Preliminary Experience with 3-Dimensional-Exoscopic Untethering of a Type II Diastematomyelia: Technical Note and Review of the Literature.

OBJECTIVE: To describe the use of a high-definition 3-dimensional (3D) exoscope (VITOM 3D exoscope; KARL STORZ GmbH) for the neurosurgical treatment of a rare pediatric disease, type II diastematomyelia with associated tethered cord. METHODS: A 13-year-old girl who presented with diastematomyelia type II with a tethered cord was surgically treated with the aid of a high-definition 3D exoscope, with a third operator moving and pivoting its arm. Intraoperative monitoring and mapping were arranged. The surgery required a bilateral access to address both the split cord malformation and the tethering of the filum terminale. The filum terminale was identified and cut, and the connective fibrovascular tissue separating the 2 medullary halves was unraveled. These steps were performed with no changes of intraoperative monitoring. Pertinent literature was addressed carefully. RESULTS: The surgery was successful, and the patient was discharged home on the eleventh postoperative day without any complications. The 3-month postoperative magnetic resonance imaging scan demonstrated regular surgical outcomes; no dynamic motor disturbances were reported. To our knowledge, this is the first spinal congenital malformation treated with the use of a 3D exoscope. CONCLUSIONS: The use of 3D exoscope is advancing in spinal surgery, as it provides magnification, stereopsis, lighting, and definition comparable with the operating microscope; the addition of a third operator simplified the operations of moving around the arm, releasing these burdens for the surgeons. Our preliminary experience proved that the use of a 3D exoscope is feasible and safe for the surgical management of a type II diastematomyelia with tethered cord.

A Benefit/Risk Assessment of Intrathecal Ziconotide in Chronic Pain: A Narrative Review.

BACKGROUND: Ziconotide is an intrathecal drug administered for the treatment of chronic pain. The current literature lacks an exhaustive benefit/risk assessment on this drug. We herein focus on Ziconotide's pharmacology and clinical applications. METHODS: Literature research was conducted to identify studies on Ziconotide administration for the treatment of chronic pain, published between January 1990 and March 2023 and located via PubMed, Embase, Medline, Cinahl, and Web of Science, using the following keywords: Ziconotide, Omega conotoxin, Prialt, SNX-111, intrathecal therapy, and neuropathic pain. Only publications written in English were selected. RESULTS: Among the 86 selected studies, we found 4 Randomized Controlled Trials (RCTs) and 3 prospective long-term studies concerning the intrathecal use of Ziconotide as a monotherapy in chronic pain. Other studies described the intrathecal infusion of Ziconotide combined with other drugs. Overall, Ziconotide has been proved to have strong efficacy for relieving chronic pain, although patients with co-morbid psychiatric disorders require a careful monitoring when treated with Ziconotide. CONCLUSIONS: Overall, the use of Ziconotide, as a monotherapy or in conjunction with other therapies for the treatment of chronic pain, was reported to be efficacious. Overall, its use in patients with chronic pain refractory to other pharmacologic agents outweighs the possible adverse consequences, thus resulting in a favorable benefit/risk assessment.

Ultrahigh-Definition-3-Dimensional Exoscope-Assisted Clipping of a Right Middle Cerebral Artery Unruptured Aneurysm with Indocyanine Green Video Angiography: Operative Video.

