CNS infections, carrying significant moribidity and mortality, especially in the elderly. Endoscopic endonasal surgery is a validated technique in the repair of anterior skull base CSF leaks. The aim of this study is to assess diagnostic management, surgical technique and clinical outcome in a consecutive series of elderly patients. Patients older than 65 years treated for anterior skull base CSF leaks through endoscopic endonasal surgery between 2003 and 2014 were retrospectively reviewed. All patients underwent preoperative nasal endoscopy, laboratory and radiological assessment. In doubtful cases endoscopic exploration was performed after intrathecal fluorescein (IF) injection. Patients were discharged between 3 and 4 days after surgery, and the endoscopic follow-up ranged from 3 to 24 months. 20 patients (age range 65-92) presented with 10 spontaneous and 10 traumatic/iatrogenic CSF leaks. In 40% of patients formal rhinoscopy and radiological assessment did not localize the CSF leak and IF injection was performed. IF enabled the identification of the skull base defect in all cases, with no adverse effects. In 11 cases the dura was repaired with fascia lata graft. All patients had successful endoscopic repair of the CSF fistula with no complications nor recurrences during follow-up. Endoscopic endonasal surgery is a minimally invasive procedure for CSF leak treatment. In our experience, IF injection proved safe and efficient in detecting skull base defects not identified by preoperative imaging. Endoscopic endonasal surgery proved effective and reliable also in elderly patients, with short hospitalization times and no morbidity.
Introduction: Cerebrospinal fluid (CSF) rhinorrhea can lead to CNS infections, carrying significa... more Introduction: Cerebrospinal fluid (CSF) rhinorrhea can lead to CNS infections, carrying significant moribid-ity and mortality, especially in the elderly. Endoscopic endonasal surgery is a validated technique in the repair of anterior skull base CSF leaks. The aim of this study is to assess diagnostic management, surgical technique and clinical outcome in a consecutive series of elderly patients. Methods: Patients older than 65 years treated for anterior skull base CSF leaks through endoscopic endonasal surgery between 2003 and 2014 were retrospectively reviewed. All patients underwent preop-erative nasal endoscopy, laboratory and radiological assessment. In doubtful cases endoscopic exploration was performed after intrathecal fluorescein (IF) injection. Patients were discharged between 3 and 4 days after surgery, and the endoscopic follow-up ranged from 3 to 24 months. Results: 20 patients (age range 65–92) presented with 10 spontaneous and 10 traumatic/iatrogenic CSF leaks. In 40% of patients formal rhinoscopy and radiological assessment did not localize the CSF leak and IF injection was performed. IF enabled the identification of the skull base defect in all cases, with no adverse effects. In 11 cases the dura was repaired with fascia lata graft. All patients had successful endoscopic repair of the CSF fistula with no complications nor recurrences during follow-up. Conclusion: Endoscopic endonasal surgery is a minimally invasive procedure for CSF leak treatment. In our experience, IF injection proved safe and efficient in detecting skull base defects not identified by preoperative imaging. Endoscopic endonasal surgery proved effective and reliable also in elderly patients, with short hospitalization times and no morbidity.
A remote cerebellar hemorrhage (RCH) is a spontaneous bleeding in the posterior fossa, which may ... more A remote cerebellar hemorrhage (RCH) is a spontaneous bleeding in the posterior fossa, which may rarely occurs as a complication of supratentorial procedures, and it shows a typical bleeding pattern defined &amp;amp;amp;amp;quot;the zebra sign.&amp;amp;amp;amp;quot; However, its pathophysiology still remains unknown. We performed a comprehensive review collecting all cases of RCH after supratentorial craniotomies reported in literature in order to identify the most frequently associated procedures and the possible risk factors. We assessed percentages of incidence and 95 % confidence intervals of all demographic, neuroradiological, and clinical features of the patients. Univariate and multivariate analyses were used to evaluate their association with outcome. We included 49 articles reporting 209 patients with a mean age of 49.09 ± 17.07 years and a male/female ratio 130/77. A RCH was more frequently reported as a complication of supratentorial craniotomies for intracranial aneurysms, tumors debulking, and lobectomies. In the majority of cases, RCH occurrence was associated with impairment of consciousness, although some patients remained asymptomatic or showed only slight cerebellar signs. Coagulation disorders, perioperative cerebrospinal fluid drainage, hypertension, and seizures were the most frequently reported risk factors. Zebra sign was the most common bleeding pattern, being observed in about 65 % out of the cases, followed by parenchymal hematoma and mixed hemorrhage in similar percentages. A multivariate analysis showed that symptomatic onset and intake of antiplatelets/anticoagulants within a week from surgery were independent predictors of poor outcome. However, about 75 % out of patients showed a good outcome and a RCH often appeared as a benign and self-limiting condition, which usually did not require surgical treatment, but only prolonged clinical surveillance, unless in the event of the occurrence of complications.
