The anterior sylvian point as a reliable landmark for the anterior temporal lobectomy in mesial temporal lobe epilepsy: technical note, case series, and cadaveric dissection.

Introduction: Mesial temporal lobe epilepsy (MTLE) is one of the most prevalent forms of focal epilepsy in surgical series, particularly among adults. Over the decades, different surgical strategies have been developed to address drug-resistant epilepsy while safeguarding neurological and cognitive functions. Among these strategies, anterior temporal lobectomy (ATL), involving the removal of the temporal pole and mesial temporal structures, has emerged as a widely employed technique. Numerous modifications have been proposed to mitigate the risks associated with aphasia, cognitive issues, and visual field defects. Methods: Our approach is elucidated through intraoperative and cadaveric dissections, complemented by neuroradiological and cadaveric measurements of key anatomical landmarks. A retrospective analysis of patients with drug-resistant MTLE who were treated using our ATL technique at IRCCS Neuromed (Pozzilli) is presented. Results: A total of 385 patients were treated with our ATL subpial technique anatomically focused on the anterior Sylvian point (ASyP). The mean FU was 9.9 ± 5.4 years (range 1-24). In total, 84%of patients were free of seizures during the last follow-up, with no permanent neurological deficits. Transient defects were as follows: aphasia in 3% of patients, visual field defects in 2% of patients, hemiparesis in 2% of patients, and cognitive/memory impairments in 0.8% of patients. In cadaveric dissections, the ASyP was found at a mean distance from the temporal pole of 3.4 ± 0.2 cm (range 3-3.8) at the right side and 3.5 ± 0.2 cm (3.2-3.9) at the left side. In neuroimaging, the ASyP resulted anterior to the temporal horn tip in all cases at a mean distance of 3.2 ± 0.3 mm (range 2.7-3.6) at the right side and 3.5 ± 0.4 mm (range 2.8-3.8) at the left side. Discussion: To the best of our knowledge, this study first introduces the ASyP as a reliable and reproducible cortical landmark to perform the ATL to overcome the patients' variabilities, the risk of Meyer's loop injury, and the bias of intraoperative measurements. Our findings demonstrate that ASyP can be a safe cortical landmark that is useful in MTLE surgery because it is constantly present and is anterior to risky temporal regions such as temporal horn and language networks.

Parasagittal Meningiomas: The Impact of Sinus Opening and Grade of Resection on Clinical Outcome and Recurrence in a Consecutive Series of Patients.

BACKGROUND: Surgical management of parasagittal meningiomas (PMs) remains controversial in the literature. The need to pursue a resection as radical as possible and the high risk of venous injuries contribute to making the sinus opening a widely argued choice. This study aimed to analyze factors affecting the risk of recurrence and to assess clinical outcomes of patients who underwent surgical resection of PMs with conservative or aggressive management of the intrasinusal portion. METHODS: A single-institution retrospective review of all patients with PM surgically treated between January 2013 and March 2021 was conducted. RESULTS: Among 56 patients, the sinus was opened in 32 patients (57%), and a conservative approach was used in 24 patients (43%). The sinus opening was found to be a predictive factor of radical resection (Simpson grade [SG] I-II) (P = 0.007). SG was the only predictive factor of recurrence (P < 0.001). The radical resection group (SG I-II) showed recurrence-free survival at 72 months of about 90% versus 30% in the non-radical resection group (SG III-IV) (log-rank test = 14.21, P < 0.001). Aggressive management of the sinus and radical resection were not found to be related to permanent deficit (P = 0.214 and P = 0.254) or worsening of Karnofsky performance scale score (P = 0.822 and P = 0.933). CONCLUSIONS: Removal of the intrasinusal portion of the tumor using standard procedures is not associated with a higher risk of permanent deficit or worsening of Karnofsky performance scale and reduces the risk of recurrence.

Anterior Petrosectomy With Intertentorial Approach.