Ultrahigh-definition 3-dimensional exoscopes represent an excellent technologic innovation in contemporary neurosurgery. They combine the advantages of operating microscopes and endoscopes, offering excellent magnification and lighting, maintaining a relatively small footprint and optimal ergonomic features.1-5 One of the most interesting employments of exoscopes in neurosurgery is represented by intracranial vascular surgery. Reports in this field are still limited, but recent experience has shown that ultrahigh definition 3-dimensional exoscopes for aneurysm surgery are noninferior to operating microscopes for surgery duration, complication rate, and patient outcomes.6 In addition, many intraoperative techniques such as the indocyanine green videoangiography (ICG-VA) have been successfully implemented to exoscope-based surgery.7 We present herein the case of a 66-year-old woman that came to our attention for the incidental finding of 3 unruptured brain aneurysms. After neurosurgical consultation, the one located at the right middle cerebral artery bifurcation was considered eligible for surgery.8,9 As shown in Video 1, ICG-VA was employed after permanent clipping to allow immediate quality assurance of occlusion and distal vessel integrity. Postoperative course was uneventful, and follow-up examinations demonstrated the complete occlusion of the aneurysm. This report highlights the feasibility of exoscopic-based ICG-VA in vascular neurosurgery, given its ease of use, ergonomics, and excellent quality of vision provided to both surgeons and operating staff.

Endoscopic Endonasal Excision of a Cavernous Hemangioma of the Orbital Apex with Cryoprobe Assistance: Two-Dimensional Surgical Video.

Cavernous hemangiomas (CHs) represent the commonest benign orbital lesion in adults, accounting for nearly 6% of overall orbital tumors.1The most common presenting symptoms include unilateral visual deficits, diplopia, ocular muscle impairment, and nonpulsatile proptosis. CHs can be asymptomatic until they reach a considerable size, but when lodged deep in the orbital apex, even small masses may cause severe functional deficits.2 If found incidentally, a wait-and-scan policy is advised. Surgical treatment is indicated in patients with visual impairment or in cases of volumetric increase during the follow-up.3 Among the different surgical corridors to the orbital apex, in the last decade, the endoscopic-assisted approaches, both transpalpebral and endonasal, have emerged as minimally invasive and effective techniques in the skull base surgeon's armamentarium.4 If those lesions are located medially to the optic nerve, the endoscopic endonasal approaches (EEAs) offer several advantages compared with standard craniotomies or orbitotomies.5,6 A 45-year-old woman was admitted to our hospital with symptoms of progressive right visual impairment for 10 months, with radiologic finding of an encapsulated small roundish lesion at the right orbital apex. The mass was completely removed by means of EEA with intraoperative use of a dedicated cryoprobe (Video 1). Histopathologic examination confirmed the CH. At follow-up, the patient experienced complete resolution of her symptoms, with no residues or relapses on magnetic resonance imaging. This case sheds light on the advantages of EEA with the assistance of a cryoprobe, including optimal visualization of the target, lack of external incision, no brain retraction, and short hospital stays.

Endoscopic endonasal approach for infradiaphragmatic craniopharyngiomas: a multicentric Italian study.

OBJECTIVE: Infradiaphragmatic craniopharyngiomas (ICs) represent a distinct subtype, harboring a sellar-suprasellar origin and generally growing in the extra-arachnoidal space contained by the diaphragma sellae. They have been considered ideal for surgical removal through the transsphenoidal approach since the 1960s. The authors present a multicentric national study, intending to selectively analyze IC behavior and the impact of the transsphenoidal endoscopic endonasal approach (EEA) on surgical outcomes. METHODS: Craniopharyngiomas that were intraoperatively recognized as infradiaphragmatic and removed with standard EEA between 2000 and 2021 at 6 Italian neurosurgical departments were included in the study. Clinical, radiological, and surgical findings and outcomes were evaluated and reviewed. RESULTS: In total, 84 patients were included, with 45.23% identified as pediatric cases and 39.28% as having recurrent tumors. The most common presenting symptoms were endocrine (75%), visual (59.52%), and hypothalamic (26.19%) disorders. ICs were classified as extending below (6 intrasellar and 41 occupying the suprasellar cistern) or above (26 obliterating the anterior recesses of the third ventricle and 11 extending up to the foramina of Monro) the chiasmatic cistern. Gross-total resection (GTR) was achieved in 54 cases (64.28%). Tumor extension above the chiasmatic cistern and calcifications were associated with lower likelihood of GTR. The cumulative rate of postoperative complications was 34.53%, with CSF leak being the most common (14.28%). Endocrine, visual, and hypothalamic functions deteriorated postoperatively in 41/78 patients (52.56%), 5/84 (5.95%), and 14/84 (16.67%), respectively. Twenty-eight patients (33.33%) had recurrence during follow-up (mean 63.51 months), with a mean 5-year progression-free survival (PFS) rate of 58%. PFS was greater in patients who achieved GTR than patients with other extent of resection. CONCLUSIONS: This is the largest series in the literature to describe ICs removed with standard EEA, without the need for additional bone and dural opening over the planum sphenoidale. EEA provides a direct route to ICs, the opportunity to manage lesions extending up to the third ventricle without breaching the diaphragma, and high rates of GTR and satisfactory clinical outcomes. Increased surgical complexity and morbidity should be expected in patients with extensive suprasellar extension and involvement of the surrounding vital neurovascular structures.

