Analysis of prognostic factors and the role of epilepsy in neurosurgical patients with brain metastases.

Background: Brain metastases (BMs) represent the most frequent brain tumors in adults. The identification of key prognostic factors is essential for choosing the therapeutic strategy tailored to each patient. Epilepsy can precede several months of other clinical presentations of BMs. This work aimed to study the impact of epilepsy and other prognostic factors on BMs patients' survival. Methods: This retrospective study included 51 patients diagnosed with BMs and who underwent neurosurgery between 2010 and 2021. The impact of BM features and patient's clinical characteristics on the overall survival (OS) was analyzed through uni- and multivariate analysis. Results: The average OS was 25.98 months and differed according to the histology of the primary tumor. The primary tumor localization and the presence of extracranial metastases had a statistically significant impact on the OS, and patients with single BM showed a superior OS to those with multifocal lesions. The localization of BMs in the temporal lobe correlated with the highest OS. The OS was significantly higher in patients who presented seizures in their clinical onset and in those who had better post-surgical Karnofsky performance status, no post-surgical complications, and who underwent post-surgical treatment. Conclusion: Our study has highlighted prognostically favorable patient and tumor factors. Among those, a clinical onset with epileptic seizures can help identify brain metastasis hitherto silent. This could lead to immediate diagnostic-therapeutic interventions with more aggressive therapies after appropriate multidisciplinary evaluation.

Radiological and blood markers predicting long term neurological outcome following decompressive craniectomy for malignant ischemic stroke: a preliminary single center study.

OBJECTIVE: Malignant ischemic stroke (MIS) is defined by progressive cerebral edema leading to intracranial pressure, compression of neural structurs and, eventually, death. Decompressive craniectomy (DC) has been advocated as a lifesaving procedure in the management of patients with MIS. This study aims to identify pre- and postoperative predictive variables of neurological outcomes in patients undergoing DC for MIS. METHODS: We conducted a retrospective study of patients undergoing decompressive hemi-craniectomy in a single center from April 2016 to April 2020. Preoperative work-up included baseline clinical status, laboratory data, and brain CT. The primary outcome was the 6-months modified ranking score (mRS). The secondary outcome was the 30-day mortality. RESULTS: During data capture a total of 58 patients fulfilled the criteria for MIS, of which 22 underwent DC for medically refractory increased ICP and were included in the present analysis. The overall median age was 58.5 years old. An immediate (24hr) postoperative GOSE score >= 5 was associated with good 6-month mRS (1-3)(p=0.004). Similarly, low postoperative neutrophils (p=0.002), low lymphocytes (p=0.004), decreased neutrophil to lymphocyte ratio (NLR)(p=0.02) and decreased platelet to lymphocytes ratio (PLR)(p=0.03) were associated with good neurological outcomes. Per-operative variables independently associated with worsened 6-month mRS were: increased age (OR 1.10, 95% CI 1.01-1.20, p=0.02), increased NIHSS score (OR 7.8, 95% CI 2.5-12.5, p=0.035), GCS < 8 at the time of neurosurgical referral (OR 21.63, 95% CI 1.42-328, p=0.02), and increased PTT time before surgery (OR 2.11, 95% CI 1.11-4, p=0.02). Decreased postoperative lymphocytes confirmed a protective role against worsened functional outcomes (OR 0.01, 95% CI 0.01-0.4, p=0.02). Decreased post-operative lymphocyte count was associated with showed a protective role against increased mRS (OR: 0.01, 95% CI: 0.01-0.4; p=0.02). The occurrence of hydrocephalus at postoperative CT scan was associated with 30-day mortality (p=0.005), while the persistence of postoperative compression of the ambient and crural cistern showed a trend towards significance (p=0.07). Conclusions This study reports that patients undergoing DC for MIS showing decreased postoperative blood inflammatory markers achieved better 6-month neurological outcomes than patients with increased inflammatory markers. Similarly, poor NIHSS, poor GCS, increased age, and larger PTT values at the time of surgery were independent predictors of poor outcomes. Moreover, the persistence of postoperative compression of basal cisterns and the occurrence of hydrocephalus is associated with 30-day mortality.

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.

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.

Application of a Scanner-Assisted Carbon Dioxide Laser System for Neurosurgery.