BACKGROUND AND OBJECTIVES: The extradural anterior petrosal approach (EAPA) can present a challenge because it deals with critical structures in a narrow, confined corridor. It is associated with several potential approach-related risks including temporal lobe and venous injuries. Tentorial peeling has the potential to largely eliminate these risks during the approach and may offer more options for tailoring the dural opening to the anatomic region that one wants to expose. METHODS: Anatomic dissections of five adult injected non-formalin-fixed cadaveric heads were performed. Anterior petrosectomy with intertentorial approach (APIA) through a tentorial peeling was completed. Step-by-step documentation of the cadaveric dissections and diagrammatic representations are presented along with an illustrative case. RESULTS: Tentorial peeling separates the tentorium into a temporal tentorial leaf and posterior fossa tentorial leaf, adding a fourth dural layer to the three classic ones described during a standard EAPA. This opens out the intertentorial space and offers more options for tailoring the dural incisions specific to the pathology being treated. This represents a unique possibility to address brainstem or skull base pathology along the mid- and upper clivus with the ability to keep the entire temporal lobe and basal temporal veins covered by the temporal tentorial leaf. The APIA was successfully used for the resection of a large clival chordoma in the illustrative case. CONCLUSION: APIA is an interesting modification to the classic EAPA to reduce the approach-related morbidity. The risk reduction achieved is by eliminating the exposure of the temporal lobe while maintaining the excellent access to the petroclival region. It also provides several options to tailor the durotomies based on the localization of the lesion.

Anatomical landmarks during high-magnification microsurgery for a safe and effective resection of high-grade gliomas: how I do it.

BACKGROUND: Gross total resection, when possible, is the first crucial treatment for high-grade gliomas, as it has been demonstrated to be associated with longer survival. Different intraoperative tools, such as neuronavigation, fluorescent agents, and intra-operative ultrasound, have been developed to help neurosurgeons to extend the resection. METHODS: We describe the high-magnification microsurgery technique used during the first surgical removal for high-grade gliomas. We illustrate the key anatomical "markers" of normal brain parenchyma, which guide the surgery. CONCLUSION: High-magnification microsurgery is an anatomically based approach that allows the identification of key anatomical "markers" of normal brain parenchyma in order to resect high-grade gliomas safely and effectively.

Key role of microsurgical dissections on cadaveric specimens in neurosurgical training: Setting up a new research anatomical laboratory and defining neuroanatomical milestones.

Introduction: Neurosurgery is one of the most complex surgical disciplines where psychomotor skills and deep anatomical and neurological knowledge find their maximum expression. A long period of preparation is necessary to acquire a solid theoretical background and technical skills, improve manual dexterity and visuospatial ability, and try and refine surgical techniques. Moreover, both studying and surgical practice are necessary to deeply understand neuroanatomy, the relationships between structures, and the three-dimensional (3D) orientation that is the core of neurosurgeons' preparation. For all these reasons, a microsurgical neuroanatomy laboratory with human cadaveric specimens results in a unique and irreplaceable training tool that allows the reproduction of patients' positions, 3D anatomy, tissues' consistencies, and step-by-step surgical procedures almost identical to the real ones. Methods: We describe our experience in setting up a new microsurgical neuroanatomy lab (IRCCS Neuromed, Pozzilli, Italy), focusing on the development of training activity programs and microsurgical milestones useful to train the next generation of surgeons. All the required materials and instruments were listed. Results: Six competency levels were designed according to the year of residency, with training exercises and procedures defined for each competency level: (1) soft tissue dissections, bone drilling, and microsurgical suturing; (2) basic craniotomies and neurovascular anatomy; (3) white matter dissection; (4) skull base transcranial approaches; (5) endoscopic approaches; and (6) microanastomosis. A checklist with the milestones was provided. Discussion: Microsurgical dissection of human cadaveric specimens is the optimal way to learn and train on neuroanatomy and neurosurgical procedures before performing them safely in the operating room. We provided a "neurosurgery booklet" with progressive milestones for neurosurgical residents. This step-by-step program may improve the quality of training and guarantee equal skill acquisition across countries. We believe that more efforts should be made to create new microsurgical laboratories, popularize the importance of body donation, and establish a network between universities and laboratories to introduce a compulsory operative training program.

Surgical morbidity of the extradural anterior petrosal approach: the Lariboisière experience.

