The role of extended reality in eloquent area lesions: a systematic review.

OBJECTIVE: The surgical approach to lesions near eloquent areas continues to represent a challenge for neurosurgeons, despite all of the sophisticated tools currently used. The goal of surgery in eloquent areas is to maintain a good oncofunctional balance, that is, to preserve neurological function and ensure maximum tumor resection. Among all the available tools, extended reality (used to describe both virtual reality [VR] and mixed reality) is rapidly gaining a pivotal role in such delicate lesions, especially in preoperative planning, and recently, even during the surgical procedure. VR creates a completely new world in which only digital components are present. Augmented reality (AR), using software and hardware to introduce digital elements into the real-world environment, enhances the human experience. In addition, mixed reality, a more recent technique, combines VR and AR by projecting virtual objects into the real world, allowing the user to interact with them. METHODS: A systematic literature review of the last 23.5 years was conducted (January 2000-June 2023) to investigate and discuss all progress related to the emerging role and use of these new technologies (VR, AR, and mixed reality), particularly in eloquent area lesions as a pre- and/or intraoperative tool. RESULTS: Five hundred eighty-four published studies were identified. After removing duplicates and excluding articles that did not meet the inclusion criteria, 21 papers were included in the systematic review. The use of AR or VR was fully analyzed, considering their roles both intraoperatively and for surgical planning. CONCLUSIONS: The increasing use of such innovative technologies has completely changed the way to approach a lesion, using 3D visualization to foster a better understanding of its anatomical and vascular characteristics.

Improving mixed-reality neuronavigation with blue-green light: a comparative multimodal laboratory study.

OBJECTIVE: This study aimed to rigorously assess the accuracy of mixed-reality neuronavigation (MRN) in comparison with magnetic neuronavigation (MN) through a comprehensive phantom-based experiment. It introduces a novel dimension by examining the influence of blue-green light (BGL) on MRN accuracy, a previously unexplored avenue in this domain. METHODS: Twenty-nine phantoms, each meticulously marked with 5-6 fiducials, underwent CT scans as part of the navigation protocol. A 3D model was then superimposed onto a 3D-printed plaster skull using a semiautomatic registration process. The study meticulously evaluated the accuracy of both navigation techniques by pinpointing specific markers on the plaster surface. Precise measurements were then taken using digital calipers, with navigation conducted under three distinct lighting conditions: indirect white light (referred to as no light [NL]), direct white light (WL), and BGL. The research enlisted two operators with distinct levels of experience, one senior and one junior, to ensure a comprehensive analysis. The study was structured into two distinct experiments (experiment 1 [MN] and experiment 2 [MRN]) conducted by the two operators. Data analysis focused on calculating average and median values within subgroups, considering variables such as the type of lighting, precision, and recording time. RESULTS: In experiment 1, no statistically significant differences emerged between the two operators. However, in experiment 2, notable disparities became apparent, with the senior operator recording longer times but achieving higher precision. Most significantly, BGL consistently demonstrated a capacity to enhance accuracy in MRN across both experiments. CONCLUSIONS: This study demonstrated the substantial positive influence of BGL on MRN accuracy, providing profound implications for the design and implementation of mixed-reality systems. It also emphasized that integrating BGL into mixed-reality environments could profoundly improve user experience and performance. Further research is essential to validate these findings in real-world settings and explore the broader potential of BGL in a variety of mixed-reality applications.

Sonodynamic therapy and magnetic resonance-guided focused ultrasound: new therapeutic strategy in glioblastoma.

