Benign ependymoma with extensive intracranial and spinal cerebrospinal fluid dissemination: case report and literature review.

Myxopapillary ependymoma (MPE) is a rare variant of ependymoma that is most commonly located in the cauda equina and filum terminale. We present a case of 23-year-old man diagnosed with MPE in the fourth ventricle and sacral canal area with extensive disseminated lesions along the cerebrospinal ventricular system. Additionally, a molecular pathological diagnosis was performed. The patient underwent a craniotomy and a lumbar laminectomy. In the course of 18 months of follow-up, the patient have recovered very well.

A New Technique in Surgical Management of the Giant Cerebral Hydatid Cysts.

OBJECTIVES: In hydatid disease, the central nervous system is affected approximately in 2% to 3% of patients. Surgical management in these patients is important. To develop a surgical technique to avoid the formation of great volume of cavity after hydatid cyst removal and prevent complications associated with brain collapse and cortical convolution. PATIENTS AND METHODS: In 2 patients, hydatid cysts were delivered by this new technique. A balloon filled with 150 cc of sterile air/distilled water was placed in the cavity until the balloon filled the entire cavity. Air/distilled water evacuation was continued at a rate of 20 cc/d and, after a week, eventually, the balloons were removed RESULTS:: All cysts were delivered without rupture. Neurologic outcomes were good. No complications were observed related to usage of the system such as balloon rupture, evacuation problems, and infection. CONCLUSION: The authors believe that the balloon insertion technique may be a useful method to prevent brain collapse, cortical convolution, and complications associated with this condition. Further technical refinements of the system are needed for better results.

Vertebral artery dolicoectasia with brainstem compression: role of microvascular decompression in relieving pyramidal weakness.

Vertebral artery dolicoectasia (VAD) can cause brainstem compression and dysfunction. Reports of pyramidal tract involvement by brainstem compression and the surgical benefits and its long-term results are sparsely reported. We hereby report three cases of medullary compression by VAD causing pyramidal weakness. Two patients with bilateral compression with quadriparesis did not want surgical treatment and were still disabled at 58 months and 50 months of follow-up, respectively. One patient with unilateral medullary compression with hemiparesis underwent microvascular decompression using Teflon sling retraction. This patient was relieved of symptoms and is asymptomatic at 14-month follow-up. This report emphasizes the need of surgical decompression in cases of brainstem compression by VAD with caution about appropriate case selection.

Cyst-cisternal shunting for cystic multirecurrent brainstem epidermoid: case report and literature review.

BACKGROUND: Surgical treatment of recurrent, posterior cranial fossa epidermoids in multioperated patients carries significant morbidity, mainly due to tumor adhesion to cranial nerves and vessels, and brainstem involvement. Radical resection is often not feasible; therefore surgery should aim to restore cerebrospinal fluid circulation, release engulfed neurovascular structures, and relieve brainstem compression. Intra-axial epidermoids are extremely rare. We present an innovative surgical technique of a cyst-cisternal shunting to treat cystic recurrent, unresectable brainstem epidermoids. METHODS: The surgical technique is stepwise described and a case illustration is reported. The pertinent literature has been reviewed. RESULTS: Few cases of brain stem epidermoid tumors have been described to date. The surgical steps of this technique and related intraoperative images are provided. One case illustration regarding the resection of a large recurrent cystic intra-axial brainstem epidermoid is reported to demonstrate the application of the technique in a clinical setting. The patient was followed up for 14 years and did not experience any recurrence, showing a stable disease at the last follow-up control. A systematic review of the competent literature has been provided. CONCLUSIONS: Cyst-cisternal shunting in case of recurrent, brainstem epidermoid is a safe and long-term effective technique to relieve mass effect into the brainstem.

Insinuating electronics in the brain.

There is an expanding interface between electronic engineering and neurosurgery. Rapid advances in microelectronics and materials science, driven largely by consumer demand, are inspiring and accelerating development of a new generation of diagnostic, therapeutic, and prosthetic devices for implantation in the nervous system. This paper reviews some of the basic science underpinning their development and outlines some opportunities and challenges for their use in neurosurgery.