A remote cerebellar hemorrhage (RCH) is a spontaneous bleeding in the posterior fossa, which can ... more A remote cerebellar hemorrhage (RCH) is a spontaneous bleeding in the posterior fossa, which can be rarely observed as a complication of spine surgery. As well as for RCH reported after supratentorial procedures, it shows a characteristic bleeding pattern defined &amp;amp;amp;amp;amp;amp;quot;zebra sign&amp;amp;amp;amp;amp;amp;quot;. Nowadays, RCH pathophysiology still remains unknown. We performed a comprehensive review, collecting all cases of RCH after spine surgery reported in literature in order to identify the procedures most frequently associated with RCH and the possible risk factors. We assessed percentages of incidence and 95 % confidence interval of all demographic, neuroradiological, and clinical features. Univariate and multivariate analyses were used to evaluate their association with outcome. We included 44 articles reporting 57 patients with mean age of 57.6 ± 13.9 years and a male/female ratio of 23/34. A RCH was more frequently reported as a complication of decompressive procedures for spinal canal stenosis, particularly when associated with instrumented fusion, followed by spinal tumor debulking and disc herniation removal. In the majority of cases, RCH occurrence was characterized by progressive impairment of consciousness, whereas some patients complained non-specific symptoms. Coagulation disorders, hypertension, and placement of postoperative subfascial drainages were the most frequently reported risk factors. The occurrence of intraoperative dural lesions was described in about 93 % of patients. Zebra sign was the most common bleeding pattern (about 43 % of cases) followed by parenchymal hematoma (37.5 %) and mixed hemorrhage (about 20 %). Impairment of consciousness at clinical onset and intake of anticoagulants/antiplatelets appeared associated with poor outcome at univariate analysis. However, more than 75 % of patients showed a good outcome and a RCH often appeared as a benign and self-limiting condition, which usually did not require surgical treatment, but only prolonged clinical surveillance, unless of the occurrence of complications.
Cerebrospinal fluid (CSF) rhinorrhea can lead to CNS infections, carrying significant moribidity ... more Cerebrospinal fluid (CSF) rhinorrhea can lead to CNS infections, carrying significant moribidity and mortality, especially in the elderly. Endoscopic endonasal surgery is a validated technique in the repair of anterior skull base CSF leaks. The aim of this study is to assess diagnostic management, surgical technique and clinical outcome in a consecutive series of elderly patients. Patients older than 65 years treated for anterior skull base CSF leaks through endoscopic endonasal surgery between 2003 and 2014 were retrospectively reviewed. All patients underwent preoperative nasal endoscopy, laboratory and radiological assessment. In doubtful cases endoscopic exploration was performed after intrathecal fluorescein (IF) injection. Patients were discharged between 3 and 4 days after surgery, and the endoscopic follow-up ranged from 3 to 24 months. 20 patients (age range 65-92) presented with 10 spontaneous and 10 traumatic/iatrogenic CSF leaks. In 40% of patients formal rhinoscopy and radiological assessment did not localize the CSF leak and IF injection was performed. IF enabled the identification of the skull base defect in all cases, with no adverse effects. In 11 cases the dura was repaired with fascia lata graft. All patients had successful endoscopic repair of the CSF fistula with no complications nor recurrences during follow-up. Endoscopic endonasal surgery is a minimally invasive procedure for CSF leak treatment. In our experience, IF injection proved safe and efficient in detecting skull base defects not identified by preoperative imaging. Endoscopic endonasal surgery proved effective and reliable also in elderly patients, with short hospitalization times and no morbidity.