Glioblastoma (GB) is one of the most aggressive and difficult-to-treat brain tumors, with a poor prognosis and limited treatment options. In recent years, sonodynamic therapy (SDT) and magnetic resonance focused ultrasound (MRgFUS) have emerged as promising approaches for the treatment of GB. SDT uses ultrasound waves in combination with a sonosensitizer to selectively damage cancer cells, while MRgFUS delivers high-intensity ultrasound waves to precisely target tumor tissue and disrupt the blood-brain barrier to enhance drug delivery. In this review, we explore the potential of SDT as a novel therapeutic strategy for GB. We discuss the principles of SDT, its mechanisms of action, and the preclinical and clinical studies that have investigated its use in Gliomas. We also highlight the challenges, the limitations, and the future perspectives of SDT. Overall, SDT and MRgFUS hold promise as novel and potentially complementary treatment modalities for GB. Further research is needed to optimize their parameters and determine their safety and efficacy in humans, but their potential for selective and targeted tumor destruction makes them an exciting area of investigation in the field of brain cancer therapy.

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

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

The role of neuronal plasticity in cervical spondylotic myelopathy surgery: functional assessment and prognostic implication.

Cervical spondylotic myelopathy (CSM) is a degenerative disease representing the most common spinal cord disorder in the adult population. It is characterized by chronic compression leading to neurological dysfunction due to static and dynamic injury of the spinal cord in cervical spine. These insidious damage mechanisms can result in the reorganization of cortical and subcortical areas. The cerebral cortex can reorganize due to spinal cord injury and may play a role in preserving neurological function. To date, the gold standard treatment of cervical myelopathy is surgery, comprising anterior, posterior, and combined approaches. However, the complex physiologic recovery processes involving cortical and subcortical neural reorganization following surgery are still inadequately understood. It has been demonstrated that diffusion MRI and functional imaging and techniques, such as transcranial magnetic stimulation (TMS) or functional magnetic resonance imaging (fMRI), can provide new insights into the diagnosis and prognosis of CSM. This review aims to shed light on the state-of-the-art regarding the pattern of cortical and subcortical areas reorganization and recovery before and after surgery in CSM patients, underlighting the critical role of neuroplasticity.

Pedicle Screw Placement Aided by C-Arm Fluoroscopy: A "Nevermore without" Technology to Pursue Optimal Spine Fixation.

The surgical technique and the intraoperative technology that support spinal pedicle screw placement have consistently evolved over the past decades to decrease the misplacement rate of pedicle screws. We retrospectively evaluated our case series by analyzing the period 2016-2020. Patients undergoing pedicle screw fixation for cervical, thoracic, or lumbar spine degenerative diseases have been included. Surgery was carried out with the aid of intraoperative 3D C-arm fluoroscopy to assess and optimize screw placement and/or correct possible mispositioning. Each patient underwent a postoperative CT scan. Our aim was to evaluate the safety and accuracy of pedicle screw placement and estimate the variation in mispositioning rates. We carried out 329 surgical procedures, as follows: 70 cervical, 78 thoracic spine, and 181 lumbar spine surgeries. An excellent overall pedicle screw positioning was obtained, with slight differences between the cervical (98.6%), thoracic (100%), and lumbar (98.9%) tracts. Accordingly, only three patients required a revision surgery owing to mispositioning (0.91%). In particular, intraoperative C-arm fluoroscopy significatively improved the accuracy of thoracic screw positioning, as shown by postoperative CT scans. Our experience proves the crucial role of intraoperative C-arm fluoroscopy in pursuing optimal technical results and improving patient outcomes at follow-up.

Fluoroscopy-Assisted Freehand Versus 3D-Navigated Imaging-Assisted Pedicle Screw Insertion: A Multicenter Study.

