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.

The "state of the art" of intraoperative neurophysiological monitoring: An Italian neurosurgical survey.

Introduction: Intraoperative Neurophysiological Monitoring (IOM) is widely used in neurosurgery but specific guidelines are lacking. Therefore, we can assume differences in IOM application between Neurosurgical centers. Research question: The section of Functional Neurosurgery of the Italian Society of Neurosurgery realized a survey aiming to obtain general data on the current practice of IOM in Italy. Materials and methods: A 22-item questionnaire was designed focusing on: volume procedures, indications, awake surgery, experience, organization and equipe. The questionnaire has been sent to Italian Neurosurgery centers. Results: A total of 54 centers completed the survey. The annual volume of surgeries range from 300 to 2000, and IOM is used in 10-20% of the procedures. In 46% of the cases is a neurologist or a neurophysiologist who performs IOM. For supra-tentorial pathology, almost all perform MEPs (94%) SSEPs (89%), direct cortical stimulation (85%). All centers perform IOM in spinal surgery and 95% in posterior fossa surgery. Among the 50% that perform peripheral nerve surgery, all use IOM. Awake surgery is performed by 70% of centers. The neurosurgeon is the only responsible for IOM in 35% of centers. In 83% of cases IOM implementation is adequate to the request. Discussion and conclusions: The Italian Neurosurgical centers perform IOM with high level of specialization, but differences exist in organization, techniques, and expertise. Our survey provides a snapshot of the state of the art in Italy and it could be a starting point to implement a consensus on the practice of IOM.

Massive bilateral paraclinoidal subdural empyema and parenchymal temporopolar abscess with anatomical infection pathway in a chronic inhaling cocaine-addicted patient: A case report and literature review.

Background: Focal suppurative bacterial infections of the central nervous system (CNS), such as subdural empyemas and brain abscesses, can occur when bacteria enter the CNS through sinus fractures, head injuries, surgical treatment, or hematogenous spreading. Chronic cocaine inhalation abuse has been linked to intracranial focal suppurative bacterial infections, which can affect neural and meningeal structures. Case Description: We present the case of a patient who developed a cocaine-induced midline destructive lesion, a vast bilateral paraclinoidal subdural empyema, and intracerebral right temporopolar abscess due to cocaine inhalation abuse. The infection disseminated from the nasal and paranasal cavities to the intracranial compartment, highlighting a unique anatomical pathway. Conclusion: The treatment involved an endoscopic endonasal approach, followed by a right frontal-temporal approach to obtain tissue samples for bacterial analysis and surgical debridement of the suppurative process. Targeted antibiotic therapy helped restore the patient's neurological status.

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.

Pericranial and scalp rotation flaps for occipitocervical hardware exposure with CSF leak in rheumatoid arthritis patient: A case report and review of the literature.

BACKGROUND: There are several etiologies of craniocervical junction instability (CCJI); trauma, rheumatoid arthritis (RA), infections, tumors, congenital deformity, and degenerative processes. These conditions often require surgery and craniocervical fixation. In rare cases, breakdown of such CCJI fusions (i.e., due to cerebrospinal fluid [CSF] leaks, infection, and wound necrosis) may warrant the utilization of occipital periosteal rescue flaps and scalp rotation flaps to achieve adequate closure. CASE DESCRIPTION: A 33-year-old female with RA, cranial settling, and high cervical cord compression underwent an occipitocervical instrumented C0-C3/C4 fusion. Two months later, revision surgery was required due to articular screws pull out, CSF leakage, and infection. At the second surgery, the patient required screws removal, the application of laminar clamps, and sealing the leak with fibrin glue. However, the CSF leak persisted, and the skin edges necrosed leaving the hardware exposed. The third surgery was performed in conjunction with a plastic surgeon. It included operative debridement and covering the instrumentation with a pericranial flap. The resulting cutaneous defect was then additionally reconstructed with a scalp rotation flap. Postoperatively, the patient adequately recovered without sequelae. CONCLUSION: A 33-year-old female undergoing an occipitocervical fusion developed a postoperative persistent CSF leak, infection, and wound necrosis. This complication warranted the assistance of plastic surgery to attain closure. This required an occipital periosteal rescue flap with an added scalp rotation flap.