Background: A subset of pediatric epilepsy patients suffer from epilepsy syndromes related to mul... more Background: A subset of pediatric epilepsy patients suffer from epilepsy syndromes related to multi-lobar or hemispheric epileptogenic networks and diseases. Most of these patients are refractory to anti-seizure drug treatment, resulting in persistent disabling seizures, neurocognitive delay and impaired quality of life. In well-selected patients, hemispheric surgery is associated with excellent seizure freedom rates and relatively low complication rates. Nevertheless, 30% of patients develop seizure recurrence after cerebral hemispheric surgery. The purpose of this study was to develop and validate a model to predict seizure freedom in children undergoing cerebral hemispheric surgery for the treatment of drug-resistant epilepsy. Methods: We analyzed 1237 hemispheric surgeries performed in pediatric patients across 31 centers and 12 countries to identify predictors of seizure freedom at 12 months after surgery. A multivariate logistic regression model was developed based on the enti...
Awake surgery and intraoperative neuromonitoring represent the gold standard for surgery of lesio... more Awake surgery and intraoperative neuromonitoring represent the gold standard for surgery of lesion located in language-eloquent areas of the dominant hemisphere, enabling the maximal safe resection while preserving language function. Nevertheless, this functional mapping is invasive; it can be executed only during surgery and in selected patients. Moreover, the number of neuro-oncological bilingual patients is constantly growing, and performing awake surgery in this group of patients can be difficult. In this scenario, the application of accurate, repeatable and non-invasive preoperative mapping procedures is needed, in order to define the anatomical distribution of both languages. Repetitive navigated transcranial magnetic stimulation (rnTMS) associated with functional subcortical fiber tracking (nTMS-based DTI-FT) represents a promising and comprehensive mapping tool to display language pathway and function reorganization in neurosurgical patients. Herein we report a case of a bil...
An 8-year-old Indian boy was admitted to the pediatric emergency department with severe and progr... more An 8-year-old Indian boy was admitted to the pediatric emergency department with severe and progressive visual loss. A CT scan and a subsequent cerebral MRI showed a large intra-axial lesion in the right parieto-occipital region with a mass effect and midline shift (Fig. 1). The patient underwent surgery and a gross total removal was achieved without complication; the pathology revealed an anaplastic ependymoma with neuronal aspects (WHO III). Reviewing the preoperative imaging, we noticed a transethmoidal encephalocele of both gyri recti associated to a bony erosion in the cribriform plate region (Fig. 2, 3a). The 3-month follow-up MRI showed an ini-
(1) Background: Surgical treatment of choroid plexus tumors is challenging, burdened by a notable... more (1) Background: Surgical treatment of choroid plexus tumors is challenging, burdened by a notable risk of bleeding. Neoadjuvant chemotherapy and preoperative embolization have been attempted, with encouraging results; however, the consensus on these procedures is lacking. (2) Methods: We present a case of a 10-month-old girl who underwent preoperative embolization of a hemorrhagic choroid plexus carcinoma of the lateral ventricle via the anterior choroidal artery, followed by total resection. (3) Results: The endovascular procedure was successfully completed, despite the rectification of the anterior choroidal artery associated with the absence of flow proximal to the plexal point. Minimal bleeding was observed during resection and the patient remained neurologically intact. (4) Conclusions: The time from entrance to exit in the anterior choroidal artery should be monitored and regarded as a potential ‘occlusion time’ in this specific group of patients. Nevertheless, our case supports the feasibility and effectiveness of preoperative embolization of a choroid plexus carcinoma of the lateral ventricle via the anterior choroidal artery, without complications. Furthermore, we suggest the use of a fast-embolic agent, such as N-butyl cyanoacrylate glue, as the preferred agent for this specific pathology and patient population.
Background Primary osteosarcoma of craniovertebral junction is extremely rare and reports in paed... more Background Primary osteosarcoma of craniovertebral junction is extremely rare and reports in paediatric patients are limited. The symptoms are subtle and mostly underestimated. Case presentation We present an unusual case of a 11-years old girl affected by an extensive and metastatic osteosarcoma of the atlas presented with cervicalgia and right torticollis refractory to medical treatment. The patient underwent open biopsy confirming the malignant histology. Conclusions Cervicalgia with or without a torticollis refractory to medical treatment, in absence of history of fell or trauma, is highly suspicious and should be considered as a warning sign for a severe pathology and it should not be neglected.
