Use of fluorescein sodium-assisted intraoperative sample validation to maximize the diagnostic yield of stereotactic brain biopsy: progress toward a new standard of care?

OBJECTIVE: In patients with contraindication to open resection, histological diagnosis is obtained through a stereotactic biopsy (SB). Missed diagnoses and sampling errors are important limitations of SB; therefore, various ways have been proposed to increase the diagnostic yield (DY). Intraoperative histopathology can obtain a DY exceeding 98% but with several drawbacks, namely prolonged operative times and logistic concerns. The objective of this study was to evaluate whether intraoperative validation of samples with fluorescein sodium can obtain a high DY with the same ease of use as standard SB. METHODS: One hundred three consecutive cases of frameless neuronavigated SB performed at the authors' center from May 2013 to June 2021 were included. Two groups were compared: 46 patients underwent standard nonassisted SB (nSB), and 57 patients underwent fluorescein sodium-assisted SB (fSB). Data were collected retrospectively before 2017 and prospectively thereafter. DY, operative time, and rate of complications were compared between the two groups. The surgical technique for fSB was standardized, and a novel classification system for intraoperative fluorescence findings was developed. RESULTS: Statistically significant differences between the two groups were identified. The DY of the fSB group (100%, 95% CI 93.73%-100%) was significantly greater than that of the nSB group (89.13%, 95% CI 80.14%-98.13%) (p = 0.0157). No statistically significant differences were observed in terms of mean operative time (p = 0.7104), intraoperative complications (p = 0.999), or postoperative complications (p = 0.5083). CONCLUSIONS: Compared with standard nSB, fSB showed a significantly higher DY and similar surgical time and rate of complications. The ease of use, wide diagnostic spectrum, and low cost make fluorescein sodium preferable to other fluorophores. The present study strengthens the limited data in the literature indicating routine use of fSB. The proposed workflow suggests that fSB should be the standard of care for contrast-enhanced cases. Intraoperative histopathology should be limited to nonenhancing cases, and nSB should be avoided. Future prospective multicenter studies will be useful for further validation of our findings.

Preliminary Validation of FoRCaSco: A New Grading System for Cerebral and Cerebellar Cavernomas.

OBJECTIVE: Surgical indications for cerebral cavernous malformations (CCMs) remain significantly center- and surgeon-dependent; available grading systems are potentially limited, as they do not include epileptologic and radiologic data. Several experienced authors proposed a new grading system for CCM and the first group of patients capable of providing its statistical validation was analyzed. METHODS: A retrospective series of 289 CCMs diagnosed between 2008 and 2021 was collected in a shared anonymous database among 9 centers. The new grading system ranges from -1 to 10. For each patient with cortical and cerebellar cavernous malformations the grading system was applied, and a retrospective outcome analysis was performed. We proposed a score of 4 as a cutoff for surgical indication. RESULTS: Operated patients with a score ≥4 were grouped with non-operated patients with a score <4, as they constituted the group that received correct treatment according to the new grading system. Patients with a score ≥4, who underwent surgery and had an improved outcome, were compared to patients with a score ≥4 who were not operated (P = 0.04), and to patients with a score <4 who underwent surgery (P < 0.001). CONCLUSIONS: This preliminary statistical analysis demonstrated that this new grading would be applicable in surgical reality. The cutoff score of 4 correctly separated the patients who could benefit from surgical intervention from those who would not. The outcome analysis showed that the treated patients in whom the grading system has been correctly applied have a better outcome than those in whom the grading system has not been applied.

Dissecting Aneurysm of the L1 Radiculomedullary Artery Associated with Subarachnoid Hemorrhage: A Case Report.

BACKGROUND: Both spinal artery aneurysm and spinal subarachnoid hemorrhage represent a very rare event. METHODS: We report a case of a ruptured dissecting aneurysm of the right L1 radiculomedullary artery associated with subarachnoid hemorrhage and severe motor weakness. RESULTS: An urgent decompressive hemilaminectomy was performed due to worsening in motor deficit. A subsequent spinal angiography showed a dissection of radiculomedullary artery of L1 on the right side, treated conservatively. CONCLUSION: Nowadays, therapeutic strategies for this aneurysm remain controversial. Conservative strategy can represent a valid alternative.

