Syringopleural shunt for refractory syringomyelia: how I do it.

BACKGROUND: Surgical treatment of syringomyelia is directed at the reconstruction of the subarachnoid space and restoration normal cerebrospinal fluid flow. Direct intervention on the syrinx is a rescue procedure and should be offered to patients with refractory syringomyelia. METHODS: We provide an overview on indications and technique of syringopleural shunt (SPS). The procedure involves the connection of syrinx with the pleural space using a lumboperitoneal shunt. The occurrence of a negative pressure inside the pleural compartment offers an appropriate gradient for drainage from the syrinx. CONCLUSIONS: The SPS allows for a safe and effective treatment of persistent syringomyelia when management of the underlying cause does not yield substantial improvement.

Clinical outcome after microvascular decompression for trigeminal neuralgia: a systematic review and meta-analysis.

Microvascular decompression (MVD) is considered an effective treatment for trigeminal neuralgia (TN). However, the anatomical and clinical variables associated with a better outcome are not fully examined. The authors performed a systematic review and meta-analysis of the literature investigating the immediate and long-term clinical results of MVD for TN, and the impact of the anatomical features of the neurovascular conflict on the outcome. The systematic search of three databases was performed for studies published between January 1990 and November 2021. PRISMA guidelines were followed. Random-effects meta-analysis was used to pool the analyzed outcomes, and random-effect meta-regression was used to examine the association between the effect size and potential confounders. A funnel plot followed by Egger's linear regression was used to test publication bias. A total of 9 studies were included in this analysis, including 2102 patients with trigeminal neuralgia. The immediate post-operative rate of BNI I was 82.9%, whereas surgical failure (BNI IV-V) was reported in approximately 2.6% of patients. CSF leak was the most common postoperative complication (2.4%). The rate of BNI I at last follow up was 64.7% (p < 0.01), showing a significant negative correlation after multiple meta-regression with the rate of patients with isolated venous conflict (p < 0.01). On the other hand, the evidence of an arterial conflict proved is positive association with a favorable outcome (p < 0.01). At the last follow-up, BNI IV-V was reported in 19.2% (95% CI 8.9-29.5%, p < 0.01, I2 = 97.3%). This meta-analysis confirms the safety and efficacy of MVD for TN. The occurrence of serious postoperative complications is very low. The long-term outcome is associated with the type of vascular structure involved, being pure venous conflict associated with a higher risk of surgical failure. These findings should be considered when planning surgery for patients with TN.

Microvascular decompression for trigeminal neuralgia due to vertebrobasilar artery compression: a systematic review and meta-analysis.

Trigeminal neuralgia (TN) caused by vertebrobasilar artery (VBA) compression is a rare event, reported between 2 and 6% (Linskey et al. J Neurosurg 81:1-9,1992, Vanaclocha et al.World Neurosurg 96:516-529,2016) of the time. Microvascular decompression (MVD) is advised for drug-resistant pain and, although technically challenging, is associated with an excellent outcome in current literature (Apra et al.Neurosurg Rev 40:577-582,2017, Cruccuet al. EurJ Neurol 15:1013-1028,2008, Linskey et al. J Neurosurg 81:1-9,1992). The authors performed a systematic review and meta-analysis of the literature examining the rate of MVD for trigeminal neuralgia caused by VBA compression and the post-operative outcome. The systematic search of three databases was performed for studies published between January 1990 and October 2020. Random-effects meta-analysis was used to pool the analyzed outcomes, and random-effects meta-regression was used to examine the association between the effect size and potential confounders. Funnel plot followed by Egger's linear regression was used to test publication bias. We included 9 studies, and the overall rate of TN due to VBA compression was 3.4% (95% CI 2.5-4.3%, p < 0.01, I2 = 67.9%) among all MVD for TN. Immediately after surgery, 96% (p < 0.01, I2 = 0%) of patients were pain-free, and at last follow-up, approximately 93% (p < 0.01, I2 = 0%) of patients were classified as BNI I-II. Hearing impairment and facial numbness were the most common long-term complications ensuing MVD for VBA compression (5% and 13%, respectively). In conclusion, the surgical management of trigeminal neuralgia caused by VBA compression is associated with good outcome and low rate of post-operative complications. Further studies are needed to analyze the long-term results and the rate of pain recurrence among this population.

