Bone Flap Resorption After Cranioplasty: Risk Factors and Proposal of the Flap Integrity Score.

BACKGROUND: Bone flap resorption is a known complication of postdecompressive autologous cranioplasty. Although several potential etiopathogenetic factors have been investigated, their role is still under discussion. To further complicate things, resorption is not an all-or-nothing event, patients frequently presenting with different degrees of flap remodeling. Focus of this paper was to describe the elaboration of a score quantifying bone resorption according to a set of clinical and radiological criteria, hopefully allowing prompt identification of patients needing resurgery before the development of adverse events. METHODS: In a 10-year period, 281 autologous cranioplasties were performed at our institution following decompressive craniectomy. Pertinent clinical and radiological information was registered. A set of 3 clinical and 3 radiological parameters was established to score the degree of resorption, identified under the acronym FIS (Flap Integrity Score). Three groups of patients emerged, respectively showing no (208), partial (32), and advanced (41) resorption. RESULTS: An overall 14.6% incidence of advanced bone resorption was found in our series. Younger age, bone multifragmentation, higher postcranioplasty Glasgow Outcome Scale scores, <2 cm distance of medial craniectomy border from the midline, and cause leading to decompressive craniectomy were associated to a statistically significant higher risk of developing a relevant bone flap resorption. The first three variables were confirmed as risk factors in multivariate analysis. Flap Integrity Score well discriminated the 3 different groups. CONCLUSIONS: Autologous bone repositioning is still a valuable, low-cost, cosmetically and functionally satisfactory procedure. Nonetheless, although resorption affects a minor percentage of patients, its early identification and treatment can improve long-term results.

Surgical Treatment of Complex Craniofacial Fractures.

OBJECTIVE: Severe craniofacial fractures may present different needs in treating intracranial lesions over facial injuries. This paper examines the results of our strategy, consisting of a single-stage combined neurosurgical-maxillofacial treatment. METHODS: A retrospective review was conducted of 33 consecutive patients with complex fractures of the anterior cranial fossa and facial skeleton, who required elective surgery for craniofacial reconstruction. Patients who required emergency surgery for intracranial clots or penetrating wounds were excluded. In all cases, all or almost all the anterior skull-base was injured with compound fractures of the frontal sinus, the orbital roofs, the lamina cribrosa, and the planum sphenoidale. In all cases, the prioritization of treatment was carefully discussed, and surgical timing and strategy were agreed. RESULTS: There was 1 dead. Olfactory injuries were always found intraoperatively. There were no mucoceles, CSF-leak recurrences, cranial infections, or neurologic worsening. The functional and neurologic results were highly satisfactory. CONCLUSIONS: The one-stage surgical treatment of complex craniofacial fractures has numerous advantages, including the possibility of reducing facial fractures without the risk of CSF leaks. It also eliminates the need for repeated procedures in fragile patients, and the need to dismantle the facial reconstruction if the skull base repair is performed later. The main issue is the surgical timing, considering that the maxillofacial surgeon usually favors early facial repair, whereas the neurosurgeon generally prefers delayed manipulation of the contused frontal lobes. A timeframe of 10-14 days after trauma may be a good compromise for safe procedures with excellent neurologic and functional outcomes.

Post-traumatic decompressive craniectomy: Prognostic factors and long-term follow-up.

Background: Decompressive craniectomy (DC) is still controversial in neurosurgery. According to the most recent trials, DC seems to increase survival in case of refractory intracranial pressure. On the other hand, the risk of postsurgical poor outcomes remain high. The present study aimed to evaluate a series of preoperative factors potentially impacting on long-term follow-up of traumatic brain injury (TBI) patients treated with DC. Methods: We analyzed the first follow-up year of a series of 75 TBI patients treated with DC at our department in five years (2015-2019). Demographic, clinical, and radiological parameters were retrospectively collected from clinical records. Blood examinations were analyzed to calculate the preoperative neutrophil-to-lymphocyte ratio (NLR). Disability rating scale (DRS) was used to classify patients' outcomes (good outcome [G.O.] if DRS ≤11 and poor outcome [P.O.] if DRS ≥12) at 6 and 12 months. Results: At six months follow-up, 25 out of 75 patients had DRS ≤11, while at 12 months, 30 out of 75 patients were included in the G.O. group . Admission Glasgow Coma Scale (GCS) >8 was significantly associated with six months G.O. Increased NLR values and the interval between DC and cranioplasty >3 months were significantly correlated to a P.O. at 6- and 12-month follow-up. Conclusion: Since DC still represents a controversial therapeutic strategy, selecting parameters to help stratify TBI patients' potential outcomes is paramount. GCS at admission, the interval between DC and cranioplasty, and preoperative NLR values seem to correlate with the long-term outcome.