BACKGROUND: Despite potential advantages, broad carbon dioxide (CO2) laser diffusion in neurosurgery was historically prevented by several operative limitations. Nonetheless, in recent decades, significant improvements, in particular the development of surgical scanners, have made CO2 laser surgery easier and reproducible. The aim of this study was to report our preliminary experience with the SmartXide2 CO2 laser system. METHODS: The SmartXide2 laser system is a CO2 laser with a radiofrequency-excited laser source, a surgical scanner, and a high-precision micromanipulator, which are connected to the surgical microscope. Ten different brain and spinal tumors were treated to evaluate the laser system potential in different neurosurgical scenarios. Four illustrative cases were presented. RESULTS: The CO2 laser was used together with the traditional instruments in every step of the procedures, from the initial pial incision (intra-axial tumors) or early debulking (extra-axial lesions), to progressive tumor removal, and, lastly, for surgical cavity hemostasis. No injury to the surrounding neurovascular structures was observed. Postoperative neuroimaging confirmed complete tumor removal and showed a marked reduction of preoperative surrounding edema without signs of cerebral/medullary contusions. CONCLUSIONS: In selected cases, the SmartXide2 CO2 laser system could be a helpful, reliable, and safe surgical instrument to treat different cerebral and spinal lesions. It addresses some of the limitations of laser systems and is able to cut/ablate and coagulate the tissue simultaneously, with minimal lateral thermal spread, preserving the surrounding eloquent neurovascular structures. Moreover, having no consumable accessories, it is also cost-effective.

Skip hemilaminectomy for the treatment of holospinal epidural abscess: A single-center experience.

Background: Holospinal epidural abscesses (HEAs) are rare with potentially devastating consequences. Urgent bony decompression and abscess evacuation with long-term antibiotic therapy are typically the treatment of choice. Methods: We reviewed cases of holospinal HEAs operated on between 2009 and 2018. Variables studied included preoperative laboratories, CT/MR studies plus clinical and radiographic follow-up for between 34 and 60 postoperative months. Results: We utilized skip hemilaminectomies to minimize the risks of segmental instability. Targeted antibiotic therapy was also started immediately and maintained for 6 postoperative weeks. MR/CT studies documented full radiographic and neurological recovery between 6 and 12-months later. Conclusion: HEAs may be treated utilizing multilevel skip hemilaminectomies to help maintain spinal stability while offering adequate abscess decompression/resolution.

Timing of cranial reconstruction after cranioplasty infections: are we ready for a re-thinking? A comparative analysis of delayed versus immediate cranioplasty after debridement in a series of 48 patients.

The optimal management of cranioplasty infections remains a matter of debate. Most authors have suggested that the infected bone/implant removal is mandatory, combined with prolonged antibiotic therapy before reconstruction. However, failures can occur, even with 12-18-month intervals between the surgeries. Longer wait times before cranial reconstruction increase the risks of socioeconomic burdens and further complications, as observed in decompressed patients hosting shunts. In our department, we treated 48 cranioplasty infections over a period of 8 years, divided into two groups. For Group A (n = 26), the treatment consisted of cranioplasty removal and debridement, followed by a delayed reconstruction. Group B (n = 22) received 2 weeks of broad-spectrum antibiotics, followed by an "aggressive" field debridement and immediate cranioplasty. All patients received a minimum of 8 weeks of post-operative antibiotic therapy and were scheduled for clinic-radiological follow-ups for at least 36 months. Significant differences were observed between Groups A and B with respect to the number of failures (respectively 7 versus 1), the global operative time (significantly longer for Group B), germ identification (respectively 7 versus 13), and the overall length of hospital stay (on average, 61.04 days in Group A versus 47.41 days in Group B). Three shunted patients in Group A developed sinking flap syndrome. Shunt resetting allowed symptom control until cranioplasty in one subject, whereas two did not improve, even after reconstruction. In selected patients, an aggressive field debridement, followed by the immediate replacement of an infected cranioplasty, may represent a safe and valuable option.

On-ward surgical management of wound dehiscence: report of a single neurosurgical center experience and comparison of safety and effectiveness with conventional treatment.