Is DAT imaging abnormality in normal pressure hydrocephalus always suggestive of degeneration?

Idiopathic normal pressure hydrocephalus (iNPH) is a debated entity with controversial pathogenesis, diagnostic criteria, and predictors of response after ventriculoperitoneal shunt (VPS). Parkinsonian signs are frequently reported in the clinical picture, sometimes due to the coexistence of an underlying neurodegenerative parkinsonism and sometimes in the absence thereof. To distinguish these two scenarios is crucial, since they may carry different long-term response to CSF drainage. 123I-FP-CIT-SPECT was believed to be helpful in this regard, however its role in predicting surgical outcome has been disputed. We illustrate a patient presented with gait disturbance, urinary incontinence, and asymmetrical parkinsonian signs, who underwent a 3T brain MRI and a 123I-FP-CIT-SPECT. VPS was performed. The patient repeated a 123I-FP-CIT-SPECT, 18 months after the operation, and was clinically followed up for 24 months. Our patient displayed clinical and radiological criteria for iNPH and an abnormal asymmetrical uptake in 123I-FP-CIT-SPECT, consistent with her asymmetrical parkinsonism. However, the organization of the substantia nigra studied with iron-sensitive sequences in 3T brain MRI scan appeared intact. The patient revealed an improvement both clinically and in 123I-FP-CIT-SPECT at postsurgical follow-up. Our report suggests that abnormal 123I-FP-CIT-SPECT may not necessarily reveal an overlap with neurodegenerative parkinsonism; its partial reversibility may suggest that the mechanical effect exerted on the striatum by ventriculomegaly ultimately leads to downregulation of dopaminergic transporters which may improve after VPS.

Radiological outcome after surgical treatment of syringomyelia-Chiari I complex in adults: a systematic review and meta-analysis.

Foramen magnum decompression (FMD) is widely accepted as the standard treatment for syringomyelia associated with Chiari type I malformation (CMI). Despite extensive clinical investigations, relevant surgical details are still matter of debate. The authors performed a systematic review and meta-analysis of the literature examining the radiological outcome of syringomyelia in adult patients with CMI after different surgical strategies. PRISMA guidelines were followed. A systematic search of three databases was performed for studies published between 1990 and 2018. Our systematic review included 13 studies with a total of 276 patients with CMI associated with syringomyelia. Overall, the rate of post-operative radiological improvement at last follow-up was 81.1% (95% CI 73.3-88.9%; p < 0.001; I2 = 71.4%). The rate of post-operative syrinx shrinkage did not differ significantly among both groups of decompression with the extra-arachnoidal technique and arachnoid dissection (90%, 95% CI 85.1-94.8%, I2 = 0% vs 79.8%, 95% CI 61.7-98%, I2 = 85.5%). A lower rate of post-operative radiological syrinx shrinkage was observed after decompression with splitting of the outer layer of the dura (55.6% 95% CI 40.5-70.8%, I2 = 0%). CSF-related complications and infections were similar among the different groups. Our meta-analysis found that FMD with the extra-arachnoidal technique and arachnoid dissection provides similar results in terms of post-operative shrinkage of syringomyelia. Patients undergoing decompression with splitting of the dura presented the lower rate of syrinx reduction. These data should be considered when choosing the surgical approach in adult patients with CMI associated with syringomyelia.

Post-operative morbidity ensuing surgery for insular gliomas: a systematic review and meta-analysis.