Managing Ventriculoperitoneal Shunt Exposure in Adult Patients: Surgical Options and Implant Removal Prevention.

BACKGROUND: Ventriculoperitoneal (VP) shunt exposure is rare. Small series reporting on managing this complication mainly focus on the pediatric population, where wound breaks over cerebrospinal fluid (CSF) chambers are observed most frequently. However, case series on adult patients are missing. METHODS: Between June 2004 and December 2019, 18 patients underwent VP shunt revision due to implant exposure. Pertinent data were retrospectively collected from the hospital database. Their full clinical history, laboratory values, neuroradiological imaging, pretreatment CSF characteristics, photographic and video material, and surgery types were reviewed. RESULTS: The ventricular catheter was exposed in 8 patients (the frontal region in 6 and the occipital region in 2), the valve chamber at the retroauricular region in 6, the shunt tube in 7 (at the neck in 4, the supraclavicular region in 2, and the abdominal incision in 1). Multiple exposure sites were found in 2 cases. Two patients with CSF infections benefitted from system removal and temporary external ventricular drainage until infection control was achieved. The remaining 16 patients underwent on-ward revision (wound curettage, skin mobilisation, and resuture over the exposed part of the shunt), which was effective in 14 patients, but further revision was required in 2 patients. CONCLUSIONS: While rare, VP shunt exposure is a serious complication. In our experience, a prompt and accurate on-ward revision could save the implant in most patients without CSF infections.

Repair of ventricular wall by pericranial flap: a valuable option?

Ventricular walls penetration frequently occurs in periventricular gliomas surgery. Even when aimed at maximal tumor resection, it can lead to several complications, including CSF leak, delayed wound healing and, potentially, distant tumor dissemination, with a negative impact on overall survival. Several authors have claimed damaged ventricular walls always need repair, especially when the additional use of intrathecal chemotherapy is scheduled. Fibrin sponge has been consistently used in the past to address small ventricular walls defects but more recently attention has been focused on TachoSilTM, that seems to be a valid alternative to close up to 1.5 cm gaps. After an accurate review of literature, we were unable to find any report describing the use of autologous pericranium to the same aim. We report the case of a 54 years-old patient who presented with symptoms of intracranial hypotension four weeks after his last surgery (performed at another Institution) for a relapsing right frontal grade III astrocytoma,. Pre-operative MRI showed a huge gap in the roof of the right frontal ventricular horn, associated to a large subdural hygroma and a massive subcutaneous CSF collection. The gap was repaired using a layer of autologous pericranium, sutured by pial stitches to the surrounding brain and reinforced by fibrin glue. Full and permanent leak sealing was obtained within the next 2 weeks, but patient immediately and fully recovered from his symptoms. Although limited by the single case experience, we believe that pericranium might be considered as an alternative to artificial materials in cases of large ventricular walls openings, being easily intraoperatively retrievable, granting maximal biocompatibility, not significantly impacting on surgery duration and overall costs.

Management of infected hydroxyapatite cranioplasty: Is salvage feasible?