OBJECTIVE: Concerns about the approach-related morbidity of the extradural anterior petrosal approach (EAPA) have been raised, especially regarding temporal lobe and venous injuries, hearing impairment, facial nerve palsy, cerebrospinal fluid fistula, and seizures. There is lack in the literature of studies with detailed analysis of surgical complications. The authors have presented a large series of patients who were treated with EAPA, focusing on complications and their avoidance. METHODS: The authors carried out a retrospective review of patients who underwent EAPA at their institution between 2012 and 2021. They collected preoperative clinical characteristics, operative reports, operative videos, findings on neuroimaging, histological diagnosis, postoperative course, and clinical status at last follow-up. For pathologies without petrous bone invasion, the amount of petrous apex drilling was calculated and classified as low (< 70% of the volume) or high (≥ 70%). Complications were dichotomized as approach related and resection related. RESULTS: This study included 49 patients: 26 with meningiomas, 10 brainstem cavernomas, 4 chondrosarcomas, 4 chordomas, 2 schwannomas, 1 epidermoid cyst, 1 cholesterol granuloma, and 1 osteoblastoma. The most common approach-related complications were temporal lobe injury (6.1% of patients), seizures (6.1%), pseudomeningocele (6.1%), hearing impairment (4.1%), and dry eye (4.1%). Approach-related complications occurred most commonly in patients with a meningioma (p = 0.02) and Meckel's cave invasion (p = 0.02). Gross-total or near-total resection was correlated with a higher rate of tumor resection-related complications (p = 0.02) but not approach-related complications (p = 0.76). Inferior, lateral, and superior tumoral extension were not correlated with a higher rate of tumor resection-related complications. No correlation was found between high amount of petrous bone drilling and approach- or resection-related complications. CONCLUSIONS: EAPA is a challenging approach that deals with critical neurovascular structures and demands specific skills to be safely performed. Contrary to general belief, its approach-related morbidity seems to be acceptable at dedicated skull base centers. Morbidity can be lowered with careful examination of the preoperative neuroradiological workup, appropriate patient selection, and attention to technical details.

Vascular anomalies in patients with growth hormone-secreting pituitary adenomas: illustrative case report and systematic review of the literature.

PURPOSE: Endonasal resection is the first-line treatment for patients harboring growth hormone (GH)-secreting pituitary adenomas. The complexity of the parasellar neurovascular structures makes pre-operative diagnostic imaging essential to understanding the anatomy of this region. We aimed to describe vascular anomalies in acromegalic patients and emphasize their relevance for surgery and preoperative planning. METHODS: A systematic review following the PRISMA statement was performed in July 2021. RESULTS: Thirty-three studies were evaluated. Elevated GH and insulin-like growth factor-1 (IGF-1) levels are linked to the occurrence of cardiovascular risk factors. This is attributed to endothelial dysfunction, mainly caused by changes in flow-mediated dilatation (FMD), which is probably the main cause of vascular anomalies in acromegaly. The occurrence of protrusions of the internal carotid artery (ICA) (35-53%), a narrow intercarotid distance, and an asymmetrical course was described. In 13-18% of acromegalic patients, the presence of an intracerebral aneurysm could be reported (incidence in the general population:0.8-1.3%). The selected studies were however performed with a small patient sample (range:1-257). We present a case report of a 57y/o male patient with anomalies of the ICA ("kissing carotid arteries") harboring a GH-secreting adenoma, which was resected via an endoscopic endonasal approach. CONCLUSIONS: There is an association between acromegaly and endothelial dysfunction, which increases cardiovascular risk factors and vascular anomalies. Preoperative vascular imaging, e.g., CT angiography, should be implemented as a standard to identify patients at risk and estimate surgical morbidity. However, no evidence-based recommendations exist so far, so future studies are necessary.

Endoscopic-Assisted Microsurgical Resection of Right Recurrent Meckel's Cave Meningioma Extended to Cavernous Sinus.