Choroid Plexus Carcinoma in Adults: Literature Review and First Report of a Location into the Third Ventricle.

Choroid plexus carcinoma (CPC) is a rare intraventricular neoplasm originating from choroid plexus. CPC is the most aggressive choroid plexus tumor. Almost all the CPCs are detected in children, and the preferred location is the lateral ventricle. We reviewed the literature to evaluate the state of the art concerning the management of CPC in adults and report the first case described of the extremely rare localization into the third ventricle. A 38-year-old woman presented a medical history of Parinaud syndrome and occasional facial weakness. Brain magnetic resonance imaging revealed a mass lesion in the pineal region and posterior part of the third ventricle with obstructive hydrocephalus. She underwent subtotal resection through a supracerebellar infratentorial approach. After the histopathological diagnosis of CPC, the patient underwent a second surgery with gross total resection and adjuvant radiotherapy. CPC in adults, given its extreme rarity, does not have a standardized treatment. Gross total resection should be the first step of the treatment: however, according to the literature, gross total resection is achieved only in 40-75% of cases in CPC as opposed to 95% in choroid plexus papilloma, mainly due to the difficulty in managing a highly vascularized tumor in such a deep location. Chemotherapy has not an established role and adjuvant treatment is based on radiotherapy. In the case described hereby the gross total resection associated with surgical treatment of hydrocephalus and adjuvant radiotherapy has achieved a good clinical and radiological outcome.

Rare Case of Dumbbell-Shaped Spinal Cavernous Hemangioma and Literature Review.

BACKGROUND: Spinal epidural cavernous hemangiomas are rare vascular malformations. Exceptionally, they present with dumbbell-shaped morphology. When they happen, it's mandatory to include their pathology in the differential diagnosis because of their similarity to schwannomas. CASE DESCRIPTION: We report the case of a 72-year-old woman with a dumbbell-shaped thoracic epidural cavernous hemangioma. A literature review of diagnostic features and current treatment options are also discussed. CONCLUSIONS: Surgery is safe and effective in both improving patient condition and preventing acute hemorrhage that can worsen the outcome, causing neurologic and potentially irreversible deficits. The favorable result we obtained in our patient suggests that surgery should be evaluated as the first option, even in patients with large epidural cavernous hemangiomas.

Translaminar Approach for Treatment of Hidden Zone Foraminal Lumbar Disc Herniations: Surgical Technique and Preoperative Selection of Patients with Long-Term Follow-Up.

BACKGROUND: Lumbar disc herniation is a common degenerative disease of the lumbar spine with a prevalence of 1%-3% in some population studies. In 10% of patients, there is a fragment migrated cranially in Macnab's "hidden zone." In selected cases, this fragment can be removed with a translaminar approach that was described in 1998. We provide a detailed description of the technical advantages and pitfalls of the translaminar approach in a consecutive series of 32 patients treated at our institution. METHODS: Patients were divided preoperatively and postoperatively into 5 classes based on the Oswestry Disability Index (ODI): class 1, ODI 0%-20% (minimal disability); class 2, 20%-40% (moderate disability); class 3, 40%-60% (severe disability); 60%-80% (crippled); 80%-100% (bedridden or disabling symptoms). RESULTS: Four (12.5%) patients were upgraded 1 ODI class after the operation; 6 (18.7%) patients were upgraded 2 classes, 8 (25%) patients were upgraded 3 classes, and 11 (34.4%) patients were upgraded 4 classes. In 3 (9.4%) patients, ODI class did not change after the operation. After surgery, 7 (21.9%) patients developed mild low back pain. Mean follow-up was 25 months. CONCLUSIONS: When performed by dedicated spinal neurosurgeons, the translaminar approach is safe and effective in patients with long-term follow-up. Most patients showed an improvement in ODI. Major pitfalls were related to surgical selection and the narrow working space.

Detailed anatomy knowledge: first step to approach petroclival meningiomas through the petrous apex. Anatomy lab experience and surgical series.