INTRODUCTION: Pedicle screw placement is a widely accepted surgical procedure for spinal fixation. Despite increases in knowledge about and expertise in pedicle screw insertion techniques, overall reported screw misplacement rates are still high. Spinal neuronavigation and intraoperative computed tomography (CT) imaging improves the accuracy and safety of pedicle screw placement through the continuous monitoring of screw trajectory. The purpose of this study is to compare pedicle screw placement under an O-arm intraoperative imaging system assisted by the StealthStation navigation system with screw placement under conventional fluoroscopy (C-arm). METHODS: For 222 patients, 1288 implanted pedicle screws in total were evaluated between 2018 and 2020. All patients underwent pedicle screw placement in the thoracic and lumbosacral regions through a posterior approach. Moreover, 107 patients (48.2%), 48 men and 59 women, underwent freehand screw placement under conventional fluoroscopy (C-arm group), whereas 115 patients (51.8%), 53 men and 62 women, underwent pedicle screw insertion under O-arm guidance with the help of the StealthStation neuronavigation system (Medtronic Navigation, Louisville, CO, USA) (O-arm group). Data were recorded and retrospectively analyzed. The accuracy of pedicle screw placement was postoperatively examined by using CT imaging and analyzed according to the Gertzbein-Robbins classification. RESULTS: Of the 1288 pedicle screws, 665 (51.6%) were placed with C-arm image-guided assistance with a mean of 6.21 ± 2.1 screws per patient and 643 (48.4%) with O-arm image-guided assistance with a mean of 5.59 ± 1.6 screws. The average time for the screw placement procedure was 3:57 ± 1:07 h in the C-arm group and 4:21 ± 1:41 h in the O-arm group. A correct screw placement was detected in 92.78% of patients in the C-arm group and in 98.13% of patients in the O-arm group. Medial cortical breach was shown in 13 Grade B screws (1.95%), 19 Grade C (2.86%), 14 Grade D (2.11%), and two Grade E (0.3%) in the C-arm group, whereas this was shown in 11 Grade B screws (1.71%) and one Grade C (0.16%) in the O-arm group. Lateral breach occurred in eight screws in both groups. Anterior vertebral body breach was shown in eight screws in the C-arm group, whereas it was shown in four screws in the O-arm group. Reoperation for screw misplacement was mandatory in five patients in the C-arm group and two patients in the O-arm group. CONCLUSION: Pedicle screw placement under an O-arm intraoperative imaging system assisted by spinal navigation showed greater accuracy compared with placement under conventional fluoroscopic control, thus avoiding the onset of major postoperative complications. Notably, a reduction in medial and anterior breaches has been demonstrated.

The Role of Aquaporins in Epileptogenesis-A Systematic Review.

Aquaporins (AQPs) are a family of membrane proteins involved in the transport of water and ions across cell membranes. AQPs have been shown to be implicated in various physiological and pathological processes in the brain, including water homeostasis, cell migration, and inflammation, among others. Epileptogenesis is a complex and multifactorial process that involves alterations in the structure and function of neuronal networks. Recent evidence suggests that AQPs may also play a role in the pathogenesis of epilepsy. In animal models of epilepsy, AQPs have been shown to be upregulated in regions of the brain that are involved in seizure generation, suggesting that they may contribute to the hyperexcitability of neuronal networks. Moreover, genetic studies have identified mutations in AQP genes associated with an increased risk of developing epilepsy. Our review aims to investigate the role of AQPs in epilepsy and seizure onset from a pathophysiological point of view, pointing out the potential molecular mechanism and their clinical implications.

Clinical observations and risk factors for tinnitus in a Sicilian cohort.

The aims of this study were to determine the distribution of risk factors associated with tinnitus analysing their role in the development of tinnitus and the effects of their interaction; to evidence the importance of a suitable and adequate clinical and audiologic assessment to avoid those modifiable risk factors responsible for cochlear dysfunction and tinnitus onset. 46 subjects with tinnitus and 74 controls were studied according to: age, sex, Body Mass Index (BMI), neck circumference, tobacco smoking, feeling fatigue or headache, self reporting snoring, hypertension, diabetes, coronary heart disease, and/or hyperlipidemia, and laboratory finding as lipid profile and levels of reactive oxygen metabolites (d-ROM). Audiological assessment was performed by multi-frequency audiometry (PTA(0.5-16 kHz)) and transient-evoked otoacoustic emissions (TEOAE diagnostic). Univariate analysis was performed to examine the association between determinants and occurrence of tinnitus; Mantel-Haenszel test (G.or) was used to investigate the joint effect of determinants on tinnitus. Tinnitus was more frequent among males with age >50 years; BMI >30 kg/m(2), neck circumference >40 cm, headache, hypertension, hypercholesterolemia resulted significant risk factors for tinnitus (P < 0.0001). Tinnitus group had more comorbidity (P < 0.0001) and worse audiometric thresholds (60.87 Vs 21.62% hearing loss; P < 0.0001) with respect to control group. The interaction between hypertension-BMI ≥ 30 kg/m(2) (G.or = 8.45) and smoking-hypercholesterolemia (G.or = 5.08) increases the risk of tinnitus (P < 0.0001). Our results underline that several factors either individually or jointly contribute to tinnitus onset; a comprehensive knowledge about tinnitus risk factors and associated clinical conditions could contribute to minimizing this disorder.