Objective This study was aimed to present the complete removal of a large recurrent Meckel's cave meningioma. Design This study is a case report. Setting The study was conducted at Department of Neurosurgery and Skull Base Laboratory at Lariboisiére Hospital, Paris. Participant A 53-year-old male was presented with a severe V1, V2, and V3 hypoesthesia and pain. He was operated 7 years ago for a right Meckel's cave meningioma with postoperative V1-V2 hypoesthesia. Magnetic resonance imaging (MRI) showed a large tumor recurrence extending into the cavernous sinus (CS), posterior fossa (PF), sphenoid sinus (SS), pterygopalatine (PPF), and infratemporal fossa (ITF; Fig. 1 ). Main Outcome Measures Radiological results and postoperative course were assessed for this study. Results The previous right frontotemporal approach was used. The lateral wall of the orbit, the middle fossa floor and the anterior temporal base were drilled to expose the orbit, PPF, and ITF. Foramen ovale (FO), foramen rotondum (FR), and superior orbital fissure (SOF) were opened. The meningoorbital band was cut and the lateral wall of CS was elevated ( Fig. 2 ). The inferior orbital fissure was opened and tumor removed into the ITF, PPF, and orbit. After entering Meckel's cave from above, tumor was removed from PF. After microsurgical tumor removal, a 45-degree endoscope was used to remove tumor remnant and mucosa into SS. A watertight dural closure with pericranium was performed, reinforced with autologous fat and fibrin glue. Postoperative MRI showed complete tumor resection ( Fig. 1 ). The patient experienced a right-side keratitis that resolved within 10 days and a V3 hypoesthesia that improved at 2 months. Conclusion This surgical case shows how the anatomical knowledge is mandatory in skull base surgery and how the integration of microsurgical and endoscopic-assisted techniques allows to obtain optimal results. The link to the video can be found at: https://youtu.be/qxt_389AdWU .

The mini-combined transpetrosal approach: an anatomical study and comparison with the combined transpetrosal approach.

BACKGROUND: The combined transpetrosal approach (CTPA) is a versatile technique suitable for challenging skull base pathologies. Despite the advantages provided by a wide surgical exposure, the soft tissue trauma, complex and time-consuming bony work, and cosmetic issues make it far from patient expectations. In this study, the authors describe a less invasive modification of the CTPA, the mini-combined transpetrosal approach (mini-CTPA), and perform a quantitative comparison between these two approaches. METHODS: Five human specimens were used for this study. CTPA was performed on one side and mini-CTPA on the opposite side. The surgical freedom, petroclival and brainstem area of exposure, and maneuverability for 6 anatomical targets, provided by the CTPA and mini-CTPA, were calculated and statistically compared. The bony volumes corresponding to each anterior petrosectomy were also measured and compared. Three clinical cases with an operative video are also reported to illustrate the effectiveness of the approach. RESULTS: The question-mark skin incision done along the muscle attachments permits an optimal cosmetic result. Even though the limited incision, the smaller craniotomy, and the less extensive bone drilling of mini-CTPA provide a smaller area of surgical freedom, the areas of exposure of petroclival region and brainstem were not statistically different between the two approaches. The antero-posterior maneuverability for the oculomotor foramen (OF), Meckel's cave (MC) and the REZ of trigeminal nerve, and the supero-inferior maneuverability for OF, MC, Dorello's canal, and REZ of CN VII are significantly reduced by the smaller opening. The bony volume of anterior petrosectomy resulted similar among the approaches. CONCLUSIONS: The mini-CTPA is an interesting alternative to the CTPA, providing comparable surgical exposure both for petroclival region and for brainstem. Although the lesser soft tissue dissection and bony opening decrease the surgical maneuverability, the mini-CTPA may reduce surgical time, potential approach-related morbidities, and improve cosmetic and functional outcomes for the patients.

The Rostral Mucosa: The Door to Open and Close for Targeted Endoscopic Endonasal Approaches to the Clivus.

BACKGROUND: Extended endoscopic endonasal approaches (EEAs) have progressively widened the armamentarium of skull base surgeons. In order to reduce approach-related morbidity of EEAs and closure techniques, the development of alternative strategies that minimize the resection of normal tissue and alleviate the use of naso-septal flap (NSF) is needed. We report on a novel targeted approach to the clivus, with incision and closure of the mucosa of the rostrum, as the initial and final step of the approach. OBJECTIVE: To present an alternative minimally invasive approach and reconstruction technique for selected clival chordomas. METHODS: Three cases of clival chordomas illustrating this technique are provided, together with an operative video. RESULTS: The mucosa of the rostrum is incised and elevated from the underlying bone, as first step of surgery. Following tumor resection with angled scope and instruments, the mucosa of the sphenoid sinus (SS) is removed and the tumor cavity and SS are filled with abdominal fat. The mucosal incision of the rostrum is then sutured. A hangman knot is prepared outside the nasal cavity and tightened after the first stitch and a running suture is performed. CONCLUSION: We propose, in this preliminary report, a new targeted approach and reconstruction strategy, applying to EEAs the classic concept of skin incision and closure for transcranial approaches. With further development in the instrumentations and visualization tools, this technique may become a valuable minimally invasive endonasal approach for selected lesions.