Introduction: The use of hydroxyapatite cranioplasties has grown progressively over the past few decades. The peculiar biological properties of this material make it particularly suitable for patients with decompressive craniectomy where bone reintegration is a primary objective. However, hydroxyapatite infection rates are similar to those of other reconstructive materials. Research question: We investigated if infected hydroxyapatite implants could be saved or not. Materials and methods: We present a consecutive series over a 10-year period of nine patients treated for hydroxyapatite cranioplasty infection. Clinical and radiological data from admission and follow-up, photo and video material documenting the different phases of infection assessment and treatment, and final outcomes were retrospectively reviewed in an attempt to identify the best options and possible pitfalls in a case-by-case decision-making process. Results: Five unilateral and four bifrontal implants became infected. Wound rupture with cranioplasty exposure was the most common presentation. At revision, all implants were ossified, requiring a new craniotomy to clean the purulent epidural collections. The cranioplasty was fully saved in one hemispheric and 2 bifrontal implants and partially saved in the remaining 2 bifrontal implants. A complete cranioplasty removal was needed in the other 4 cases, but immediate cranial reconstruction was possible in 2. Skin defects were covered by free flaps in 3 cases. Four patients underwent adjunctive hyperbaric therapy, which was effective in one case. Discussion and conclusion: In our experience, infected hydroxyapatite cranioplasty management is complex and requires a multidisciplinary approach. Salvage of a hydroxyapatite implant is possible under specific circumstances.

Evaluation of prognostic preoperative factors in patients undergoing surgery for spinal metastases: Results in a consecutive series of 81 cases.

Background: Surgical treatment of spinal metastases should be tailored to provide pain control, neurological deficit improvement, and vertebral stability with low operative morbidity and mortality. The aim of this study was to analyze the predictive value of some preoperative factors on overall survival in patients undergoing surgery for spinal metastases. Methods: We retrospectively analyzed a consecutive series of 81 patients who underwent surgery for spinal metastases from 2015 and 2021 in the Clinic of Neurosurgery of Ancona (Italy). Data regarding patients' baseline characteristics, preoperative Karnofsky Performance Status Score (KPS), and Frankel classification grading system, histology of primary tumor, Tokuhashi revised and Tomita scores, Spine Instability Neoplastic Score, and Epidural Spinal Cord Compression Classification were collected. We also evaluated the interval time between the diagnosis of the primary tumor and the onset of spinal metastasis, the type of surgery, the administration of adjuvant therapy, postoperative pain and Frankel grade, and complications after surgery. The relationship between patients' overall survival and predictive preoperative factors was analyzed by the Kaplan-Meier method. For the univariate and multivariate analysis, the log-rank test and Cox regression model were used. P ≤ 0.05 was considered as statistically significant. Results: After surgery, the median survival time was 13 months. In our series, the histology of the primary tumor (P < 0.001), the Tomita (P < 0.001) and the Tokuhashi revised scores (P < 0.001), the preoperative KPS (P < 0.001), the adjuvant therapy (P < 0.001), the postoperative Frankel grade (P < 0.001), and the postoperative pain improvement (P < 0.001) were significantly related to overall survival in the univariate analysis. In the multivariate analysis, the Tomita (P < 0.001), Tokuhashi revised scores (P < 0.001), and the adjuvant therapy were confirmed as independent prognostic factors. Conclusion: These data suggest that patients with limited extension of primitive tumor and responsive to the adjuvant therapy are the best candidates for surgery with better outcome.

Ventriculoatrial Shunting: An Escape Option in Patients with Idiopathic Normal Pressure Hydrocephalus Failing Ventriculoperitoneal Drainage.

BACKGROUND: Ventriculoperitoneal (VP) shunting is widely accepted as the gold-standard treatment for idiopathic normal pressure hydrocephalus (iNPH). However, a restricted group of patients experience only minimal or no improvement after the operation. In such cases, the question whether the diagnosis was incorrect or the shunt is malfunctioning remains unanswered. METHODS: We retrospectively collected data on a 10-year series of VP-shunted patients with iNPH showing transient or minimal improvement of symptoms within 3 weeks from surgery. A full workup (including noninvasive diagnostic, cognitive, and invasive tests) was performed. After ruling out mechanical malfunction, we performed a tap test followed by a Katzman test 2 weeks later. The confirmed persistence of disturbance of cerebrospinal fluid dynamics was treated by shunt revision and, if found working, by its replacement into the atrial cavity. RESULTS: Twenty patients were diagnosed with shunt insufficiency. At surgery, the distal end of the shunt was easily extruded and found working in all cases. It was then repositioned into the right atrium (the first 8 patients of the series also underwent failed contralateral abdominal replacement). Early postoperative clinical improvement was always confirmed. In 1 case, shunt overdrainage was corrected by valve upregulation. CONCLUSIONS: According to our experience, inadequate distal end placement of a shunt might be one of the reasons needing investigation in patients with iNPH failing improvement after surgery. In such situations, the conversion to a ventriculoatrial shunt proved to be a low-cost and successful treatment option.