Petroclival meningiomas are a challenge for neurosurgeons due to the complex anatomy of the region that is rich of vessels and nerves. A perfect and detailed knowledge of the anatomy is very demanding in neurosurgery, especially in skull base surgery. The authors describe the microsurgical anatomy to perform an anterior petrosectomy based on their anatomical and surgical experience and perform a literature review. The temporal bone is the most complex and fascinating bone of skull base. The apex is located in the angle between the greater wing of the sphenoid and the occipital bone. Removing the petrous apex exposes the clivus. The approach directed through the temporal bone in this anatomical area is referred to as an anterior petrosectomy. The area that must be drilled is the rhomboid fossa that is defined by the Kawase, premeatal, and postmeatal triangles. In Division of Neurosurgery - University of Turin, 130 patients, from August 2013 to September 2015, underwent surgical resection of intracranial meningiomas. In this group, we have operated 7 PCMs and 5 of these were approached performing an anterior petrosectomy with good results. In our conclusions, we feel that this surgery require an advanced knowledge of human anatomy and a specialized training in interpretation of radiological and microsurgical anatomy both in the dissection lab and in the operating room.

Glioma Surgery: Technological Advances to Achieve a Maximal Safe Resection.

Glioblastoma multiforme (GBM) is the most frequent primary central nervous system (CNS) tumor. Despite the best treatment and advances in therapy, prognosis remains poor. One of the mainstays of therapy in GBM is surgical excision. Several studies have confirmed that the extent of resection (EOR) positively influences overall survival (OS) in patients with high-grade gliomas (HGGs). A literature search was performed using PubMed to assess the useful neurosurgical tools to achieve the best neurosurgical performance. In order to achieve the major extent of resection, preserving neurological function, many tools are now available, especially neuronavigation, intraoperative fluorescence, intraoperative ultrasound, and neuromonitoring. In addition to the maximal excision of tumor, the neurosurgeon can use photodynamic therapy (PTD) and local drug delivery (LDD) to improve the local control and bridge conventional radio and chemotherapy. EOR improves OS in patients with HGGs. There are technological possibilities for achieving a complete resection preserving neurological function, and it is not acceptable to perform only biopsy of these lesions.

Intracranial aneurysms in patients with internal carotid artery occlusion: management and outcome in 22 cases.

BACKGROUND: There is little information about clinical characteristics, management, and outcome of patients with intracranial aneurysms and internal carotid artery occlusion. We will describe clinical characteristics, treatment and outcome of patients with coexistent internal carotid artery occlusion and intracranial aneurysms. METHODS: We conducted a retrospective chart review of 22 patients (eight males and 14 females) with coexistent internal carotid artery (ICA) occlusion and intracranial aneurysms. RESULTS: This series includes 14 females and eight males with a mean age of 63 years (range, 49 to 80). These patients harbored a total of 35 aneurysms, which were located on the same side of the ICA occlusion in five cases, on the contralateral side in 20 cases, while in ten cases the aneurysm had a midline location (AcomA 9, Basilar tip 1). Treatment consisted of surgery for eight aneurysms and endovascular embolization for 13 aneurysms. No invasive treatment was recommended for 14 aneurysms (eight patients with single aneurysm). No permanent perioperative or periprocedural complications occurred in the selected group of patients undergoing invasive treatment. At a mean follow-up of 57 months (range, 3-203), no patient had a subarachnoid hemorrhage and three patients had died of causes not related to the aneurysm. CONCLUSION: Surgical and endovascular treatment can be accomplished safely in selected patients with coexistent ICA occlusion and intracranial aneurysms. Conservative treatment is a valid alternative, especially in elderly patients or in patients with very small aneurysms, especially if not located along the collateral pathway.

Marked decrease in coil and stent utilization following introduction of flow diversion technology.