The surgical resection of insular gliomas remains a challenge. Middle cerebral artery perforating arteries and deep functional pathways affect the extent of resection and the rate of post-operative morbidity. The authors performed a systematic review and meta-analysis of the literature examining early and permanent post-operative deficits in patients who underwent resection of insular gliomas using awake craniotomy with direct electrical stimulation (DES) versus surgery under general anesthesia. A systematic search of three databases was performed for studies published between 1990 and 2018. Random-effect meta-analysis was used to pool the rate of early and permanent post-operative deficits. Random-effect meta-regression was used to examine the association between the rate of post-operative deficit and the anesthesia protocol. We included eight studies evaluating 227 patients with insular glioma. The rate of permanent sequelae was lower after awake craniotomy with DES (3.5% vs 15.7%; P = .001), and early deficits were lower after surgery under general anesthesia (27.3% vs 47.7%; P = .04). Awake surgery was significantly more common among patients with tumor located within the dominant hemisphere (P < .001). No significant association arose between the rates of post-operative deficits and the use of intraoperative neuronavigation and the neurophysiological monitoring. Furthermore, neither extent of resection nor tumor histology influenced the onset of permanent sequelae. Awake craniotomy with DES is associated with a significantly lower rate of permanent neurological morbidity after an early increase of transient post-operative deficits. These data support the use of awake mapping in insular glioma resection.

IDH wild-type WHO grade II diffuse low-grade gliomas. A heterogeneous family with different outcomes. Systematic review and meta-analysis.

WHO grade II diffuse low-grade gliomas (DLGGs) were recently divided into sub-groups on the basis of their molecular profiles. IDH wild-type (IDH-wt) tumors seem to be associated with unfavorable prognoses due to biological similarities to glioblastomas. The authors performed a systematic review and meta-analysis of literature examining epidemiology, clinical characteristics, management, and the outcome of IDH-wt grade II DLGGs. According to PRISMA guidelines, a comprehensive review of studies published from January 2009 to October 2017 was carried out. The authors identified series that examined the prevalence rate, clinical and radiological characteristics, treatment, and outcome of IDH-wt DLGGs. Variables influencing outcomes were analyzed using a random-effects meta-analysis model. Finally, a meta-regression analysis was performed to examine the impact of therapeutic strategies on the effect-size. Twenty-two studies were included in this systematic review. The IDH-wt prevalence rate was 22.9% (95% CI 18.4-27.4%). The hazard ratio for this molecular subgroup in the DLGGs population was 3.46 (95% CI 2.24-5.36; p < 0.001), and the heterogeneity was significant (I2 = 85%, τ2 = 0.88) (HR range 1.28-376). Nonetheless, publication bias did not affect the analysis (p = 0.176). The meta-regression revealed that the extent of resection and post-operative chemotherapy affected the outcome in the IDH-wt subgroup (p < 0.001 and 0.015, respectively), with no significant association of the HR with the rate of RT or RT + CHT. The prevalence of IDH-wt tumors is approximately 23% of DLGGs. The absence of IDH mutation is associated with a heterogeneous outcome, and its therapeutic relevance for postoperative management remains unclear. Maximal surgical resection improves the overall survival in the DLGGs population, beyond molecular status. Further molecular stratification is needed to better understand IDH-wt behavior and therapeutic response.

Multiple high-grade gliomas: epidemiology, management, and outcome. A systematic review and meta-analysis.