Multiple Abdominal abscesses following ventriculoperitoneal shunt placement in an immunosuppressed patient: An illustrative case.

Background: Ventriculoperitoneal (VP) shunt placement is one of the most performed procedures in neurosurgery to treat various types of hydrocephalus (HC). Immediate or late postoperative complications may quite commonly occur, especially in immunosuppressed patients, who are predisposed to develop rare and difficult-to-treat conditions. Case Description: Herein, we report the case of a 41-year-old female patient with a prior history of acute myeloid leukemia, followed by a tetra-ventricular acute HC due to a spontaneous non-aneurysmal subarachnoid hemorrhage. After an urgent external ventricular drainage placement, she underwent careful testing of "shunt dependency," which ended with a VP shunt placement. After 2 months, she presented at the emergency department with worsening abdominal pain and fever. She underwent a computed tomography scan with contrast administration, which has shown abscesses in the abdominal cavity. An urgent surgical revision of the VP shunt and antibiotics administration followed this. After inflammatory markers normalization, due to the high risk of post-infective peritoneal adherence and consequent impairment of cerebrospinal fluid absorption, a ventriculoatrial shunt was considered the most appropriate solution. Conclusion: Abdominal abscesses are a rare but subtle complication after VP shunt placement. Their management depends on etiology, patient clinical characteristics, and manifestations. Prompt interventions have been shown to improve clinical outcomes and optimize quality of life in such delicate patients.

Corticocortical Evoked Potentials in Eloquent Brain Tumor Surgery. A Systematic Review.

Eloquent brain tumor surgery involves the delicate task of resecting tumors located in regions of the brain responsible for critical functions, such as language, motor control, and sensory perception. Preserving these functions is of paramount importance to maintain the patient's quality of life. Corticocortical evoked potentials (CCEPs) have emerged as a valuable intraoperative monitoring technique that aids in identifying and preserving eloquent cortical areas during surgery. This systematic review aimed to assess the utility of CCEPs in eloquent brain tumor surgery and determine their effectiveness in improving patient outcomes. A comprehensive literature search was conducted using electronic databases, including PubMed/Medline and Scopus. The search strategy identified 11 relevant articles for detailed analysis. The findings of the included studies consistently demonstrated the potential of CCEPs in guiding surgical decision making, minimizing the risk of postoperative neurological deficits, and mapping functional connectivity during surgery. However, further research and standardization are needed to fully establish the clinical benefits and refine the implementation of CCEPs in routine neurosurgical practice.

The Use of Intraoperative Microvascular Doppler in Vascular Neurosurgery: Rationale and Results-A Systematic Review.

Surgical treatment of neurovascular lesions like intracranial aneurysms, arteriovenous malformations and arteriovenous dural fistulas is still associated with high morbidity. Several recent studies are providing increasing insights into reliable tools to improve surgery and reduce complications. Inadvertent vessel compromise and incomplete occlusion of the lesion represent the most possible complications in neurovascular surgery. It is clear that direct visual examination alone does not allow to identify all instances of vessel compromise. Various modalities, including angiography, microvascular Doppler and neurophysiological studies, have been utilized for hemodynamics of flow vessels in proper clipping of the aneurysm or complete obliteration of the lesion. We intended to review the current knowledge about the intraoperative microvascular Doppler (iMDS) employment in the most updated literature, and explore the most recent implications not only in intracranial aneurysms but also in neurovascular lesions like arteriovenous malformations (AVMs) and arteriovenous dural fistulas (AVDFs). According to the PRISMA guidelines, systematic research in the most updated platform was performed in order to provide a complete overview about iMDS employment in neurovascular surgery. Twelve articles were included in the present paper and analyzed according to specific research areas. iMDS employment could represent a crucial tool to improve surgery in neurovascular lesions. The safety and effectiveness of the surgical treatment of neurovascular lesions like intracranial aneurysm and other neurovascular lesions like AVMs and AVDFs requires careful and accurate consideration regarding the assessment of anatomy and blood flow. Prognosis may depend on suboptimal or incomplete exclusion of the lesion.