Background: Radiological parameters predicting the postoperative neurological outcome after resec... more Background: Radiological parameters predicting the postoperative neurological outcome after resection of a spinal meningioma (SM) are poorly studied, with controversial results. Methods: Observational multicenter cohort (2011–2018) of adult patients undergoing surgery for resection of SM. Tumor-canal volume ratio (TCR), the areas related to the cord and tumor occupancy at maximum compression, the presence of dural tail, calcifications, signs of myelopathy, and postoperative cord expansion were compared with the modified McCormick scale (mMCS) preoperative and at follow-up. Results: In the cohort (n = 90 patients), cord and tumor occupancy as well as cord compression and tumor volume showed a correlation with preoperative mMCS (p < 0.05, R −0.23; p < 0.001, R 0.35; p < 0.005, R −0.29; p < 0.001, R 0.42). Cord occupancy had a strong correlation with cord compression (p < 0.001, R 0.72). Tumor occupancy and TCR were correlated with relative outcome at follow-up (p < 0...
OBJECTIVE This study was undertaken to determine whether the vertical parasagittal approach or th... more OBJECTIVE This study was undertaken to determine whether the vertical parasagittal approach or the lateral peri-insular/peri-Sylvian approach to hemispheric surgery is the superior technique in achieving long-term seizure freedom. METHODS We conducted a post hoc subgroup analysis of the HOPS (Hemispheric Surgery Outcome Prediction Scale) study, an international, multicenter, retrospective cohort study that identified predictors of seizure freedom through logistic regression modeling. Only patients undergoing vertical parasagittal, lateral peri-insular/peri-Sylvian, or lateral trans-Sylvian hemispherotomy were included in this post hoc analysis. Differences in seizure freedom rates were assessed using a time-to-event method and calculated using the Kaplan-Meier survival method. RESULTS Data for 672 participants across 23 centers were collected on the specific hemispherotomy approach. Of these, 72 (10.7%) underwent vertical parasagittal hemispherotomy and 600 (89.3%) underwent lateral peri-insular/peri-Sylvian or trans-Sylvian hemispherotomy. Seizure freedom was obtained in 62.4% (95% confidence interval [CI] = 53.5%-70.2%) of the entire cohort at 10-year follow-up. Seizure freedom was 88.8% (95% CI = 78.9%-94.3%) at 1-year follow-up and persisted at 85.5% (95% CI = 74.7%-92.0%) across 5- and 10-year follow-up in the vertical subgroup. In contrast, seizure freedom decreased from 89.2% (95% CI = 86.3%-91.5%) at 1-year to 72.1% (95% CI = 66.9%-76.7%) at 5-year to 57.2% (95% CI = 46.6%-66.4%) at 10-year follow-up for the lateral subgroup. Log-rank test found that vertical hemispherotomy was associated with durable seizure-free progression compared to the lateral approach (p = .01). Patients undergoing the lateral hemispherotomy technique had a shorter time-to-seizure recurrence (hazard ratio = 2.56, 95% CI = 1.08-6.04, p = .03) and increased seizure recurrence odds (odds ratio = 3.67, 95% CI = 1.05-12.86, p = .04) compared to those undergoing the vertical hemispherotomy technique. SIGNIFICANCE This pilot study demonstrated more durable seizure freedom of the vertical technique compared to lateral hemispherotomy techniques. Further studies, such as prospective expertise-based observational studies or a randomized clinical trial, are required to determine whether a vertical approach to hemispheric surgery provides superior long-term seizure outcomes.
As far as the ventriculoatrial shunt placement in children is concerned, the percutaneous approac... more As far as the ventriculoatrial shunt placement in children is concerned, the percutaneous approach to the internal jugular vein under ultrasonographic control has been hitherto strongly recommended. Unfortunately, children still represent a challenge, having them peculiar characteristics for which the internal jugular vein cannulation shows some disadvantages. In this manuscript, we describe a percutaneous placement of ventriculoatrial shunt via right brachiocephalic vein under intraoperative ultrasonographic control. Brachiocephalic vein cannulation in surgery provides notable advantages in paediatric population and it may be considered as the first choice in younger children.
BACKGROUND The optimal treatment for posthemorrhagic hydrocephalus in newborns has not been estab... more BACKGROUND The optimal treatment for posthemorrhagic hydrocephalus in newborns has not been established yet. Moreover, despite many valid therapeutic alternatives, unfavorable neurodevelopmental outcomes are frequent. According to recent literature, these discouraging results could be related to secondary inflammatory damage of the white matter due to the gradual dissolution of the intraventricular hematoma, which should be removed. OBSERVATIONS Neuroendoscopic lavage (NEL) has proven to be a safe and reliable procedure, able to adequately remove the intraventricular clots and the products of blood degradation. To increase surgical control of the entire ventricular system, the authors illustrated a case in which they associated real-time transfontanellar ultrasound monitoring with NEL. LESSONS Coupling these two techniques, the authors performed a rapid ventricular wash and obtained intraoperative confirmation of complete and accurate clot removal.