Multiple high-grade gliomas (M-HGGs) are well--separated tumors, differentiated as multifocal (MF) and multicentric (MC) by their MRI features. The authors performed a systematic review and meta-analysis of literature examining epidemiology, clinical and radiological characteristics, management, and the overall survival from M-HGGs. According to PRISMA guidelines, a comprehensive review of studies published between January 1990 and January 2017 was carried out. The authors identified studies that examined the prevalence rate, clinical and radiological characteristics, treatment, and overall survival from M-HGGs in patients with HGG. Data were analyzed using a random-effects meta-analysis model. Finally, we systematically reviewed demographic characteristics, lesion location, and surgical and adjuvant treatments. Twenty-three studies were included in this systematic review. The M-HGGs prevalence rate was 19% (95% CI 13-26%) and the hazard ratio of death from M-HGGs in the HGGs population was 1.71 (95% CI 1.49-1.95, p < 0.0001). The MC prevalence rate was 6% (CI 95% 4-10%), whereas MF prevalence rate was 11% (CI 95% 6-20%) (p < 0.0001). There were no statistically significant differences between MF and MC HGGs in gender, lesion location, histological type, and surgical treatment. Survival analysis of MC tumors showed that surgical resection (gross total resection or subtotal resection) is an independent predictor of improved outcome (HR 7.61 for biopsy subgroup, 95% CI 1.94-29.78, p = 0.004). The prevalence of M-HGGs is approximately 20% of HGGs. The clinical relevance of separating M-HGGs in MF and MC tumors remains questionable and its prognostic significance is unclear. When patient status and lesion characteristics make it safe and feasible, cytoreduction should be attempted in patients with M-HGGs because it improves overall survival.

Refinement of the Transoral Approach to Craniovertebral Junction Malformations.

BACKGROUND: The transoral approach provides the most direct surgical corridor for treatment of congenital bony abnormalities that exert irreducible ventral compression of the cervicomedullary junction. In this paper, based on our experience with the transoral approach over the past three decades, we briefly describe the surgical strategies and the operative nuances that allow effective decompression of the craniovertebral junction (CVJ) while minimizing postoperative morbidity. METHODS: The surgical strategy is dictated by the type and severity of the malformation. Fibre-optic nasotracheal intubation obviates the necessity of preoperative tracheostomy, and avoidance of a soft-palate incision significantly reduces oropharyngeal morbidity. When feasible, the atlas-sparing technique minimizes postoperative instability. The transoral transatlas approach is generally required in patients with severe basilar invagination and allows wider exposure of the anterior CVJ at the price of a higher incidence of postoperative instability. CONCLUSION: The transoral approach is extremely effective in providing excellent decompression of the anterior cervicomedullary junction in patients with fixed malformations. Tailoring the approach to the peculiar anatomy of each malformation reduces iatrogenic instability and minimizes postoperative complications.

Microsurgical anatomy of the sagittal stratum.

BACKGROUND: The sagittal stratum (SS) is a critical neural crossroad traversed by several white matter tracts that connect multiple areas of the ipsilateral hemisphere. Scant information about the anatomical organization of this structure is available in literature. The goal of this study was to provide a detailed anatomical description of the SS and to discuss the functional implications of the findings when a surgical approach through this structure is planned. METHODS: Five formalin-fixed human brains were dissected under the operating microscope by using the fiber dissection technique originally described by Ludwig and Klingler. RESULTS: The SS is a polygonal crossroad of associational fibers situated deep on the lateral surface of the hemisphere, medial to the arcuate/superior longitudinal fascicle complex, and laterally to the tapetal fibers of the atrium. It is organized in three layers: a superficial layer formed by the middle and inferior longitudinal fascicles, a middle layer corresponding to the inferior fronto-occipital fascicle, and a deep layer formed by the optic radiation, intermingled with fibers of the anterior commissure. It originates posteroinferiorly to the inferior limiting sulcus of the insula, contiguous with the fibers of the temporal stem, and ends into the posterior temporo-occipito-parietal cortex. CONCLUSION: The white matter fiber dissection reveals the tridimensional architecture of the SS and the relationship between its fibers. A detailed understanding of the anatomy of the SS is essential to decrease the operative risks when a surgical approach within this area is undertaken.

Surgical management of acute subdural haematomas in elderly: report of a single center experience.