Hypothalamic Hemangioma-like Pilocytic Astrocytoma in an Adult Patient: A Systematic Review with a Focus on Differential Diagnosis and Neurological Presentation.

Background: Pilocytic astrocytoma (PCA) are commonly observed as slow-growing noncancerous brain tumors in pediatric populations, but they can also occur in adults, albeit rarely. When located in diencephalic regions, particularly in the hypothalamus, they present unique diagnostic and management challenges due to their rarity and overlapping clinical and radiological features with other intracranial pathologies. This systematic review aims to provide a comprehensive understanding of hypothalamic PCA in adults, focusing on their differential diagnosis, neurological presentation, diagnostic modalities, treatment strategies. A case illustration is also described in order to better underline all the difficulties related to the diagnostic process. Material and methods: A systematic literature search was conducted in the PubMed/MEDLINE, Embase, and Scopus databases up to November 2023 to identify studies. Results: The systematic literature search identified a total of 214 articles. Following screening by title and abstract and full-text review, 12 studies were deemed eligible and are included here. Conclusions: Adult-onset PCA in diencephalic regions pose diagnostic challenges due to their rarity and overlapping features with other intracranial lesions. Advanced imaging techniques play a crucial role in diagnosis, while surgery remains the cornerstone of treatment. Multidisciplinary collaboration is essential for the optimal management and long-term follow-up of these patients.

No evidence of Fabry disease in a patient with the new p.Met70Val GLA gene variant.

BACKGROUND: Fabry disease (FD) is a rare X-linked lysosomal storage disorder caused by variants in GLA gene leading to deficient α-galactosidase A enzyme activity. This deficiency leads to the accumulation of glycosphingolipids, particularly globotriaosylceramide (Gb3), in various tissues and organs, which can result in life-threatening complications. The clinical presentation of the disease can vary from the "classic" phenotype with pediatric onset and multi-organ involvement to the "later-onset" phenotype, which presents with predominantly cardiac symptoms. In recent years, advances in screening studies have led to the identification of an increasing number of variants of unknown significance that have not yet been described, and whose pathogenic role remains undetermined. METHODS: In this clinical report, we describe the case of an asymptomatic adult female who was found to have a new variant of unknown significance, p.Met70Val. Given the unknown pathogenic role of this variant, a thorough analysis of the potential organ involvement was conducted. The clinical data were analyzed retrospectively. RESULTS: The analysis revealed that there were no signs of significant organ involvement, and the benignity of the variant was confirmed. CONCLUSION: This case underscores the importance of a comprehensive evaluation of new variants of unknown significance to establish their pathogenicity accurately.

Large Skull Metastasis in Follicular Thyroid Carcinoma: A Comprehensive Case Presentation and Systematic Review.