Tailoring Endoscopic Approach to Colloid Cysts of the Third Ventricle: A Multicenter Experience.

BACKGROUND: Endoscopic removal of third ventricular colloid cysts has grown in popularity. The biggest issues concern radicality, cure or at least long-term control of the disease, and endoscopic remnants. Technologic advances in instrumentation and introduction of novel tools have greatly improved endoscopic results. Deeper knowledge of surrounding anatomy and awareness that colloid cysts vary in their position (foraminal or retroforaminal) can further improve with the selection of a tailored approach for each patient. METHODS: During the last 12 years, 22 colloid cysts were treated endoscopically in our centers. Cysts were classified into 3 groups: A, foraminal (n = 6); B, foraminal with retroforaminal extension (n = 10); C, retroforaminal (n = 6). The following entry points and trajectories were selected: precoronal foraminal (n = 7), precoronal retroforaminal (n = 4), precoronal combined retroforaminal/foraminal (n = 5), supraorbital foraminal (n = 6). Navigation guidance was used in 17 cases. RESULTS: Major complications resulted in permanent deficits in 1 case, and 2 other patients experienced transient memory impairment. Remnants were noted by surgeon's intraoperative assessment in 6 cases; only 2 remnants were large, whereas the others were small bits of coagulated cyst stem. In 18 cases, no remnant was found on postoperative magnetic resonance imaging. CONCLUSIONS: A traditional precoronal transforaminal approach should be considered only for pure foraminal cysts (group A), as the retroforaminal component is poorly controlled. Retroforaminal cysts (groups B and C) should be resected through a retroforaminal transpellucidum interfornicialis route. A supraorbital transforaminal approach is a more versatile approach suitable for most cases.

Versatility of sub-occipital approach for foramen magnum meningiomas: a single centre experience.

BACKGROUND: Foramen magnum meningiomas (FMM) represent a challenge for neurosurgeons. Multiple surgical strategies have been reported to treat these lesions in their variable location. Contemporary technical innovations allow the utilization of common sub-occipital craniotomy to treat ventrally, ventro-laterally and dorsally located FMMs. We present our technique and experience. METHODS: From November 2004 to November 2015, we treated 14 patients with FMM at the Department of Neurosurgery of the Santa Maria delle Grazie Hospital in Pozzuoli, Naples, Italy. There were 10 females and 4 males, with a mean age of 64.5 years (range, 55-77 years). All patients had high field magnetic resonance imaging (MRI) with contrast enhancement preoperatively, which led to the radiological diagnosis. A sub-occipital craniotomy was performed in all patients as well as the removal of the posterior arch of C1. Partial removal of C2 was necessary in 2 patients. Neck pain was the most common symptom of presentation. Paraparesis was present in patients in 3 patients. Upper limbs dysesthesia or pain existed in 3 cases. RESULTS: Thirty days after surgery neck pain and dysesthesia decreased in all patients affected. Neurological improvement was observed in 2 patients affected by weakness in lower limbs at 6 months follow up. Paraparesis was unchanged in 1 patient. Two patients presented transient worsening after surgery. Transient dysphagia occurred in one case and postoperative hemorrhage with subsequent surgery in another patient. We had no postoperative mortality. CONCLUSIONS: FMM surgery should be tailored to the lesion at hand as in most instances it is possible to avoid the use of extensive skull base approaches.

Combined intra-extradural approach for posterolateral thoracic disk herniations. Preliminary study and technical note.