BACKGROUND AND PURPOSE: Tractography of the facial nerve based on single-shell diffusion MR imagi... more BACKGROUND AND PURPOSE: Tractography of the facial nerve based on single-shell diffusion MR imaging is thought to be helpful before surgery for resection of vestibular schwannoma. However, this paradigm can be vitiated by the isotropic diffusion of the CSF, the convoluted path of the facial nerve, and its crossing with other bundles. Here we propose a multishell diffusion MR imaging acquisition scheme combined with probabilistic tractography that has the potential to provide a presurgical facial nerve reconstruction uncontaminated by such effects. MATERIALS AND METHODS: Five patients scheduled for vestibular schwannoma resection underwent multishell diffusion MR imaging (bvalues ¼ 0, 300, 1000, 2000 s/mm 2). Facial nerve tractography was performed with a probabilistic algorithm and anatomic seeds located in the brain stem, cerebellopontine cistern, and internal auditory canal. A single-shell diffusion MR imaging (b-value ¼ 0, 1000 s/mm 2) subset was extrapolated from the multishell diffusion MR imaging data. The quality of the facial nerve reconstruction based on both multishell diffusion MR imaging and single-shell diffusion MR imaging sequences was assessed against intraoperative videos recorded during the operation.
To develop and validate a model to predict seizure freedom in children undergoing cerebral hemisp... more To develop and validate a model to predict seizure freedom in children undergoing cerebral hemispheric surgery for the treatment of drug‐resistant epilepsy.
The favorable outcome generally associated with spinal meningioma surgery is the result of the co... more The favorable outcome generally associated with spinal meningioma surgery is the result of the continuing refinement of the surgical technique, the use of intraoperative neuromonitoring, and a better understanding of the tumor biological behavior. Among all the technological advancements, visualization tools are the keys to any successful surgical procedure. The operating microscope is the gold standard in all neurosurgical procedures. In recent years, high-definition exoscope systems have entered the field of neurosurgery, as another tool in the armamentarium of the contemporary neurosurgeon. After initial experiences and technical improvements, the exoscope has proven to be best suited for spinal procedures. This study aims to briefly review the exoscope journey in neurosurgery, with a special focus on spinal meningioma surgery. Benefits and limitations are analyzed and an illustrative case is reported. Spinal meningiomas removal under exoscope visualization has proven to be feasi...
Background Neurocysticercosis is the most frequent parasitic disease of the central nervous syste... more Background Neurocysticercosis is the most frequent parasitic disease of the central nervous system, and its incidence in the developed countries is increasing due to immigration and travels from endemic areas. The intraventricular location has been found to involve up to 61.3% of the patients; moreover, only 22 cases of migrating intraventricular cyst have been reported so far. Despite the rarity of the condition in western countries, its occurrence generates some concerns and the aim of this paper is to update the information concerning pathogenesis, clinical presentation, diagnosis and management of this entity. Methods and results All the pertinent literature was analysed, focused on the cases of migrating intraventricular neurocysticercosis and its peculiar features. An illustrative case regarding a 14-year-old girl is also presented. Conclusions Migrating intraventricular neurocysticercosis is a pathognomonic entity usually presenting with hydrocephalus, and its treatment is mainly surgical, preferring an endoscopic approach. When the resection of the intraventricular cyst is not performed, an accurate follow-up is mandatory to detect clinical changes due to a recurrent hydrocephalus or to the effect of the dying cyst on the surrounding area. In case of permanent shunt placement, the cysticidal and steroid treatment is recommended to reduce the risk of shunt failure.
Objective Ventriculopleural shunt is still considered a third-line option for CSF diversion, when... more Objective Ventriculopleural shunt is still considered a third-line option for CSF diversion, when both peritoneal and atrial cavity are contraindicated. Different approaches have been used and in modern surgery, lesser invasive techniques are predominant. The goal of this manuscript is to present a minimally invasive placement of a pleural catheter. Methods We describe a minimally invasive approach to the pleural space using an a-traumatic peel-away introducer under ultrasonographic intraoperative control. Furthermore, consideration about complications, follow-up and advantages of the abovementioned technique will be discussed. Conclusions Percutaneous US guided placement for pleural catheter is a safer and modern minimally invasive approach to the pleural space. Pleural effusion is the predominant complication, encountered especially in younger children.
