Giant Thoracic Meningocele: A Multidisciplinary Surgical Approach with Innovative Exclusion Technique.

Thoracic meningocele is a rare medical condition that is usually linked to neurofibromatosis type I.1 Respiratory and neurologic symptoms characterize it.2 Although there have been some improvements in surgical techniques, the condition has a high recurrence rate, with most cases recurring within a year of surgery.3 A 56-year-old woman was observed due to respiratory and pyramidal signs. A chest computed tomography scan and magnetic resonance imaging revealed a thoracic meningocele, occupying the lower sectors of the right hemithorax, communicating with the cerebrospinal fluid space at the T10-T11 level. Multidisciplinary surgery was performed. After selectively intubating both bronchi, the patient was placed in prone position and a posterior median thoracic spine approach was performed. After T10-T11 laminectomy, 3 dural longitudinal incisions were performed. The first incision was placed in the middle to deflate the collection, the second was made on the right side to obtain a complete view of the meningocele, and the third was made on the right lateral side to exclude the meningocele. The lateral dura at the last incision was sutured to the dura propria lining the vertebral body of T11 and T10. The paramedian and median incisions were closed, with Tachosil placed above and below the sutures. Subsequently, the patient was placed in a supine position, the right lung was deflated, and a triportal thoracoscopic approach was performed to dissect and remove the lesion.4 The breach was closed using Tachosil (Baxter Healthcare Corp, Deerfield, Illinois, USA) and fibrin glue. An early 1-month computed tomography and magnetic resonance imaging confirmed the surgery was successful.

Giant "Dumbbell" Thoracic Schwannoma: Radical Excision of Rare Lesion in One Surgical Time by Combined Neurosurgical and Thoracoscopic Approach.

Dumbbell-shaped schwannomas are slow-growing tumors that are typically benign lesions. They account for 6%-14% of spinal neoplasms, with 30% having intradural and extradural components.1 A schwannoma is considered "giant" if it extends beyond the spine by >2.5 cm and involves more than 2 vertebral levels.2 The Eden classification categorizes these tumors into 4 types on the basis of the primary component.3 Surgery is recommended for individuals experiencing prolonged nerve damage and persistent neurogenic pain that cannot be managed.2 There are 3 surgical options for managing thoracic dumbbell schwannomas4: the single-stage posterior-only approach,5 the single-stage anterior-only approach,6 and the single-stage combined posteroanterior neurosurgical and video-assisted thoracoscopic approach. The latter option allows for the most comprehensive lesion control including vascular and nerve structures and optimal hemostasis control. It also avoids spinal instrumentation and provides certainty for complete tumor removal.7Video 1 shows a surgical procedure performed on a 58-year-old woman to remove a thoracic dumbbell neurinoma. The patient consented to the procedure and publication of her image. A simultaneous thoracoscopic and neurosurgical approach was performed. The surgical team successfully removed the schwannoma, and the patient's recovery was smooth, with no neurologic issues or pain. This case highlights the benefits of using a single-stage combined approach for treating Eden II and Eden III giant dumbbell thoracic schwannomas.

A Root in Synapsis and the Other One in the Gut Microbiome-Brain Axis: Are the Two Poles of Ketogenic Diet Enough to Challenge Glioblastoma?

Glioblastoma is the most frequent and aggressive brain cancer in adults. While precision medicine in oncology has produced remarkable progress in several malignancies, treatment of glioblastoma has still limited available options and a dismal prognosis. After first-line treatment with surgery followed by radiochemotherapy based on the 2005 STUPP trial, no significant therapeutic advancements have been registered. While waiting that genomic characterization moves from a prognostic/predictive value into therapeutic applications, practical and easy-to-use approaches are eagerly awaited. Medical reports on the role of the ketogenic diet in adult neurological disorders and in glioblastoma suggest that nutritional interventions may condition outcomes and be associated with standard therapies. The acceptable macronutrient distribution of daily calories in a regular diet are 45-65% of daily calories from carbohydrates, 20-35% from fats, and 10-35% from protein. Basically, the ketogenic diet follows an approach based on low carbohydrates/high fat intake. In carbohydrates starvation, body energy derives from fat storage which is used to produce ketones and act as glucose surrogates. The ketogenic diet has several effects: metabolic interference with glucose and insulin and IGF-1 pathways, influence on neurotransmission, reduction of oxidative stress and inflammation, direct effect on gene expression through epigenetic mechanisms. Apart from these central effects working at the synapsis level, recent evidence also suggests a role for microbiome and gut-brain axis induced by a ketogenic diet. This review focuses on rationales supporting the ketogenic diet and clinical studies will be reported, looking at future possible perspectives.