Endoscope-assisted far-lateral transcondylar approach for craniocervical junction chordomas: a retrospective case series and cadaveric dissection.

OBJECTIVE: Craniocervical junction (CCJ) chordomas are a neurosurgical challenge because of their deep localization, lateral extension, bone destruction, and tight relationship with the vertebral artery and lower cranial nerves. In this study, the authors present their surgical experience with the endoscope-assisted far-lateral transcondylar approach (EA-FLTA) for the treatment of CCJ chordomas, highlighting the advantages of this corridor and the integration of the endoscope to reach the anterior aspect and contralateral side of the CCJ and the possibility of performing occipitocervical fusion (OCF) during the same stage of surgery. METHODS: Nine consecutive cases of CCJ chordomas treated with the EA-FLTA between 2013 and 2020 were retrospectively reviewed. Preoperative characteristics, surgical technique, postoperative results, and clinical outcome were analyzed. A cadaveric dissection was also performed to clarify the anatomical landmarks. RESULTS: The male/female ratio was 1.25, and the median age was 36 years (range 14-53 years). In 6 patients (66.7%), the lesion showed a bilateral extension, and 7 patients (77.8%) had an intradural extension. The vertebral artery was encased in 5 patients. Gross-total resection was achieved in 5 patients (55.6%), near-total resection in 3 (33.3%), and subtotal resection 1 (11.1%). In 5 cases, the OCF was performed in the same stage after tumor removal. Neither approach-related complications nor complications related to tumor resection occurred. During follow-up (median 18 months, range 5-48 months), 1 patient, who had already undergone treatment and radiotherapy at another institution and had an aggressive tumor (Ki-67 index of 20%), showed tumor recurrence at 12 months. CONCLUSIONS: The EA-FLTA provides a safe and effective corridor to resect extensive and complex CCJ chordomas, allowing the surgeon to reach the anterior, lateral, and posterior portions of the tumor, and to treat CCJ instability in a single stage.

Extreme Lateral Supracerebellar Infratentorial Approach: Surgical Anatomy and Review of the Literature.

OBJECTIVE: The extreme lateral supracerebellar infratentorial (ELSI) approach has the potential to access several distinct anatomical regions that are otherwise difficult to reach. We have illustrated the surgical anatomy through cadaveric dissections and provided an extensive review of the literature to highlight the versatility of this approach, its limits, and comparisons with alternative approaches. METHODS: The surgical anatomy of the ELSI has been described using 1 adult-injected cadaveric head. Formalized noninjected brain specimens were also dissected to describe the brain parenchymal anatomy of the region. An extensive review of the literature was performed according to each targeted anatomical region. Illustrative cases are also presented. RESULTS: The ELSI approach allows for wide exposure of the middle and posterolateral incisural spaces with direct access to centrally located intra-axial structures such as the splenium, pulvinar, brainstem, and mesial temporal lobe. In addition, for skull base extra-axial tumors such as petroclival meningiomas, the ELSI approach represents a rapid and adequate method of access without the use of extensive skull base approaches. CONCLUSIONS: The ELSI approach represents one of the most versatile approaches with respect to its ability to address several anatomical regions centered at the posterior and middle incisural spaces. For intra-axial pathologies, the approach allows for access to the central core of the brain with several advantages compared with alternate approaches that frequently involve significant brain retraction and cortical incisions. In specific cases of skull base lesions, the ELSI approach is an elegant alternative to traditionally used skull base approaches, thereby avoiding approach-related morbidity.

Characteristics and management of hydrocephalus associated with vestibular schwannomas: a systematic review.

Hydrocephalus (HC) can be associated with vestibular schwannoma (VS) at presentation. Although spontaneous resolution of HC after VS removal is reported, first-line treatment is varied including preoperative ventriculoperitoneal (VP) shunt, external ventricular drainage (EVD), or lumbar drainage (LD). We performed a systematic review to clarify optimal management of HC associated with VS at presentation, as well as characteristics of patients with initial and persistent HC after VS removal, and prevalence of HC associated with VS. Fourteen studies were included. Patients were grouped according to the timing of HC treatment. The overall rate of VP shunts was 19.4%. Among patients who received VS removal as first-line treatment, 6.9% underwent permanent shunts. In a subgroup of 132 patients (studies with no-aggregate data), t test analysis for mean tumor size (P = 0.02) and mean CSF protein level (P < 0.001) demonstrated statistically significant differences between patients with resolved HC (3.48 cm and 201 mg/dL) and patients with persistent HC (2.46 cm and 76.8 mg/dL) after VS resection. Transient treatment of HC using EVD or LD further resolved the HC in 87.5% and 82.9% of patients, respectively, before and after VS removal. The overall prevalence of HC associated with VS in a population of 2336 patients was 9.3%. Schwannoma removal as first-line treatment is justified by its low rate of persistent HC requiring VP shunt (roughly 7%). Patients with smaller VS and lower CSF proteins present higher risk of persistent HC after schwannoma removal. Temporary treatment of HC contributes to its resolution, both before and after VS removal.

