Role of sodium fluorescein in pediatric low-grade glioma surgery: an update.

PURPOSE: Complete surgical resection is still the mainstay in the treatment of central nervous system low-grade tumors, eventually resulting curative. The complete surgical removal of these lesions, however, may be difficult in some cases because of their infiltrative nature. Intraoperative adjuncts may be a game changer. Sodium fluorescein (SF) is among the ideal candidates as intraoperative tools to favor the actual recognition of the tumor extension, since it accumulates in areas of altered blood-brain barrier, a typical characteristic of pediatric gliomas, and has a low rate of adverse events. This work proposes an update of previous works about the evaluation of the feasibility and usefulness of a systematic use of SF in a low-grade lesion group of pediatric patients. METHODS: Pediatric patients operated on for a resection or a biopsy of a low-grade glial or glioneuronal lesion (WHO grade I and II) at our Institution between September 2021 and December 2023, with the intraoperative use of sodium fluorescein (SF), were enrolled in the study. We collected pre-operative and postoperative clinical and radiological data, intraoperative findings, and post-operative pathological diagnoses. RESULTS: No adverse events were registered related to the intraoperative use of SF. SF appeared useful for the localization of boundaries of tumors, especially when characterized by a high degree of infiltration or by a deep-seated location, and for the checking of possible tumor remnants at the end of surgery. A good tumor-to-healthy tissue contrast was registered when tumor visualization was in a range between 1 to 2 h and 30 min after SF injection. Possible "false positives" due to intraoperative vascular wall injury and clearance of SF from both tumor and healthy tissue were observed in some cases and still remain open issues. CONCLUSIONS: SF is a feasible and safe intraoperative adjunct tool in the surgical removal of pediatric low-grade tumors. SF may show its usefulness especially in selected cases, such as deep-seated lesions and infiltrating tumors. Its safety profile, user-friendly management, and potential utility in both tumor resections and neuronavigated biopsies favor its wider use in the surgical treatment of pediatric low-grade tumors.

Updates on Intraoperative Neurophysiology During Surgery for Spinal Dysraphism.

Spinal dysraphism is a group of disorders resulting from an embryologic failure of spinal cord development which can lead to a radicular-medullary mechanical stretch that generates vascular compromise and hypoxic-ischemic damage to the nervous structures of the conus-cauda region.Thus, the clinical relevance of the different types of spinal dysraphism is related to the possible neurologic deficits resulting from spinal cord tethering. The clinical presentation is heterogenous: from asymptomatic to very compromised patients. The indications and the time of a detethering surgery are still subject of debate, although there is an agreement on the high standards of treatment that have to be offered by the surgery. Intraoperative neurophysiology (ION) contributes to the safety of tethered cord surgery in reducing the risks of iatrogenic neurological damages.

Selective dorsal rhizotomy: functional anatomy of the conus-cauda and essentials of intraoperative neurophysiology.

INTRODUCTION: Spasticity is the result of an exaggeration of the monosynaptic muscle stretch reflex due to lesions affecting the central nervous system, in particular an upper motor neuron lesion. Selective dorsal rhizotomy (SDR) is a surgical technique developed to treat spastic diplegia, one of the common forms of cerebral palsy, resulting from the lack of supraspinal inhibitory controls. The aim of SDR is to identify and cut a critical amount of the sensory rootlets, in particular those contributing the most to spasticity, in order to relieve the patient from lower limb spasticity while preserving motor strength and sphincter control. Various surgical techniques to perform SDR have been proposed over time. Similarly, intraoperative neurophysiology (ION)-first introduced by Fasano and colleagues in 1976-is a safe and effective tool to guide the surgeon in the procedure of SDR, but different ION strategies are used by different authors, and the value of ION itself has been questioned. METHODS: The purpose of this paper is to review the anatomo-physiological background of SDR, the historical development of the surgical technique, and the essential principles of ION. RESULTS: While some surgeons privilege a single-level approach and others a multi-level approach, nowadays, there are still neither agreement nor guidelines on the percentage of roots to be cut. Rather, a tailored approach based on both the preoperative functional status as well as intraoperative ION findings seems reasonable. ION is considered not essential to decide the percentage of roots to cut, but it assists to distinguish between ventral and dorsal roots, and to preserve sphincterial function, whenever S2 rootlets are included in SDR. CONCLUSIONS: To optimize the balance between reduction of spasticity and preservation of motor strength while minimizing the neurological damage remains the main goal of SDR.

Evaluation of a commercial Model Based Iterative reconstruction algorithm in computed tomography.

INTRODUCTION: Iterative reconstruction algorithms have been introduced in clinical practice to obtain dose reduction without compromising the diagnostic performance. PURPOSE: To investigate the commercial Model Based IMR algorithm by means of patient dose and image quality, with standard Fourier and alternative metrics. MATERIALS AND METHODS: A Catphan phantom, a commercial density phantom and a cylindrical water filled phantom were scanned both varying CTDIvol and reconstruction thickness. Images were then reconstructed with Filtered Back Projection and both statistical (iDose) and Model Based (IMR) Iterative reconstruction algorithms. Spatial resolution was evaluated with Modulation Transfer Function and Target Transfer Function. Noise reduction was investigated with Standard Deviation. Furthermore, its behaviour was analysed with 3D and 2D Noise Power Spectrum. Blur and Low Contrast Detectability were investigated. Patient dose indexes were collected and analysed. RESULTS: All results, related to image quality, have been compared to FBP standard reconstructions. Model Based IMR significantly improves Modulation Transfer Function with an increase between 12% and 64%. Target Transfer Function curves confirm this trend for high density objects, while Blur presents a sharpness reduction for low density details. Model Based IMR underlines a noise reduction between 44% and 66% and a variation in noise power spectrum behaviour. Low Contrast Detectability curves underline an averaged improvement of 35-45%; these results are compatible with an achievable reduction of 50% of CTDIvol. A dose reduction between 25% and 35% is confirmed by median values of CTDIvol. CONCLUSION: IMR produces an improvement in image quality and dose reduction.