Purpose Thoracic disk herniation is uncommon. It still represents a challenge for spinal surgeons. Multiple surgical strategies are available and, often, they are matter of debate. We describe a preliminary experience about a combined extra-intra dural approach for posterolateral disk herniation in patients affected by spinal cord compression. METHODS: We performed a combined extra-intra dural approach in two preliminary cases. We performed bilateral laminectomy of adjacent vertebrae and unilateral partial medial arthrectomy of the involved segment. After a lateral extradural diskectomy, we, subsequently, performed a median longitudinal durotomy. The conflict between disk herniation and spinal cord was identified. We removed disk herniation moving disk fragments in the extradural compartment without ventral spinal dura opening. RESULTS: We solved spinal cord compression in both cases. Postoperative neurological improvement was observed in both cases. No major complications were observed. CONCLUSION: Our preliminary results are probably insufficient to establish surgical criteria but offer another surgical perspective to especially treat patients with contraindication to anterior approaches.

Adult idiopatic occlusion of Monro foramina: intraoperative endoscopic reinterpretation of radiological data and review of the literature.

Adult idiopathic occlusion of the foramen of Monro (AIOFM) is a rare condition, with only few cases described in the modern literature. We propose that AIOFM may result from unilateral or bilateral occlusion of Monro foramina, as well as from progression of a monolateral hydrocephalus. Different surgical strategies may be required for effective treatment according to the type of occlusion. To date, only 12 cases of AIOFM have been reported in the literature. We report the cases of two patients, aged 20 and 47 years respectively, who presented with intracranial hypertension secondary to bilateral ventricular dilatation due to obstruction at the level of the foramen of Monro. Both patients were successfully treated with endoscopic fenestration of the primarily obstructed foramen of Monro and, in one patient, fenestration of the septum. We propose that septum pellucidum displacement could play a role in the occlusion of the second foramen of Monro. AIOFM can, therefore, result also from unilateral stenosis of Monro. The difference in AIOFM (i.e. unilateral vs bilateral) will be useful in guiding the most suitable surgical approach in this rare condition.

Current state and future development of intracranial neuroendoscopic surgery.

Since the introduction of the modern, smaller endoscopes in the 1960s, neuroendoscopy has become an expanding field of neurosurgery. Neuroendoscopy reflects the tendency of modern neurosurgery to aim towards minimalism; that is, access and visualization through the narrowest practical corridor and maximum effective action at the target point with minimal disruption of normal tissue. Transventricular neuroendoscopy allows the treatment of several pathologies inside the ventricular system, such as obstructive hydrocephalus and intra-/paraventricular tumors or cysts, often avoiding the implantation of extracranial shunts or more invasive craniotomic approaches. Endoscopic endonasal transphenoidal surgery allows the treatment of pathologies of the sellar and parasellar region, with the advantage of a wider vision of the surgical field, less traumatism of the nasal structures, greater facility in the treatment of possible recurrences and reduced complications. However, an endoscope may be used to assist microsurgery in virtually any kind of neurosurgical procedures (endoscope-assisted microsurgery), particularly in aneurysm and tumor surgery. Basic principles of optical imaging and the physics of optic fibers are discussed, focusing on the neuroendoscope. The three main chapters of neuroendoscopy (transventricular, endonasal transphenoidal and endoscope-assisted microsurgery) are reviewed, concerning operative instruments, surgical procedures, main indications and results.

Intraepithelial carcinoma arising in an endodermal cyst of the posterior fossa.

Endodermal cysts of the central neuraxis are benign, non-neoplastic epithelium-lined cysts arising from endodermal tissue that have been displaced early in fetal life. Intracranial endodermal cysts are rare and usually located in the posterior fossa. The present study involves a 36-year-old man with a typical epithelial cyst in the posterior fossa. Microscopically, the cyst has a simple columnar epithelium with mucus-producing cells, containing an area composed of dysplastic epithelium with evidence of an intraepithelial carcinoma. The atypical cells have a high proliferative fraction demonstrated by Ki-67 immunostain. Based on these findings, the authors view this case as evidence of a malignant transformation of a classic endodermal cyst. The clinicopathologic features and a review of the literature are discussed.