The Interhemispheric Transgenual Approach for Microsurgical Removal of Third Ventricle Colloid Cysts. Technical Note.

BACKGROUND: Colloid cysts of the third ventricle are rare benign lesions, which amount to approximately 1% of all intracranial tumors. Because these lesions grow predominantly in the anterior aspect of the third ventricle, they may cause the occlusion of the foramina of Monro, generating obstructive hydrocephalus. Surgery is mandatory in cases of large cysts and/or in symptomatic patients. Among the different surgical strategies described in colloid cysts surgery, the microsurgical transcallosal approach still constitutes the procedure of choice in many centers. In this study, we describe a modified microsurgical transcallosal approach, the interhemispheric transgenual approach, in a series of 13 consecutive patients operated on for colloid cysts of the third ventricle. METHODS: All the procedures were performed by the senior author (V.E.) at Neuromed Institute of Pozzilli (Is, Italy). The operative procedure is described in its various steps, illustrating the differences and potential advantages compared with the traditional microsurgical transcallosal approach. RESULTS: No surgical complications or new-onset neurologic deficits were observed in the postoperative period. The postoperative magnetic resonance imaging confirmed in all cases complete lesion removal without any sign of parenchymal damage. No lesion recurrence or need for permanent cerebrospinal fluid diversion was detected in the patients of this series during the follow-up period. CONCLUSIONS: In our experience, the interhemispheric transgenual approach has been effective in providing complete colloid cyst removal with minimal risk of vascular and parenchymal damage. Further studies are required to confirm its efficacy in improving the overall outcome of the microsurgical transcallosal approach.

Petroclival meningiomas: the risk of post-operative cranial nerve deficits among different surgical approaches-a systematic review and meta-analysis.

BACKGROUND: The surgical resection of petroclival meningiomas (PCMs) remains a challenge. Both the relationship with neurovascular structures and the deep location of the tumor can affect the extent of resection and the rate of post-operative morbidity. METHODS: The authors performed a systematic review and meta-analysis of the literature examining the rate of new cranial nerve (CN) deficits after resection of PCM. A systematic search of two databases was performed for studies published between 1990 and 2018. Random-effect meta-analysis was used to pool the rate of post-operative CN deficits, mortality rate, and rate of radical resection. RESULTS: We included twelve studies and 334 patients harboring PCM. The overall rate of complete resection was 68% (95% CI 57.9-78.2%; p < 0.01; I2 = 83%). The rate of early and late post-operative CN deficits was the following: 3.8 and 2.7% (III CN), 6.6 and 3% (IV), 7.3 and 5.5% (V CN), 8 and 3.6% (VI CN), 8.9 and 8.9%% (VIII), and 4 and 2.7% (IX-XI CNs) (I2 = 0%, and p < 0.01 for all analyses). The risk of post-operative deficit of the IV CN was higher among the petrosal group (7.6%; I2 = 0% vs 2.1%; I2 = 0%), whereas the impairment of VII CN function was higher among retrosigmoid group (16.6%; I2 = 64.6% vs 11.4%; I2 = 52.8%), but it was transient in the majority of cases. CONCLUSIONS: This systematic review and meta-analysis provides a detailed overview of post-operative CN deficits ensuing surgical resection of PCMs. These findings should be acknowledged when counseling patients with PCMs regarding the more appropriate approach for their tumor.

Oculomotor Neurofibroma: A Different Histology Implying an Unsatisfying Clinical Outcome.