Cranioplasty Enhanced by Three-Dimensional Printing: Custom-Made Three-Dimensional-Printed Titanium Implants for Skull Defects.

The authors studied to demonstrate the efficacy of custom-made three-dimensional (3D)-printed titanium implants for reconstructing skull defects. From 2013 to 2015, 21 patients (8-62 years old, mean = 28.6-year old; 11 females and 10 males) with skull defects were treated. Total disease duration ranged from 6 to 168 months (mean = 33.6 months). The size of skull defects ranged from 84 × 104 to 154 × 193 mm. Custom-made implants were manufactured by Medyssey Co, Ltd (Jecheon, South Korea) using 3D computed tomography data, Mimics software, and an electron beam melting machine. The team reviewed several different designs and simulated surgery using a 3D skull model. During the operation, the implant was fit to the defect without dead space. Operation times ranged from 85 to 180 minutes (mean = 115.7 minutes). Operative sites healed without any complications except for 1 patient who had red swelling with exudation at the skin defect, which was a skin infection and defect at the center of the scalp flap reoccurring since the initial head injury. This patient underwent reoperation for skin defect revision and replacement of the implant. Twenty-one patients were followed for 6 to 24 months (mean = 14.1 months). The patients were satisfied and had no recurrent wound problems. Head computed tomography after operation showed good fixation of titanium implants and satisfactory skull-shape symmetry. For the reconstruction of skull defects, the use of autologous bone grafts has been the treatment of choice. However, bone use depends on availability, defect size, and donor morbidity. As 3D printing techniques are further advanced, it is becoming possible to manufacture custom-made 3D titanium implants for skull reconstruction.

[A Patient with Sinking Skin Flap Syndrome who Underwent Perfusion MRI before and after Cranioplasty].

Background:Sinking skin flap syndrome(SSFS)manifests as subjective symptoms, such as headache, dizziness, and undue fatigability, in addition to neurologic symptoms, such as hemiplegia, aphasia, and perceived failure, when the skin over a bone defect sinks in the weeks or months following a decompressive craniectomy. Indeed, these symptoms can improve after a cranioplasty. Case presentation:A 58-year-old woman presented with a disturbance of consciousness. She was found to have a subarachnoid hemorrhage due to a ruptured right middle cerebral artery aneurysm. She underwent a craniotomy with clipping of the affected artery and a decompressive craniectomy on the same day. Post-operatively, the disturbance of consciousness improved, but the left-sided paralysis persisted. She complained of intractable headaches, was disoriented, and a lack of spontaneity emerged as the skin over the bone defect sank. She underwent cranioplasty on the 43rd day after admission, and the symptoms resolved promptly after surgery. Rehabilitation was canceled at the onset of symptoms, but resumed after the symptoms improved. Based on perfusion MRI, the cerebral blood flow(CBF):cerebral blood volume(CBV)ratio of the affected side increased before and after surgery compared with the healthy side. A lumboperitoneal shunt was placed on the 52nd day after admission to manage the hydrocephalus. She was discharged from the hospital with higher brain dysfunction and a mild state of paralysis. Conclusion:The timing of cranioplasty in patients with SSFS has not yet been established, but surgery should be performed before symptoms appear because SSFS impairs rehabilitative efforts.

Cerebral sparganosis: case report and review of the European cases.