OBJECTIVE: To evaluate the clinical outcome of patients over 70 years old who have received surgical treatment for traumatic acute subdural haematoma (aSDH) in our Neurosurgical Department. We also disclose related surgical and medical costs. METHODS: A retrospective analysis was performed by analyzing the medical records of patients older than 70 who had undergone surgery for evacuation of traumatic aSDH between June 2011 and December 2014. Through univariate and multivariate analyses, we correlated clinical and radiological pre-operatory features with outcome at one and six months after surgery. Overall costs for each patient were recorded. RESULTS: We observed 67 patients, 36 male and 31 female, with a median age of 80.5 years old (range 71-94). The mortality rate at one month and six months after surgery was respectively 55.1% and 67.2% while functional recovery was respectively 10.4% and 13.4%. Multivariate analysis age and Glasgow Coma Score (GCS) are the most significant parameters in relation to clinical outcome. Age greater than 90, shift midline >20 mm and volume of the haematoma >200 cu cm were independent parameters to predict mortality within 10 days of surgery. CONCLUSION: Our study confirms a poor outcome for patients of 70 years and over who received surgical treatment for traumatic aSDH.

Wrapping of intracranial aneurysms: Single-center series and systematic review of the literature.

BACKGROUND: Circumferential wrapping of the aneurysm wall with a variety of materials is a well-known therapeutic approach for the repair of unclippable intracranial aneurysms (IAs). Wrapping materials can stimulate foreign-body inflammatory reactions and parent artery narrowing with resultant ischemic stroke. In this study, a single-center retrospective review of the outcome with wrapping of IAs is presented beside an analysis of existing literature. METHODS: For the institutional analysis, all patients who underwent wrapping of IAs in the last five years were analyzed. For the analysis of the literature, a MEDLINE search between 1990 and the present was performed for clinical series reporting wrapping of IAs. Specifically, the risk of rebleeding, cerebrovascular complications, and the incidence of granuloma formation were evaluated. RESULTS: Two hundred and ninety patients with IA were surgically treated in our department. Fifteen patients (5.2%) underwent wrapping of IA. Early parent artery narrowing occurred in one patient (6.7%) and was associated with ischemic stroke. Delayed cerebrovascular complications, including parent artery narrowing (one case), granuloma formation (one case), and fatal bleeding from an unruptured aneurysm, occurred in three patients (20%). For the review of the literature, 197 cases of wrapped aneurysms were collected. Bleeding after wrapping occurred in 16 (12%) of the patients with ruptured aneurysms. Acute ischemic complications were reported in 7 cases (3.5%) and granuloma formation was observed in 3 patients (1.5%). CONCLUSIONS: These data suggest that the microsurgical wrapping of IAs present a risk of ischemic complications and granuloma formation. Additionally, the rebleeding rate of ruptured aneurysms remains high, although still lower than the natural history of untreated ruptured aneurysms.

The bacterial protein toxin, cytotoxic necrotizing factor 1 (CNF1) provides long-term survival in a murine glioma model.

BACKGROUND: Glioblastomas are largely unresponsive to all available treatments and there is therefore an urgent need for novel therapeutics. Here we have probed the antineoplastic effects of a bacterial protein toxin, the cytotoxic necrotizing factor 1 (CNF1), in the syngenic GL261 glioma cell model. CNF1 produces a long-lasting activation of Rho GTPases, with consequent blockade of cytodieresis in proliferating cells and promotion of neuron health and plasticity. METHODS: We have tested the antiproliferative effects of CNF1 on GL261 cells and human glioma cells obtained from surgical specimens. For the in vivo experiments, we injected GL261 cells into the adult mouse visual cortex, and five days later we administered either a single intracerebral dose of CNF1 or vehicle. To compare CNF1 with a canonical antitumoral drug, we infused temozolomide (TMZ) via minipumps for 1 week in an additional animal group. RESULTS: In culture, CNF1 was very effective in blocking proliferation of GL261 cells, leading them to multinucleation, senescence and death within 15 days. CNF1 had a similar cytotoxic effect in primary human glioma cells. CNF1 also inhibited motility of GL261 cells in a scratch-wound migration assay. Low dose (2 nM) CNF1 and continuous TMZ infusion significantly prolonged animal survival (median survival 35 days vs. 28 days in vehicle controls). Remarkably, increasing CNF1 concentration to 80 nM resulted in a dramatic enhancement of survival with no obvious toxicity. Indeed, 57% of the CNF1-treated animals survived up to 60 days following GL261 glioma cell transplant. CONCLUSIONS: The activation of Rho GTPases by CNF1 represents a novel potential therapeutic strategy for the treatment of central nervous system tumors.