Cerebrospinal fluid (CSF) rhinorrhea can lead to CNS infections, carrying significant moribidity ... more Cerebrospinal fluid (CSF) rhinorrhea can lead to CNS infections, carrying significant moribidity and mortality, especially in the elderly. Endoscopic endonasal surgery is a validated technique in the repair of anterior skull base CSF leaks. The aim of this study is to assess diagnostic management, surgical technique and clinical outcome in a consecutive series of elderly patients. Patients older than 65 years treated for anterior skull base CSF leaks through endoscopic endonasal surgery between 2003 and 2014 were retrospectively reviewed. All patients underwent preoperative nasal endoscopy, laboratory and radiological assessment. In doubtful cases endoscopic exploration was performed after intrathecal fluorescein (IF) injection. Patients were discharged between 3 and 4 days after surgery, and the endoscopic follow-up ranged from 3 to 24 months. 20 patients (age range 65-92) presented with 10 spontaneous and 10 traumatic/iatrogenic CSF leaks. In 40% of patients formal rhinoscopy and radiological assessment did not localize the CSF leak and IF injection was performed. IF enabled the identification of the skull base defect in all cases, with no adverse effects. In 11 cases the dura was repaired with fascia lata graft. All patients had successful endoscopic repair of the CSF fistula with no complications nor recurrences during follow-up. Endoscopic endonasal surgery is a minimally invasive procedure for CSF leak treatment. In our experience, IF injection proved safe and efficient in detecting skull base defects not identified by preoperative imaging. Endoscopic endonasal surgery proved effective and reliable also in elderly patients, with short hospitalization times and no morbidity.
Introduction: Cerebrospinal fluid (CSF) rhinorrhea can lead to CNS infections, carrying significa... more Introduction: Cerebrospinal fluid (CSF) rhinorrhea can lead to CNS infections, carrying significant moribid-ity and mortality, especially in the elderly. Endoscopic endonasal surgery is a validated technique in the repair of anterior skull base CSF leaks. The aim of this study is to assess diagnostic management, surgical technique and clinical outcome in a consecutive series of elderly patients. Methods: Patients older than 65 years treated for anterior skull base CSF leaks through endoscopic endonasal surgery between 2003 and 2014 were retrospectively reviewed. All patients underwent preop-erative nasal endoscopy, laboratory and radiological assessment. In doubtful cases endoscopic exploration was performed after intrathecal fluorescein (IF) injection. Patients were discharged between 3 and 4 days after surgery, and the endoscopic follow-up ranged from 3 to 24 months. Results: 20 patients (age range 65–92) presented with 10 spontaneous and 10 traumatic/iatrogenic CSF leaks. In 40% of patients formal rhinoscopy and radiological assessment did not localize the CSF leak and IF injection was performed. IF enabled the identification of the skull base defect in all cases, with no adverse effects. In 11 cases the dura was repaired with fascia lata graft. All patients had successful endoscopic repair of the CSF fistula with no complications nor recurrences during follow-up. Conclusion: Endoscopic endonasal surgery is a minimally invasive procedure for CSF leak treatment. In our experience, IF injection proved safe and efficient in detecting skull base defects not identified by preoperative imaging. Endoscopic endonasal surgery proved effective and reliable also in elderly patients, with short hospitalization times and no morbidity.
A remote cerebellar hemorrhage (RCH) is a spontaneous bleeding in the posterior fossa, which may ... more A remote cerebellar hemorrhage (RCH) is a spontaneous bleeding in the posterior fossa, which may rarely occurs as a complication of supratentorial procedures, and it shows a typical bleeding pattern defined &amp;amp;amp;amp;quot;the zebra sign.&amp;amp;amp;amp;quot; However, its pathophysiology still remains unknown. We performed a comprehensive review collecting all cases of RCH after supratentorial craniotomies reported in literature in order to identify the most frequently associated procedures and the possible risk factors. We assessed percentages of incidence and 95 % confidence intervals of all demographic, neuroradiological, and clinical features of the patients. Univariate and multivariate analyses were used to evaluate their association with outcome. We included 49 articles reporting 209 patients with a mean age of 49.09 ± 17.07 years and a male/female ratio 130/77. A RCH was more frequently reported as a complication of supratentorial craniotomies for intracranial aneurysms, tumors debulking, and lobectomies. In the majority of cases, RCH occurrence was associated with impairment of consciousness, although some patients remained asymptomatic or showed only slight cerebellar signs. Coagulation disorders, perioperative cerebrospinal fluid drainage, hypertension, and seizures were the most frequently reported risk factors. Zebra sign was the most common bleeding pattern, being observed in about 65 % out of the cases, followed by parenchymal hematoma and mixed hemorrhage in similar percentages. A multivariate analysis showed that symptomatic onset and intake of antiplatelets/anticoagulants within a week from surgery were independent predictors of poor outcome. However, about 75 % out of patients showed a good outcome and a RCH often appeared as a benign and self-limiting condition, which usually did not require surgical treatment, but only prolonged clinical surveillance, unless in the event of the occurrence of complications.