Sparganosis is a severe parasitic infection caused by the larvae of Spirometra mansoni, also called "sparganum." In human hosts, the Spirometra mansoni larva commonly targets the subcutaneous tissue or muscle. Sometimes it can also migrate into the brain, resulting in cerebral sparganosis, mainly characterized by focal neurological symptoms such as seizures and radiological "wandering lesions" on magnetic resonance images (MRIs). Clinical cases of cerebral sparganosis have been reported worldwide, mainly in Asian countries, but also in North America, South America and Australia. Only two cases have been previously reported in Europe. A 29-year-old male from Bolivia, who lived in Spain, presented to our service for seizures and a multicystic brain lesion, initially suspected to be a dysembryoplastic neuroepithelial tumor (DNET). He underwent gross total resection of the mixed solid/cystic lesion. Pathology revealed gliosis, multiple interconnected cystic cavities with fibrous walls, inflammatory cell infiltration and no necrotizing granulomatous reaction. Inside the cavities, a parasitic form was identified as the larva of the cestode Spirometra mansoni. At 1-year follow-up, the patient had no deficits and was seizure free. Clinicians should be alerted to the possible existence of this rare entity in Europe, especially in patients from endemic areas with a possible infection history as well as "wandering lesions" on the MRI.

Uncal herniation in a fully conscious patient-The sliding uncus syndrome.

Uncal herniation is accompanied by a decreased level of consciousness. We describe a patient who remained fully alert despite the uncal herniation. The computed tomography (CT) scans allowed us to visualize the uncus and its spatial relation to the cerebral peduncle. We describe the sliding uncus syndrome.

Craniotomy in sitting position: anesthesiology management.

PURPOSE OF REVIEW: Sitting position to surgically approach posterior fossa disorder continues to be the first choice for some neurosurgical teams. We underwent a literature research for recent published studies involving neurosurgical patients operated on in this position. Preoperative evaluation, anesthetic technique, intraoperative monitoring, detection and treatment of venous or arterial air embolism episodes, and all the reported complications were recorded. RECENT FINDINGS: A modified semisitting (lounging) position aiming to create a positive pressure in the transverse and sigmoid sinuses, with lower head and higher legs positioned above the top of the head, decreases the incidence and severity of venous air embolism. Hyperventilation, compromising cerebral blood flow, has to be avoided during a sitting position. Precordial Doppler or transesophageal echocardiography monitoring improves the detection of small venous air embolism enabling its early treatment and diminishing its consequences. Patients with known patent foramen ovale can be operated on in a sitting position, under strict protocol, with few reported clinical venous air embolism and no paradoxical air embolism. SUMMARY: Sitting position for neurosurgical procedures may be a well tolerated approach for the patient if neurosurgeons and neuroanesthesiologists undergo a strict team protocol, including all necessary monitoring and meticulously followed.

Endoscopic odontoidectomy for brainstem compression in association with posterior fossa decompression and occipitocervical fusion.

OBJECTIVE: Endonasal endoscopic odontoidectomy (EEO) is an alternative to transoral surgery for symptomatic ventral compression of the anterior cervicomedullary junction (CMJ), allowing for earlier extubation and feeding. Because the procedure destabilizes the C1-2 ligamentous complex, posterior cervical fusion is often performed concomitantly. The authors' institutional experience was reviewed to describe the indications, outcomes, and complications in a large series of EEO surgical procedures in which EEO was combined with posterior decompression and fusion. METHODS: A consecutive, prospective series of patients who underwent EEO between 2011 and 2021 was studied. Demographic and outcome metrics, radiographic parameters, extent of ventral compression, extent of dens removal, and increase in CSF space ventral to the brainstem were measured on the preoperative and postoperative scans (first and most recent scans). RESULTS: Forty-two patients (26.2% pediatric) underwent EEO: 78.6% had basilar invagination, and 76.2% had Chiari type I malformation. The mean ± SD age was 33.6 ± 3.0 years, with a mean follow-up of 32.3 ± 4.0 months. The majority of patients (95.2%) underwent posterior decompression and fusion immediately before EEO. Two patients underwent prior fusion. There were 7 intraoperative CSF leaks but no postoperative CSF leaks. The inferior limit of decompression fell between the nasoaxial and rhinopalatine lines. The mean ± SD vertical height of dens resection was 11.98 ± 0.45 mm, equivalent to a mean ± SD resection of 74.18% ± 2.56%. The mean increase in ventral CSF space immediately postoperatively was 1.68 ± 0.17 mm (p < 0.0001), which increased to 2.75 ± 0.23 mm (p < 0.0001) at the most recent follow-up (p < 0.0001). The median (range) length of stay was 5 (2-33) days. The median time to extubation was 0 (0-3) days. The median time to oral feeding (defined as, at minimum, toleration of a clear liquid diet) was 1 (0-3) day. Symptoms improved in 97.6% of patients. Complications were rare and mostly associated with the cervical fusion portion of the combined surgical procedures. CONCLUSIONS: EEO is safe and effective for achieving anterior CMJ decompression and is often accompanied by posterior cervical stabilization. Ventral decompression improves over time. EEO should be considered for patients with appropriate indications.