Transoral approach to extradural non-neoplastic lesions of the craniovertebral junction.

BACKGROUND: The transoral approach allows for an unobstructed anterior view of the craniovertebral junction from the lower clivus to C1 and C2. It can be applied to a heterogeneous spectrum of pathological lesions involving this area including craniovertebral junction malformations, atlanto-axial synovial cysts, pseudoarthrosis following odontoid fractures, selected cases of retro-odontoid pannus, and vertical translocation in rheumatoid patients. METHODS: Microsurgical strategy is dictated by the nature and site of the target lesion. Atlas preservation during transoral approach (atlas-sparing technique) minimizes postoperative instability and is suitable for the majority of extradural non-neoplastic lesions of the craniovertebral junction. The transoral trans-atlas approach allows for a wider exposure of the anterior craniovertebral junction, but at the price of a higher incidence of postoperative instability; it is usually required in patients with severe basilar invagination or irreducible vertical translocation in rheumatoid arthritis. CONCLUSIONS: The transoral corridor is an effective route to approach a variety of anterior extradural lesions of the craniovertebral junction. Tailoring the approach to each specific lesion provides the needed exposure whilst limiting postoperative instability.

Use of near-infrared indocyanine videoangiography and Flow 800 in the resectioning of a spinal cord haemangioblastoma.

Haemangioblastomas are hypervascularized tumours. Their surgical management requires a complete resectioning and a prompt handling of the vascular inlets and outlets. The use of intraoperative indocyanine green video angiography (ICG-VAG) depicts the precise vascular pattern for the surgeon. Its use is safe and easy, and the procedure can be repeated during the operation. Here we present a case of spinal haemangioblastoma treated with the aid of intraoperative ICG-VAG and the Flow 800 software. The use of the Flow 800 allowed the surgeon to detect, at a glance, minimal changes in the vascular supply during the dissection. The colour-coded images generated by the Flow 800 increase the ICG-CAG sensitivity, improving the capability to detect changes in vascular patterns.

Clip assisted use of gelatin-thrombin matrix sealant as a rescue procedure to treat a hidden arterial tear.

Major intracranial arteries can be injured during tumor removal. Surgeons routinely manage this event by using either microvascular direct repair, by-pass of the wounded segment or the placement of a sutureless device. These procedures, however, are not always possible due to artery brittleness, deep operating field, vascular configuration, or restricted viewing field. In this particular case, we illustrate an example of innovative use of gelatin-thrombin matrix sealant used to repair a hidden tear of pericallosal-callosomarginal bifurcation. A 49-year-old man underwent resection of a recurrent left frontal glioma. During an attempt to remove a firmly attached portion of the tumor, a tear occured in the pericallosal-callosomarginal bifurcation. The wall defect was repaired with a temporary vascular clip placed on the pericallosal artery and gelatin-thrombin matrix sealant sprayed over the tear. An intraoperative indocyanine videoangiography showed patency of both the pericallosal and callosomarginal arteries. Gelatin-thrombin matrix sealant is useful to control bleeding from an artery when the viewing field is restricted. In some cases, however, blood outflow must first be reduced in order to allow clot formation.

Surgical Treatment of Long-Standing Overt Ventriculomegaly in Adults (LOVA): A Comparative Case Series between Ventriculoperitoneal Shunt (VPS) and Endoscopic Third Ventriculostomy (ETV).