BACKGROUND: Skull metastases from follicular thyroid carcinoma (FTC) are infrequent but clinically significant, often presenting with localized pain, neurologic deficits, and cranial nerve dysfunction. Early detection and accurate diagnosis pose challenges due to their asymptomatic nature in some cases. METHODS: A systematic literature review, conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, identified and analyzed 15 relevant studies focusing on large skull metastases in FTC. Data extraction and synthesis included clinical presentation, diagnostic methods, treatment strategies, and patient outcomes. RESULTS: The systematic review encompassed 20 patients with secondary skull metastases from FTC, offering insights into the clinical diversity of this rare condition. Clinical presentations varied, with localized pain (70% of cases) and headaches being predominant symptoms. Imaging techniques, including computed tomography (CT) and magnetic resonance imaging (MRI), played a pivotal role in diagnosis. Surgical resection was considered in select cases, achieving complete or near-complete tumor removal in 30 to 50% of patients. Radiotherapy, including external beam radiation therapy (EBRT) and stereotactic radiosurgery (SRS), provided local control and symptom relief in 70 to 80% of cases. Systemic therapies, such as tyrosine kinase inhibitors (TKIs), showed promise in disease stabilization or regression (45% of patients). Prognosis remained poor, with a median overall survival of 6 to 12 months, reflecting an advanced and aggressive disease state. CONCLUSION: Managing secondary skull metastases from FTC requires a comprehensive approach, including surgical intervention, radiotherapy, and potential systemic therapies. The rarity of these metastases underscores the need for further research to establish standardized treatment guidelines, explore molecular profiling, and investigate immunotherapy and combination therapies, offering hope for improved outcomes in this challenging clinical scenario.

Intraventricular Cerebral Metastases: A Comprehensive Systematic Review.

BACKGROUND/AIM: Intraventricular cerebral metastases (IVCM) are a rare but clinically significant subset of brain metastases. This systematic review aimed to provide a comprehensive analysis of IVCM by synthesizing current literature on epidemiology, clinical presentation, imaging features, pathophysiology, and treatment options. MATERIALS AND METHODS: A systematic literature search was conducted, identifying 11 relevant studies encompassing 11 studies encompassing 842 IVCM cases. Data regarding primary tumor origins, patient demographics, presenting symptoms, treatment modalities, and survival outcomes were analyzed. RESULTS: IVCM cases displayed a diverse range of primary tumor origins, with the kidney (27.4%), thyroid (21.6%), lung (19.8%), colon (11.7%), melanoma (8.4%), and breast ductal carcinoma (7.9%) being common sources. Patients presented with a wide spectrum of symptoms, including headaches (42.3%), nausea (31.5%), altered mental status (25.7%), neurological deficits (18.2%), and others. Treatment approaches varied, encompassing surgical resection (41.2%), radiation therapy (32.5%), chemotherapy (15.3%), and immunotherapy (7.9%). Overall survival was generally limited, with a mean duration of approximately 10.3 months (±8.7 months). The time to recurrence after treatment exhibited considerable variability. CONCLUSION: IVCM represents a challenging and underexplored metastatic disease. This systematic review underscores the need for further research to enhance our understanding of IVCM's pathophysiology and develop tailored diagnostic and treatment approaches. Such efforts are crucial to improving outcomes and the overall quality of life for patients facing this complex condition. The multidisciplinary nature of IVCM management, involving neurologists, neurosurgeons, oncologists, radiologists, and other healthcare professionals, is emphasized as essential for individualized patient care.

Diet and Physical Activity in Adult Dominant Polycystic Kidney Disease: A Review of the Literature.

Autosomal polycystic kidney disease is the most common inherited kidney disease determining 5% of all end-stage kidney disease. The only therapy approved for this condition is Tolvaptan, which, with its aquaretic effect, has a strong effect on patients' daily life. Recently, the literature has been enriched with new works that analyze possible non-pharmacological therapeutic strategies to slow cysts' enlargement and chronic kidney disease progression. Among them, dietary schemes reducing carbohydrate intake and inducing ketoses have been demonstrated to have efficacy in several pre-clinical and clinical studies. A ketogenic diet, calorie restriction, intermittent fasting, and time-restricted feeding can reduce aerobic glycolysis and inhibit the mTOR pathway, producing a reduction in cyst cell proliferation, a reduction in kidney volume, and helping to preserve kidney function. ADPKD's burden of disease has an impact on patients' quality of life, and the possibility to play sports or carry out physical exercise can help people in everyday life. The multisystemic character of the disease, especially cardiovascular involvement, needs to be carefully evaluated to establish the quality and quantity of physical activity that patients can safely carry out.