Intraoperative sealing of dura mater defects with a novel, synthetic, self adhesive patch: application experience in 25 patients.

BACKGROUND: The quest for an ideal sealant for dura mater defects persists. The clinical experience with a novel, synthetic self-adhesive patch (TissuePatchDural(®), Tissuemed, Leeds, UK) and its ability to prevent postoperative cerebrospinal fluid (CSF) leakage is described in this article. METHODS: A recently developed, synthetic, self adhesive patch was implanted in 25 patients who underwent intradural neurosurgical procedures. The indication for use was to adjunctively seal dura mater defects. The device is a multi-laminate consisting of thin films of a commonly used structural polymer, poly(lactide-co-glycolide) and a tissue reactive polymer providing fast and strong chemical bonding of the patch with the underlying biological surface. Intraoperative handling and efficacy, biocompatibility, and postoperative observations/follow-up were analysed. Infectious complications, surgical wound features, and postoperative MRI scans were especially reviewed. The mean follow up period was 4.4 months. RESULTS: The device provided fast and efficacious sealing of circumscribed dura mater defects within 1 minute in 23 patients (92%). Two of 25 patients developed a postoperative CSF leakage (8%), which may be secondary to particular factors predisposing these patients to CSF leaks. Surgical handling was straightforward. No infectious complications were recorded; furthermore, wound healing was unremarkable. No clinical evidence of foreign body reactions was observed. In 18 patients, postoperative MRI scans were available which did not show irregularities in any case. CONCLUSIONS: Safe and effective sealing can be accomplished with this bioabsorbable, purely synthetic and thin dural sealant, avoiding the application of foreign biologic material. The product has been shown to be effective in achieving watertight closure of the dura mater and has prevented CSF leakage in 92% of patients treated.

[Endoscopic treatment for fourth ventricular outlet obstruction].

OBJECTIVE: To explore the therapeutic efficacies of endoscope for fourth ventricular outlet obstruction (FVOO). METHODS: Endoscopic third ventriculostomy (ETV) was performed for 30 cases. The circumstances of third ventricular floor and basal cistern were observed and recorded intra-operatively. Meanwhile the fourth ventricular exploration and fistulation were performed across enlarged aqueduct. And the velocity and flow rate of aqueduct, fourth ventricular outlet and stoma were evaluated post-operatively with Cine-MR (magnetic resonance). RESULTS: Standard ETV was performed successfully in 28 patients. Fourth ventricular exploration (n = 6) and outlet membrane fistulation (n = 2) were carried out. The mean follow-up period was 2.3 years (range: 0.5 - 4.0). The overall success rate was 78.6%. CONCLUSION: ETV is a viable therapeutic option for FVOO patients. The therapeutic effects of outlet membrane fistulation require further observations.

[Application of SPECT/CT in neurosurgical practice].

The paper presents the experience of application of single-photon emission computed tomography (SPECT) and CT in neurosurgery. Combination of these two techniques in the single system provides higher precision of both methods. The novel technique allows assessment of tumor spread in the brain, differential diagnosis of tumor regrowth and radiation-induced necrosis, evaluation of cerebral perfusion in epilepsy, traumatic brain injury (TBI), and diagnostics of secondary CNS lesions. Examples of primary diagnosis, dynamic follow-up and differential diagnosis of cerebral neoplasms, localization of epileptogenic foci in planning of surgery, prediction of outcome after TBI and evaluation of spread of metastatic skeletal involvement and further application of acquire data are presented.