Background: Long-standing overt ventriculomegaly in adults (LOVA) is an uncommon type of adult chronic hydrocephalus. In recent years, conflicting case series described different outcomes after treatment of LOVA with endoscopic third ventriculostomy (ETV) or ventriculoperitoneal shunt (VPS). The aim of this study is to report a single institutional surgical experience of patients with LOVA in order to evaluate the clinical outcome of those patients treated with one or, sometimes, both surgical procedures, analyzing the main clinical features of these patients, before and after surgery. Methods: We conducted a retrospective study on 31 patients with diagnosis of LOVA, who were treated in our University Hospital between December 2010 and October 2020. We reported gender, age, clinical presentation, surgical treatment, and clinical outcome according to the Kiefer index (KI). Evans' index, head circumference, aqueductal stenosis and expanded/destroyed sella turcica were assessed on preoperative MRI. Results: The most common clinical manifestation was gait disturbances (100%) followed by urinary incontinence in 23 (74.2%) patients and cognitive deficits in 22 (71%) patients. On preoperative MRI, the overall mean Evans's Index was 0.49, whereas the overall mean head circumference was 57.3 cm. Twenty-three patients (74.2%) had obliterated cortical sulci, 20 (64.5%) patients had aqueductal stenosis, and 22 (71%) patients had an expanded/destroyed sella turcica on preoperative MRI. Fifteen (48.4%) patients underwent ETV and sixteen (51.6%) were treated with VPS as first surgical procedure. Four (26.6%) out of fifteen patients treated with ETV required a subsequent VPS. The overall median age of patients was 64 (IQR: 54.5-74) and the overall median follow-up was 57 months (IQR 21.5-81.5). Overall morbidity was 22.5%. Mean recovery index (RI), according to KI, was 3.8 ± 4.3 and 2.2 ± 5.6 (p = 0.05) at last follow-up in patients treated with ETV and VPS, respectively. Conclusions: The choice of surgical treatment of LOVA remains under discussion. Although EVT is a tempting option for patients with LOVA, conversion to VP shunt is not uncommon.

Microsurgical Resection of Cervical Intradural Juxtamedullary Solitary Fibrous Tumor: 2-Dimensional Operative Video.

Solitary fibrous tumors (SFTs) are uncommon mesenchymal lesions originally described as pleura-based neoplasms. Intradural juxtamedullary SFTs are rare, hard, and scarcely vascularized and generally present a conspicuous extramedullary exophytic component without dural attachment and nerve root involvement. Gross-total resection is the mainstay of treatment, although the absence of an arachnoidal plane and the firm adherence to the spinal cord make resection challenging. We describe the case of a 74-yr-old female patient presenting with a history of progressive spastic tetraparesis due to a cervical juxtamedullary SFT. The patient was not able to walk and magnetic resonance imaging (MRI) of the cervical spine demonstrated a possible intramedullary lesion at C2-C3 with homogeneous enhancement after gadolinium injection. Given the progressive nature of symptoms, the patient elected to have surgical resection of the tumor. The patient underwent C2-C3 laminoplasty and tumor resection under neurophysiologic monitoring. The tumor presented extremely hard without dural attachment or nerve root involvement and was progressively debulked using microsurgical techniques and ultrasonic aspirator. The identification of a plane between the mass and the spinal cord white matter allowed for a gross total resection. Permanent pathological analysis eventually demonstrated SFT. The patient's neurological condition was unchanged postoperatively. MRI performed 2 mo after the operation demonstrated gross total resection of the lesion. At the 6-mo follow-up visit, the patient was able to walk with assistance. The patient signed the Institutional Consent Form to undergo the surgical procedure and to allow the use of her images and videos for any type of medical publications.

Neuronavigated percutaneous approach to the sphenopalatine ganglion.

The sphenopalatine ganglion (SPG) has been assumed to be involved in the genesis of several types of facial pain, including Sluder's neuralgia, trigeminal neuralgia, persistent idiopathic facial pain, cluster headache, and atypical facial pain. The gold standard treatments for SPG-related pain are percutaneous procedures performed with the aid of fluoroscopy or CT. In this technical note the authors present, for the first time, an SPG approach using the aid of a neuronavigator.