The early identification and optimized treatment of wound dehiscence are a complex issue, with implications on the patient's clinical and psychological postoperative recovery and on healthcare system costs. The most widely accepted treatment is surgical debridement (also called "wash out"), performed in theater under general anesthesia (GA), followed by either wide-spectrum or targeted antibiotic therapy. Although usually effective, in some cases, such a strategy may be insufficient (generally ill, aged, or immunocompromised patients; poor tissue conditions). Moreover, open revision may still fail, requiring further surgery and, therefore, increasing patients' discomfort. Our objective was to compare the effectiveness, costs, and patients' satisfaction of conventional surgical revision with those of bedside wound dehiscence repair. In 8 years' time, we performed wound debridement in 130 patients. Two groups of patients were identified. Group A (66 subjects) underwent conventional revision under GA in theater; group B (64 cases) was treated under local anesthesia in a protected environment on the ward given their absolute refusal to receive further surgery under GA. Several variables-including length and costs of hospital stay, antibiotic treatment modalities, and success and resurgery rates-were compared. Permanent wound healing was observed within 2 weeks in 59 and 55 patients in groups A and B, respectively. Significantly reduced costs, shorter antibiotic courses, and similar success rates and satisfaction levels were observed in group B compared with group A. In our experience, the bedside treatment of wound dehiscence proved to be safe, effective, and well-tolerated.

Sinking flap syndrome revisited: the who, when and why.

The sinking flap syndrome (SFS) is one of the complications of decompressive craniectomy (DC). Although frequently presenting with aspecific symptoms, that may be underestimated, it can lead to severe and progressive neurological deterioration and, if left untreated, even to death. We report our experience in a consecutive series of 43 patients diagnosed with SFS and propose a classification based on the possible etiopathogenetic mechanisms. In 10 years' time, 43 patients presenting with severely introflexed decompressive skin flaps plus radiological and clinical evidence of SFS were identified. We analysed potential factors involved in SFS development (demographics, time from decompression to deterioration, type, size and cause leading to DC, timing of cranioplasty, CSF dynamics disturbances, clinical presentation). Based on the collected data, we elaborated a classification system identifying 3 main SFS subtypes: (1) primary or atrophic, (2) secondary or hydrocephalic and (3) mixed. Very large DC, extensive brain damage, medial craniectomy border distance from the midline < 2 cm, re-surgery for craniectomy widening and CSF circulation derangements were found to be statistically associated with SFS. Cranioplasty led to permanent neurological improvement in 37 cases. In our series, SFS incidence was 16%, significantly larger than what is reported in the literature. Its management was more complex in patients affected by CSF circulation disturbances (especially when needing the removal of a contralateral infected cranioplasty or a resorbed bone flap). Although cranioplasty was always the winning solution, its appropriate timing was strategical and, if needed, we performed it even in an emergency, to ensure patient's improvement.

Adipofascial Radial Forearm Free Flap for Anterior Skull Base Reconstruction in Complicated Forebrain Oncological Surgery.

BACKGROUND: Radical resections of ethmoidal tumors with intracranial extension present highly complex surgical and reconstructive problems. The purpose of report is to describe the authors' use of adipofascial radial forearm free flaps following unsuccessful anterior cranial fossa oncological surgery. METHODS: Adipofascial radial forearm free flaps were used to treat 3 similar cases of cutaneous fistula following bone resorption with communication to anterior cranial fossa and nasal cavity. RESULTS: No flap loss, no deaths, and no postoperative complications were observed. All patients underwent a nasal endoscopy, revealing adequate vitality and integration of the free flaps. One of the patients consented to additional surgery to improve outcome. CONCLUSIONS: Meticulous preoperative selection and an experienced interdisciplinary team are required to achieve the best surgical outcomes in complex cases. Free adipofascial forearm flaps could be an excellent therapeutic option in the reconstruction of the anterior skull base, notably in cases involving major postoperative complications.

Coil Extrusion into the Naso- and Oropharynx Ten Years after Internal Carotid Artery Pseudoaneurysm Embolization: A Case Report.