BACKGROUND: Tumors arising from oculomotor nerve are rare, with few cases reported in the literature. Generally, whereas schwannomas are well encapsulated tumors, neurofibromas tend to invade the entire nerve fibers. These differences influence surgical resection and neurological clinical outcome, with neurofibroma often requiring the sacrifice of the nerve. Accordingly, an incorrect preoperative diagnosis can lead to incomplete patient counseling before surgery. CASE DESCRIPTION: We report 2 cases: a patient with oculomotor schwannoma and a patient with oculomotor neurofibroma. After tumor resection, the patient with a diagnosis of schwannoma recovered with 3rd nerve palsy, while patient with the neurofibroma developed a complete oculomotor nerve deficit. For each patient, surgical strategy and neurological outcome are elucidated in relation with differences in preoperative magnetic resonance imaging and histology. CONCLUSIONS: To the best of our knowledge, this is the first report of an oculomotor neurofibroma. When an oculomotor nerve tumor is suspected, a careful preoperative evaluation of magnetic resonance imaging guides in distinguishing the different histology, in selecting the treatment strategy, and in correctly informing the patient on expected postoperative neurologic outcome.

Effectiveness of Gamma Knife Radiosurgery in Improving Psychophysical Performance and Patient's Quality of Life in Idiopathic Trigeminal Neuralgia.

OBJECTIVE: To assess effectiveness of Gamma Knife Radiosurgery (GKRS) in improving quality of life (QoL) in patients with idiopathic trigeminal neuralgia (TN). METHODS: Between January 2001 and October 2013, 166 patients with medically resistant TN were treated at our institution with GKRS. Patients were divided into 2 groups: patients with typical TN (TTN) and patients with atypical TN (ATN). All patients underwent clinical evaluation using Marseille and Barrow Neurological Institute pain and numbness scales; in addition, they completed the Short-Form 36 Health Survey, Activities of Daily Living, and Excellent Good Fair Poor questionnaires and underwent psychological and neurologic examination. RESULTS: Mean follow-up time was 64.7 months. All Short-Form 36 domains were significantly improved in both groups after treatment, with an evident trend to reach the median values of healthy Italian population. Mean postoperative Activities of Daily Living score in the TTN group and ATN group were 5.8 and 5.4, respectively, and Karnofsky Performance Status increased to 94.2 and 86.4, respectively. Pain recurrence negatively affected patients' QoL and psychofunctional performance without reaching statistical significance. At the last follow-up, 73% of patients were clustered in the pain-relief group. CONCLUSIONS: GKRS significantly improves QoL and functional and psychosocial performance of patients with idiopathic trigeminal neuralgia. A trend was observed toward a more favorable outcome in patients with TTN, compared with patients with ATN, without reaching a statistically significant distinction.

Gamma Knife Radiosurgery for Low-Grade Gliomas: Clinical Results at Long-Term Follow-Up of Tumor Control and Patients' Quality of Life.

OBJECTIVE: First-line therapy for low-grade gliomas (LGGs) is surgery, in some cases followed by radiotherapy and chemotherapy. Gamma Knife radiosurgery (GKRS) has gained more relevance in the management of these tumors. The aim of this study was to assess efficacy and safety of GKRS for treatment of LGGs. METHODS: Between 2001 and 2014, 42 treatments were performed on 39 patients harboring LGGs; 48% of patients underwent previous surgery, and 20.5% underwent previous radiotherapy. Mean tumor volume was 2.7 cm3, and median margin dose was 15 Gy. RESULTS: Mean follow-up was 60.5 months (range, 6-164 months). Actuarial progression-free survival was 74.9%, 52.8%, and 39.1% at 1 year, 5 years, and 10 years; actuarial overall survival was 97.4%, 94.6%, and 91.8% at 9 months, 1 year, and 5 years. Solid tumor control was achieved in 69.2% of patients, whereas cystic enlargement was recorded in 12.9% of cases. At last follow-up, volume reduction was recorded in 57.7% of cases, and median volume decreased by 33.3%. Clinical improvement was observed in 52.4% of patients. Karnofsky performance scale score was improved in 15 patients (45.5%), unchanged in 17 patients (51.5%), and worsened in 1 patient (3%). Mean posttreatment scores of 36-item short form health survey domains did not significantly differ from scores in a healthy Italian population. CONCLUSIONS: This study confirms safety and effectiveness of GKRS for LGGs in controlling tumor growth, relevantly improving patients' overall and progression-free survival. GKRS improved patients' functional performance and quality of life, optimizing social functioning and minimizing disease-related psychological impact.