A remote cerebellar hemorrhage (RCH) is a spontaneous bleeding in the posterior fossa, which can ... more A remote cerebellar hemorrhage (RCH) is a spontaneous bleeding in the posterior fossa, which can be rarely observed as a complication of spine surgery. As well as for RCH reported after supratentorial procedures, it shows a characteristic bleeding pattern defined &amp;amp;amp;amp;amp;amp;quot;zebra sign&amp;amp;amp;amp;amp;amp;quot;. Nowadays, RCH pathophysiology still remains unknown. We performed a comprehensive review, collecting all cases of RCH after spine surgery reported in literature in order to identify the procedures most frequently associated with RCH and the possible risk factors. We assessed percentages of incidence and 95 % confidence interval of all demographic, neuroradiological, and clinical features. Univariate and multivariate analyses were used to evaluate their association with outcome. We included 44 articles reporting 57 patients with mean age of 57.6 ± 13.9 years and a male/female ratio of 23/34. A RCH was more frequently reported as a complication of decompressive procedures for spinal canal stenosis, particularly when associated with instrumented fusion, followed by spinal tumor debulking and disc herniation removal. In the majority of cases, RCH occurrence was characterized by progressive impairment of consciousness, whereas some patients complained non-specific symptoms. Coagulation disorders, hypertension, and placement of postoperative subfascial drainages were the most frequently reported risk factors. The occurrence of intraoperative dural lesions was described in about 93 % of patients. Zebra sign was the most common bleeding pattern (about 43 % of cases) followed by parenchymal hematoma (37.5 %) and mixed hemorrhage (about 20 %). Impairment of consciousness at clinical onset and intake of anticoagulants/antiplatelets appeared associated with poor outcome at univariate analysis. However, more than 75 % of patients showed a good outcome and a RCH often appeared as a benign and self-limiting condition, which usually did not require surgical treatment, but only prolonged clinical surveillance, unless of the occurrence of complications.
Cerebrospinal fluid (CSF) rhinorrhea can lead to CNS infections, carrying significant moribidity ... more Cerebrospinal fluid (CSF) rhinorrhea can lead to CNS infections, carrying significant moribidity and mortality, especially in the elderly. Endoscopic endonasal surgery is a validated technique in the repair of anterior skull base CSF leaks. The aim of this study is to assess diagnostic management, surgical technique and clinical outcome in a consecutive series of elderly patients. Patients older than 65 years treated for anterior skull base CSF leaks through endoscopic endonasal surgery between 2003 and 2014 were retrospectively reviewed. All patients underwent preoperative nasal endoscopy, laboratory and radiological assessment. In doubtful cases endoscopic exploration was performed after intrathecal fluorescein (IF) injection. Patients were discharged between 3 and 4 days after surgery, and the endoscopic follow-up ranged from 3 to 24 months. 20 patients (age range 65-92) presented with 10 spontaneous and 10 traumatic/iatrogenic CSF leaks. In 40% of patients formal rhinoscopy and radiological assessment did not localize the CSF leak and IF injection was performed. IF enabled the identification of the skull base defect in all cases, with no adverse effects. In 11 cases the dura was repaired with fascia lata graft. All patients had successful endoscopic repair of the CSF fistula with no complications nor recurrences during follow-up. Endoscopic endonasal surgery is a minimally invasive procedure for CSF leak treatment. In our experience, IF injection proved safe and efficient in detecting skull base defects not identified by preoperative imaging. Endoscopic endonasal surgery proved effective and reliable also in elderly patients, with short hospitalization times and no morbidity.
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Papers by Valentina Baro