Coil migration and extrusion outside the cranial compartment after embolization of cerebral aneurysms represents a very rare complication of the endovascular procedures and few cases are reported in the literature. Instability of the vascular malformation wall and the resolution of the intramural hematoma, especially in pseudoaneurysm, might generate extravascular migration of the coils in the first months after embolization. However, to the best of our knowledge, an extrusion of coil 10 years after embolization has never been reported. We reported the unique case of a patient with coil extrusion into the naso- and oropharynx 10 years after internal carotid artery pseudoaneurysm embolization. The pseudoaneurysm occurred after an internal carotid artery injury during an endoscopic endonasal surgery for a clival giant cell tumor.

Cord Splitting Access to Ventral Intradural Cysts of Cervicothoracic Junction and Thoracic Spine.

OBJECTIVE: Surgical treatment of ventrally located intradural cysts is difficult and controversial. Laminectomy with division of the denticulate ligaments and gentle cord mobilization remains the standard approach but risks further neurologic deterioration secondary to cord manipulation. Our purpose is to evaluate the safety and effectiveness of a midline cord-splitting approach as an alternative for treating ventral thoracic intradural cysts. METHODS: We describe 2 patients who were treated for ventral intradural cysts causing progressive and severe myelopathy. Under general anesthesia and continuous neurophysiologic monitoring, laminectomy, durotomy, and cord splitting through a midline approach gave direct access to both lesions. Cyst drainage was supplemented by a cystopleural shunt in 1 case. RESULTS: Cyst collapse and cord reexpansion were documented in both patients with a magnetic resonance imaging scan 1 week after surgery. In both cases there was a significant neurologic improvement, which was maintained 2 years postoperatively. Intraoperative monitoring recorded no loss of somatosensory or motor potentials during surgery. Follow-up magnetic resonance imaging scans 2 years postoperatively showed no evidence of cyst recurrence, and both patients remained neurologically improved and stable. CONCLUSIONS: We have been able to drain 2 ventral intradural cysts using a cord-splitting technique. This has allowed safe access to purely ventrally located lesions, which were inaccessible dorsally or dorsolaterally. By using this method we have been able to avoid a more invasive ventral transthoracic approach necessitating vertebrectomy and reconstruction and risking serious complications.

Skip Hemilaminectomy for Large, Multilevel Spinal Epidural Hematomas: Report of a Series of 11 Patients.

OBJECTIVE: We present our experience with a modification of the conventional techniques for the removal of large spinal epidural hematomas (SEHs), based on multilevel "skip hemilaminectomies." METHODS: Eleven patients with SEHs extending over 5 or more spinal segments were treated at our institution via a modified hemilaminectomy technique from 2008 to 2014. This procedure, that we called "skip hemilaminectomy," consists in performing consecutive, alternating, unilateral laminar decompressions at 2-3 levels, followed by sublaminar undercutting, ipsi- and contralateral flavectomy, plus hematoma removal. RESULTS: Complete clot evacuation and full neurologic recovery were always achieved. A short hospital stay, fast postoperative mobilization, a minimized need of analgesic drugs, and no complications were recorded. CONCLUSIONS: In our preliminary experience, skip hemilaminectomy seems to be as safe as more conventional techniques (laminectomy, extended hemilaminectomy) for the removal of large multilevel SEHs, granting full neurologic improvement, short surgical times-even for very large lesions-and no complications at follow-up.

Endoscopic Endonasal Odontoidectomy with Anterior C1 Arch Preservation in Rheumatoid Arthritis: Long-Term Follow-Up and Further Technical Improvement by Anterior Endoscopic C1-C2 Screw Fixation and Fusion.