[A case of late-onset aqueductal membranous occlusion and a successful treatment with neuro-endoscopic surgery].

A 57 year-old man developed broad-based unsteady gait and memory loss over a period of one year. On admission, bradykinesia and impairment of postural reflex were evident. Mini-mental state examination scored 27/ 30. Urinary control was normal. MRI revealed symmetric dilatation of lateral and 3rd ventricles, but the 4th ventricle appeared normal. Partial obstruction of the aqueduct with a membranous structure was disclosed by fast imaging employing steady state acquisition (FIESTA), and the diagnosis of late-onset aqueductal membranous occlusion (LAMO) was made. The symptoms were ameliorated shortly after endoscopic aqueductoplasty (EAP) and endoscopic third ventriculostomy (ETV). Membranous occlusion of the aqueduct can be detected by FIESTA and it can be cured by neuro-endoscopic measures.

Integrated care pathways in neurosurgery: A systematic review.

INTRODUCTION: Integrated care pathways (ICPs) are a pre-defined framework of evidence based, multidisciplinary practice for specific patients. They have the potential to enhance continuity of care, patient safety, patient satisfaction, efficiency gains, teamwork and staff education. In order to inform the development of neurosurgical ICPs in the future, we performed a systematic review to aggregate examples of neurosurgical ICP, to consider their impact and design features that may be associated with their success. METHODS: Electronic databases MEDLINE, EMBASE, and CENTRAL were searched for relevant literature published from date of inception to July 2020. Primary studies reporting details of neurosurgical ICPs, across all pathologies and age groups were eligible for inclusion. Patient outcomes in each case were also recorded. RESULTS: Twenty-four studies were included in our final dataset, from the United States, United Kingdom, Italy, China, Korea, France, Netherlands and Switzerland, and a number of sub-specialties. 3 for cerebrospinal fluid diversion, 1 functional, 2 neurovascular, 1 neuro-oncology, 2 paediatric, 2 skull base, 10 spine, 1 for trauma, 2 miscellaneous (other craniotomies). All were single centre studies with no regional or national examples. Thirteen were cohort studies while 11 were case series which lacked a control group. Effectiveness was typically evaluated using hospital or professional performance metrics, such as length of stay (n = 11, 45.8%) or adverse events (n = 17, 70.8%) including readmission, surgical complications and mortality. Patient reported outcomes, including satisfaction, were evaluated infrequently (n = 3, 12.5%). All studies reported a positive impact. No study reported how the design of the ICP was informed by published literature or other methods. CONCLUSIONS: ICPs have been successfully developed across numerous neurosurgical sub-specialities. However, there is often a lack of clarity over their design and weaknesses in their evaluation, including an underrepresentation of the patient's perspective.

Primary extradural hydatid cyst associated with nephrotic syndrome in a pediatric patient.

BACKGROUND: Primary intracranial extradural hydatid cyst is a very rare entity. Overlying bony erosion and extension of an extradural hydatid cyst into the scalp has never been described in literature. Association of nephrotic syndrome is described in pulmonary and hepatic hydatid cysts, but never reported in intracranial hydatidosis. CASE REPORT: We report a 6-year-old girl with primary extradural hydatid cyst having unusual radiological features. The child initially presented with features of nephrotic syndrome. Steroid therapy failed to achieve complete remission of the nephrotic syndrome, which was later abolished by cyst removal and albendazole therapy. CONCLUSION: Because of the very slow increase in the volume of the extradural hydatid cyst, intensification of symptoms may also be very slow. Sometimes, the cyst may already be very large at the time of the diagnosis. The hydatid disease should be considered in the etiology of nephrotic syndrome especially in the endemic zones.