Endoscopic Endonasal Transethmoidal-Transsphenoidal Approach to a Cavernous Sinus Chondrosarcoma.

Objective We illustrate a cavernous sinus chondrosarcoma treated with an endoscopic endonasal transethmoidal-transsphenoidal approach. Design Case report of a 15-year-old girl with diplopia and esotropia due to complete abducens palsy. Preoperative images showed a right cavernous sinus lesion with multiple enhanced septa and intralesional calcified spots ( Fig. 1 ). Considering tumor location and the lateral dislocation of the carotid artery, an endoscopic endonasal approach was performed to relieve symptoms and to optimize the target geometry for adjuvant conformal radiotherapy. Setting The study was conducted at University of Insubria, Department of Neurosurgery, Varese, Italy. Participants Skull base team was participated in the study. Main Outcome Measures A transethmoidal-transsphenoidal approach was performed by using a four-hand technique. We used a route lateral to medial turbinate to access ethmoid and the sphenoid sinus. During the sphenoid phase, we exposed the medial wall of the cavernous sinus ( Fig. 2 ) and the lesion was then removed using curette. Skull base reconstruction was performed with fibrin glue and nasoseptal flap. Results No complications occurred after surgery, and the patient experienced a complete recovery of symptoms. A postoperative magnetic resonance imaging showed a small residual tumor inside the cavernous sinus ( Fig. 1 ). After percutaneous proton-bean therapy, patient experienced only temporary low-grade toxicity with local control within 2 years after treatment completion. Conclusion Endoscopic endonasal extended approach is a safe and well-tolerated procedure that is indicated in selected cases (intracavernous tumors, soft tumors not infiltrating the vessels and/or the nerves). A tailored approach according to tumor extension is crucial for the best access to the compartments involved. The link to the video can be found at: https://youtu.be/TsqXjqpuOws .

Frameless neuronavigation-assisted brain biopsy with electromagnetic tracking: how I do it?

BACKGROUND: In recent years, thanks to several technological innovations, stereotactic cerebral biopsies have evolved from frame-based to frameless neuronavigation-assisted techniques. METHODS: The authors provide herein a detailed step-by-step description of the technique, shedding light on surgical tips and how to avoid complications. The practical application of the technique is demonstrated with a high-quality video. CONCLUSION: The neuronavigation-assisted brain biopsy with electromagnetic tracking is a "true frameless" procedure. It represents a simple, safe, and effective innovation for frameless biopsy of cerebral lesions. This technique is time efficient, offering a high degree of accuracy required for the establishment of a definitive diagnosis, enabling optimal further treatment, and thus improving patient outcome.

Endoscopic Endonasal Pituitary Hemi-Rotation Approach to the Upper Clivus: Anatomical Study and Clinical Report.