OBJECTIVE: To examine the long-term outcomes (minimum of 4.5 years) of endoscopic endonasal odontoidectomy (EEO) with preservation of anterior C1 ring to treat irreducible ventral bulbo-medullary compressions in rheumatoid arthritis (RA) and to illustrate a novel technique of anterior pure endoscopic craniovertebral junction (CVJ) reconstruction and fusion. In fact, long-term clinical studies are still lacking to elucidate the effective role of EEO and whether it can obviate the need for posterior fixation. METHODS: From November 2008 to January 2012, clinical and radiologic data of 7 patients presenting with RA and associated irreducible bulbo-medullary compression treated with EEO were analyzed retrospectively. In all patients, decompression was achieved by EEO with anterior C1 arch preservation. In the last 2 patients, after EEO, we used the spared anterior C1 arch for reconstruction of anterior column of CVJ by positioning, under pure endoscopic guidance, autologous bone and 2 tricortical screws between the anterior arch of C1 and the residual odontoid. All patients were examined clinically with Ranawat classification and radiographically with computed tomography, magnetic resonance imaging, and dynamic radiography immediately after surgery and during follow-up. RESULTS: Adequate bulbo-medullary decompression with anterior C1 arch preservation was obtained in all cases. At follow-up (average, 66.2 months; range, 51-91 months) all patients experienced an improvement at least of one Ranawat classification level and presented no clinical or radiologic signs of instability. CONCLUSIONS: EEO with anterior C1 arch sparing provides satisfying long-term results for irreducible ventral CVJ lesions in RA. The preservation of anterior C1 arch and, when possible, the reconstruction of anterior CVJ can prevent the need for posterior fusion.

Mini-Craniotomy under Local Anesthesia to Treat Acute Subdural Hematoma in Deteriorating Elderly Patients.

Background and Study Aims Surgical treatment for acute subdural hematomas (ASDHs) in elderly patients is still considered unsatisfactory. Series focusing on the use of conventional craniotomy or decompressive craniectomy in such patients report discouraging results. Glasgow Coma Scale (GCS) score at admission seems to be crucial in the decision-making process. Deteriorating patients with a GCS score between 9 and 11 are those who would benefit most from the surgical treatment. Unfortunately, elderly patients often present other comorbidities that greatly increase the risk of severe complications after major neurosurgical procedures under general anesthesia. The aim of the present study was to evaluate the feasibility of performing a mini-craniotomy under local anesthesia to treat ASDHs in a select group of elderly patients who were somnolent but still breathing autonomously at admission (GCS 9-11). Material and Methods Twenty-eight elderly patients (age > 75 years) with ASDH and a GCS score at surgery ranging from 9 to 11 were surgically treated under local anesthesia by a single burr-hole mini-craniotomy (transverse diameter 3-5 cm) and hematoma evacuation. At the end of the procedure, an endoscopic inspection of the surgical cavity was performed to look for residual clots that were not visible under direct vision. Results The median operation time was 65 minutes. Hematoma evacuation was complete in 22 cases, complete consciousness recovery was observed in all patients but one, and reoperation was required for two patients. Conclusion Historically, elderly patients with ASDH treated with a traditional craniotomy performed under general anesthesia have not had a good prognosis. Our preliminary experience with this less invasive surgical and anesthesiological approach suggests that somnolent but autonomously breathing elderly patients could benefit from this approach, achieving an adequate hematoma evacuation and bypassing the complications related to intubation and artificial respiratory assistance.

Supraorbital subfrontal trans-laminar endoscope-assisted approach for tumors of the posterior third ventricle.

BACKGROUND: Different surgical approaches have been developed for dealing with third ventricle lesions, all aimed at obtaining a safe removal minimizing brain manipulation. The supraorbital subfrontal trans-lamina terminalis route, commonly employed only for the anterior third ventricle, could represent, in selected cases with endoscopic assistance, an alternative approach to posterior third ventricular lesions. METHODS: Seven patients underwent a supraorbital subfrontal trans-laminar endoscope-assisted approach to posterior third ventricle tumors (two craniopharyngiomas, one papillary tumor of the pineal region, one pineocytoma, two neurocytomas, one glioblastoma). Moreover, a conventional third ventriculostomy was performed via the same trans-laminar approach in four cases. RESULTS: Complete tumor removal was accomplished in four cases, subtotal removal in two cases, and a simple biopsy in one case. Adjuvant radiotherapy and/or chemotherapy was administered, if required, on the basis of the histologic diagnosis. No major complications occurred after surgery except for an intratumoral hemorrhage in a patient undergoing a biopsy for a glioblastoma, which simply delayed the beginning of adjuvant radiochemotherapy. No ventriculoperitoneal shunt placement was needed in these patients at the most recent clinical and radiologic session (average 39.57 months, range 13-85 months). Two illustrative cases are presented. CONCLUSIONS: The supraorbital subfrontal trans-laminar endoscope-assisted approach may provide, in selected cases, an efficient and safe route for dealing with posterior third ventricular tumors.