BACKGROUND: Flow diversion represents a major paradigm shift in the treatment of unruptured intracranial aneurysms. The potential impact of this technique on coil utilization and adjunctive techniques such as balloon-assisted and stent-assisted coiling is unknown. In this study, the effect of introduction of flow diversion devices on the utilization of coil and adjunctive techniques was assessed. METHODS: A retrospective review was conducted of consecutive patients with unruptured aneurysms treated at our institution comparing two groups: Group 1 (patients treated in the 2-year interval preceding the introduction of the Pipeline Embolization Device (PED) and Group 2 (patients treated during the 2-year interval following introduction in our practice of the PED). RESULTS: Mean aneurysm diameter was 8.7 ± 6.3 mm in Group 1 and 8.5 ± 6.1 mm in Group 2 (p=0.79). PED therapy was employed in 38 (21.7%) of 175 aneurysms in Group 2. The proportion of stent-assisted procedures was significantly less in Group 2 than in Group 1 (6.9% vs 14.7%, p=0.04), as was the proportion of patients undergoing parent artery sacrifice (0.6% vs 3.9%, p=0.046). The mean and median number of coils used per aneurysm were 5.4 ± 3.6 and 5 (range 1-18) for Group 1 and 3.2 ± 3.2 and 3 (range 0-19) for Group 2 (p ≤ 0.0001). CONCLUSIONS: Flow diversion represents a disruptive technology. More than one-fifth of unruptured aneurysms at our institution were treated with PED after introduction of this technology, resulting in marked decreases in coil and stent utilization.

Aneurysms of the medullary segments of the posterior-inferior cerebellar artery: considerations on treatment strategy and clinical outcome.

Proximal aneurysms of the medullary postero-inferior cerebellar artery (PICA) tract are peculiar due to critical anatomical location, small size and tortuosity of the parent vessel, close origin to brainstem perforators, and fragility of the sac wall. Moreover, most patients present after bleeding, increasing the challenges. Aim of this study is to evaluate the treatment modality and outcome of these patients during the last decade at the University Clinic of Torino. Databases of the Neurosurgical and Neuroradiological Department of the University of Torino were analyzed to retrieve patients treated for aneurysms of the medullary PICA tract. Charts and neuroradiological documentation were revised to complete the database. Of 621 patients treated for an intracranial aneurysm, 23 had PICA aneurysm, 18 located at the medullary tract. Only two were unruptured and 16 were ruptured aneurysms. Sixteen underwent endovascular treatment and two underwent surgery. In six cases the aneurysm was cured by parent vessel occlusion. At 6 months follow-up, the Glasgow outcome scale was high (5 and 4) in 16 patients; two patients had died in the acute phase, for reasons unrelated to the procedure. If not adequately compensated, parent vessel occlusion associates with high risks of ischemia and related brain swelling. In the present series sufficient collateral flow contributed to a good tolerance toward occlusion in all cases. Despite the small size of the present series, most treated cases presented a good outcome. Nevertheless, distal revascularization of the occluded artery would be indicated where collateral flow is insufficient.

Subarachnoid hemorrhage in elderly: advantages of the endovascular treatment.

AIM: Subarachnoid hemorrhage (SAH) from aneurysm rupture accounts for approximately 3% of all strokes. A significant improvement in surgery and endovascular procedures has reduced mortality and morbidity. Nowadays, endovascular treatment is a viable alternative to conservative treatment in elderly patients. We designed a retrospective observational study on all endovascular procedures carried out in our department in order to evaluate the outcome in elderly patients compared with a younger cohort. METHODS: A total of 378 patients with aneurysmal SAH were treated with detachable platinum coils in our department (1994-2009). Of these, 310 patients were aged 20-69 years and 68 were aged over 70 years. Data were stratified according to Hunt-Hess (H-H) grade at admission. The mean follow up was 4.8 years. The final outcome was evaluated through the Glasgow Outcome Scale (GOS). RESULTS: We observed a favorable outcome (GOS 5-4) in both groups of patients admitted with moderately good clinical conditions (H-H 1-3), with no statistically significant difference. In contrast, in the case of H-H grade at admission > 3, we observed a statistically significant poor outcome in elderly patients. CONCLUSIONS: We consider the endovascular treatment as first choice for elderly patients presenting with a good H-H grade at admission. Quick functional recovery and reduced hospitalization time were observed. Unlike young patients, a chance of recovery in elderly patients with H-H 4-5 is more difficult to achieve. Therefore, a conservative approach should be considered.