AIM: To report on the endoscopic endonasal pituitary hemi-rotation approach (EPHRA) in a preclinical setting and in a preliminary clinical experience. MATERIAL AND METHODS: EPHRA was performed in five fresh-frozen head and neck specimens (a total of 10 sides) and in a selected case of a right-sided dorsum sellae chordoma. RESULTS: The approach described allowed exposure of the lateral part of the upper clivus in all the specimens and in the case reported. To evaluate the maximum possible degree of hypophyseal hemi-rotation, the hemi-rotation angle (HRA) of the approach was measured and reported for all sides of the specimens. In 9 out of 10 cadaver head sides, and in the clinical case, it was possible to avoid sectioning of the inferior hypophyseal artery. No complications occurred during or after the procedure. CONCLUSION: EPHRA represents an addition to the techniques already described and finds indications in case of non-massive neoformations of the lateral upper clivus. Clinical applications and limitations still need to be clarified in further clinical studies.

Cauda equina syndrome secondary to portal vein thrombosis: case report of favorable outcome with conservative treatment.

Epidural varicosis is a rare though well-known cause of cauda equina syndrome (CES). Although inferior vena cava (IVC) obstruction is the most common finding in such cases, portal vein hypertension can lead to epidural venous plexus engorgement by means of lumbar portocaval shunt activation.A 40-year-old woman presented with right-sided sciatica, which progressed to right foot drop and a 3-day history of vesical tenesmus and fecal retention. She was initially diagnosed with L4-5 lumbar disc protrusion. However, contrast-enhanced lumbar MRI scan showed the presence of epidural varices in the L3-S1 tract. Given the absence of vascular anomalies amenable to resection, etiological conservative treatment was addressed. Therefore, a complete diagnostic workup was performed and revealed deep vein thrombosis (DVT), pulmonary embolism, and portal vein thrombosis. Oral anticoagulant therapy was initiated and prompt resolution of CES was observed. To the authors' knowledge, this is the first report of CES secondary to epidural varicosis in the setting of acute portal vein thrombosis and extrahepatic portal vein obstruction (EHPVO). In cases of epidural varicosis, conservative etiological treatment is the most appropriate choice as CES may be the epiphenomenon of underlying systemic pathophysiological processes.

A novel management proposal for intrinsic brainstem neurenteric cysts: case report.

Neurenteric cysts (NCs) are rare congenital lesions with epithelial mucin-secreting walls. They can occur anywhere along the neural axis, and an intrinsic midbrain cyst is extraordinary. Surgical management may pose a challenge due to the location of the lesion and adhesion of the cyst wall to the surrounding brainstem. The authors describe the first case of pediatric NC that was treated successfully with intracystic interferon-α (IFN-α).A 16-month-old baby girl presented with a 2-week history of progressive croup, vomiting, and swallowing difficulty. MRI revealed a 1.8-cm cystic intrinsic lesion in the pontomedullary region. She initially underwent posterior fossa craniotomy and drainage of the cyst under intraoperative neurophysiology monitoring. Three weeks following the procedure, her symptoms recurred, and follow-up MRI demonstrated cystic recurrence. She underwent repeat aspiration of the cyst and biopsy of the cyst wall, and INF-α-2b was injected into the cystic cavity. Her symptoms improved and completely resolved after 5 months. A 9-month follow-up brain MRI study showed complete resolution of the NC. Intracystic IFN-α injection after cystic content aspiration may be a safe treatment option for the management of intrinsic brainstem NCs. Long-term clinical and radiological follow-up is recommended.

Acute Hydrocephalus Caused by Cerebellar Abscess in HIV-Negative Castleman's Disease.

Castleman's disease (CD) is a rare and indolent hematologic disorder characterized by solitary bulky adenopathy. Multiple nodal nonbulky localizations are described, while central nervous system involvement is rare. Immunodeficiency is associated with higher incidence of CD, and HIV serology should be performed at initial diagnosis. We report the case of a 64-year-old HIV-negative man affected by CD, presenting with acute hydrocephalus caused by a large cerebellar abscess.