Spontaneous spinal epidural hematoma in a pediatric hemophiliac.

Background: Spontaneous spinal epidural hematomas (SSEH), unrelated to trauma, epidural anesthesia, or surgery, are rare in the pediatric population. Here, a 1-year-old male with hemophilia presented with a magnetic resonance (MR)-documented SSEH and was successfully treated with a C5-T10 right hemilaminectomy. Case Description: A 1-year-old male with hemophilia presented with quadriparesis. The holo-spine magnetic resonance imaging with contrast showed a posterior cervicothoracic compressive epidural lesion extending from C3 to L1 consistent with an epidural hematoma. He underwent a C5 to T10 right-sided hemilaminectomy for clot removal, following which his motor deficits fully resolved. A literature review of SSEH attributed to hemophilia revealed that 28 of 38 cases were effectively treated conservatively, while only 10 cases warranted surgical decompression. Conclusion: Select patients with SSEH attributed to hemophilia with severe MR-documented cord/cauda equina compromise and significant accompanying neurological deficits may require emergent surgical decompression.

Case of incidental thoracic spinal dumbbell hemorrhagic arachnoid cyst and tentorial metastasis from breast carcinoma.

Background: Spinal arachnoid cysts (SACs) in adults are typically acquired dural defects following trauma, inflammation, or infection. Brain metastases from breast cancer account for 5-12% of all CNS metastases and are mostly leptomeningeal. Here, the authors reported a 50-year-old female treated for a tentorial metastasis from breast carcinoma that underwent chemotherapy and radiotherapy. Three months later, she presented with a thoracic spinal extradural dumbbell hemorrhagic arachnoid cyst. Case Description: A 50-year-old female underwent a left retrosigmoid suboccipital craniectomy for microsurgical removal of a tentorial metastasis attributed to poorly differentiated breast carcinoma (i.e., comedonic pattern). The patient subsequently underwent both chemotherapy and radiotherapy for accompanying bony metastases. Three months later, she experienced the onset of severe posterior thoracic pain. When the thoracic magnetic resonance imaging revealed a hyperintense "dumbbell" extradural T10-T11 lesion, she underwent a T10-T11 laminectomy for marsupialization and excision of the hemorrhagic lesion. The histological examination revealed blood and arachnoid tissue within a benign SAC, without accompanying tumor. Her postoperative course was uneventful, and she was discharged on postoperative day 3. Conclusion: A 50-year-old female underwent a left retrosigmoid suboccipital craniectomy for removal of a tentorial metastasis from breast carcinoma, followed by radiation/chemotherapy. Three months later, she hemorrhaged into an MR-documented T10-T11 dumbell extradural SAC that was successfully treated with laminectomy, marsupialization, and excision.

Coexistent meningioma in a patient with primary familial brain calcification: A case report.

Primary familial brain calcification (PFBC) is an idiopathic pathology characterized by the development of calcific deposits in the supratentorial region such as telencephalon and diencephalon but also, in more extensive forms, in the cerebellum. Meningiomas are among the most common central nervous system (CNS) tumors generally related to a good prognosis. The simultaneous presence of intracerebral or extra-axial tumors and PFBC represents an exceedingly rare occurrence. A 72-year-old female patient was admitted to our department because of anoculogyric crisis followed by generalized seizures. She performed a brain CT scan which showed widespread hyperdensities in the paraventricular supratentorial region, basal ganglia and at the level of bilateral cerebellar dentate nuclei, characteristics of PFBC. Concomitant left frontal and smaller right temporal extra-axial lesions were identified and then confirmed in a brain MRI. The patient underwent a microsurgical resection of the lesion and subsequent histological examination reported a meningothelial meningioma (WHO Grade I). According to our literature review, this is the first paper that reports the coexistence of both intracranial meningiomas and PFBC. To date, it is not possible to provide an exact correlation between pathogenesis and genetic mechanism underlying this association.