Characterization and Ex Vivo Application of Indocyanine Green Chitosan Patches in Dura Mater Laser Bonding.

Dura mater repair represents a final and crucial step in neurosurgery: an inadequate dural reconstruction determines dreadful consequences that significantly increase morbidity and mortality rates. Different dural substitutes have been used with suboptimal results. To overcome this issue, in previous studies, we proposed a laser-based approach to the bonding of porcine dura mater, evidencing the feasibility of the laser-assisted procedure. In this work, we present the optimization of this approach in ex vivo experiments performed on porcine dura mater. An 810-nm continuous-wave AlGaAs (Aluminium Gallium Arsenide) diode laser was used for welding Indocyanine Green-loaded patches (ICG patches) to the dura. The ICG-loaded patches were fabricated using chitosan, a resistant, pliable and stable in the physiological environment biopolymer; moreover, their absorption peak was very close to the laser emission wavelength. Histology, thermal imaging and leak pressure tests were used to evaluate the bonding effect. We demonstrated that the application of 3 watts (W), pulsed mode (Ton 30 ms, Toff 3.5 ms) laser light induces optimal welding of the ICG patch to the dura mater, ensuring an average fluid leakage pressure of 216 ± 105 mmHg, falling within the range of physiological parameters. This study demonstrated that the thermal effect is limited and spatially confined and that the laser bonding procedure can be used to close the dura mater. Our results showed the effectiveness of this approach and encourage further experiments in in vivo models.

Laminectomy versus Unilateral Hemilaminectomy for the Removal of Intraspinal Schwannoma: Experience of a Single Institution and Review of Literature.

BACKGROUND AND STUDY AIMS: Spinal schwannomas are benign slow-growing tumors, and gross total resection is the gold standard of treatment. The conventional surgical approach is laminectomy, which provides a wide working area. Today minimally invasive surgery (MIS) is popular because it is associated with shorter hospital stay, less operative blood loss, minimized tissue traumas and relative postoperative pain, and, and spine surgery, avoidance of spinal instability. MATERIAL AND METHODS: From January 2016 to December 2019, we operated on 40 patients with spinal intradural extramedullary tumor (schwannoma) with laminectomy or hemilaminectomy. Baseline medical data, including patients' sex and age, tumor location, days of postoperative bed rest, operative time, length of hospitalization, and 1-month visual analog scale (VAS) value were collected and analyzed. Data analysis was performed using STATA/IC 13.1 statistical package (StataCorp LP, College Station, Texas, United States). RESULTS: Hemilaminectomy was associated with faster operative time (p < 0.001), shorter postoperative time spent in bed (p < 0.001), and shorter hospitalization (p < 0.001). At 1-month follow-up, the mean VAS score was 4.6 (1.7) among the laminectomy patients and 2.5 (1.3) among the hemilaminectomy patients (p < 0.001). Postoperative complications occurred in 1 (7.7%) and 7 (25.9%) patients in the hemilaminectomy and laminectomy groups, respectively (p = 0.177). CONCLUSIONS: Unilateral hemilaminectomy has significant advantages compared with laminectomy in spinal schwannoma surgery including shorter operative time, less time spent in bed, shorter hospitalization, and less postoperative pain.

The relationship between preoperative predictive factors for clinical outcome in patients operated for lumbar spinal stenosis by decompressive laminectomy.

BACKGROUND: Our hypothesis was that by identifying certain preoperative predictive factors, we could favorably impact clinical outcomes in patients undergoing decompressive surgery for lumbar spinal stenosis (LSS). METHODS: In this retrospective study, there were 65 patients (2016-2018) with symptomatic LSS who underwent decompressive laminectomy without fusion. Their clinical outcomes were assessed utilizing the Oswestry Disability Index (ODI). Multiple preoperative variables were studied to determine which ones would help predict improved outcomes: gender, age, body mass index (BMI), general/neurological examination, smoking, and drug therapies (anxiolytics and/or antidepressants). RESULTS: All patients demonstrated statistically significant improvement on the ODI. Multivariate analysis revealed that those with higher preoperative BMI had significantly lower ODI on 1-year follow-up examinations, reflecting poorer outcomes. Postoperatively, 44 patients (67%) exhibited lower utilization of anxiolytic medications, 52 patients (80%) showed reduced use of antidepressant drugs, and pain medications utilization was reduced in 33 patients (50%). CONCLUSION: Decompressive laminectomy without fusion effectively managed LSS. It reduced patients' use of pain, anxiety, and antidepressant medications. In addition, we found that increased preoperative BMIs contributed to poorer postoperative outcomes (e.g., ODI values).

Endoscope-assisted microsurgical evacuation versus external ventricular drainage for the treatment of cast intraventricular hemorrhage: results of a comparative series.

Cast intraventricular hemorrhage (IVH) is associated to high morbidity/mortality rates. External ventricular drainage (EVD), the most common treatment adopted in these patients, may be unsuccessful due to short-term drain obstruction and requires weeks for cerebrospinal fluid (CSF) clearing, increasing the risks of ventriculits. Administration of intraventricular fibrinolytic agents and endoscopic evacuation have been proposed as alternative treatments, but with equally poor results. We present a retrospective analysis of two groups of patients who respectively underwent endoscope-assisted microsurgical evacuation versus EVD for the treatment of cast IVH. In a 10-year time, 25 patients with cast IVH underwent microsurgical, endoscope-assisted evacuation. Twenty-seven were instead treated by EVD. The two groups were compared in terms of hematoma evacuation, CSF clearing time, infection rates, need for permanent shunting, short/long-term survival, and functional outcome. In endoscope-assisted surgeries, full CSF clearance required 14 ± 3 days in 20 patients and 21 ± 3 days in 5; in the EVD group, 21 ± 3 days were needed in 12 patients, 28 ± 3 days in 11, and 35 ± 3 days in 4. Permanent shunting was inserted respectively in 19 endoscopic and 23 EVD patients. Final mRs score was 0-3 in 13 endoscopic cases, 4-5 in the remaining 12. In the EVD group, 7 subjects scored mRs 0-3, 16 scored 4-5; 4 died. In our experience, endoscope-assisted evacuation of cast IVH reduced ICU staying and CSF clearance times. It also seemed to improve neurological outcome, but without affecting the need for permanent shunt. On the counterside, it increases the number of severely disabled survivors.

Epidemiological Study of Huntington's Disease in the Province of Ferrara, Italy.

BACKGROUND: Huntington's disease (HD) is an autosomal dominant neurodegenerative disorder caused by the abnormal expansion of CAG triplet repeat. We aimed to reappraise HD epidemiology in a northern Italian population, in relation to introduction of genetic testing. METHODS: Through ICD-9M code 333.4 and medical fare exemption code RF0080, HD cases were identified from administrative health data and medical records from the Units of Neurology and Genetics, Ferrara University Hospital, and from other provincial neurological structures. RESULTS: HD mean annual incidence rate in 1990-2009 was 0.3 per 100,000 (95% CI 0.2-0.5). All incident cases were found to have symptoms of the disease's classic form, and neither juvenile nor the rigid Westphal variant was detected. The mean (SD) age at onset was 50.2 (12.7 years; range 32-82 years), 54.9 (14.6) for men and 45.8 (9.4) for women. On prevalence day, December 31, 2014, HD prevalence was 4.2 per 100,000 (95% CI 2.4-7.0), with a male:female ratio of 1:2. CONCLUSIONS: The prevalence and incidence of HD in our population were lower than the prevalence and incidence reported for other European and Italian populations, but higher compared to those of Asia, Africa, and Eastern Europe. Compared to previous studies, HD incidence and prevalence did not change significantly.