Sodium fluorescein application in brain tumor biopsy.

BACKGROUND: Needle biopsy is a routinely, relatively safe, and effective tool for patients with brain tumors not suitable for surgical resection. Despite technical advancements, missed diagnosis is still reported in up to 24% of cases. The aim of this study is to investigate the role of sodium fluorescein (NaFL), a cheap and safe fluorophore, in the biopsy setting mainly with the perspective of an enhancement of the sampling accuracy. METHODS: Between January 2018 and March 2020, we prospectively enrolled 48 consecutive patients with suspicion of high-grade glioma to receive NaFL-guided brain tumor biopsy. We compared results between NaFL-group and our historical cohort of patients that underwent biopsy without any dye administration (N.=58). RESULTS: In the NaFL-guided biopsy group, there was a statistically significant increase in diagnostic accuracy compared to the historical cohort (100% vs. 86.2%, P<0.05). The mean number of samples was significantly reduced, (3.3 instead of 4.4 of the control group, P<0.05). Differences in terms of complications related to the procedure, hospital stay, and surgical time were not significant (P=0.49). CONCLUSIONS: To the authors' knowledge, this is the largest published series supporting the usefulness of NaFL during biopsy procedure, with improved diagnostic accuracy. This also allows a reduction in the number of samples needed for diagnosis, and subsequent risks of procedure-related complications, without adding risks related to the drug itself.

Lag screws for reduction of bilateral lateral mass fractures due to spinal trauma.

Introduction: Bilateral fracture of the C1 lateral mass is a relatively uncommon type of traumatic lesion. Treatment of this kind of fractures is usually conservative, with either external immobilization or traction. Research question: Whether surgical management, with placement of lag screws in lateral mass of C1, could represent a first-line treatment. Material and methods: We describe a case of 67-years old man with bilateral fractures of lateral mass of Atlas due to road accident trauma without ligament lesion but severe gap between bone edges. We performed Computed Tomography and Magnetic Resonance scans for pre-operative imaging, X-Ray and CT scan for follow-up. Medtronic navigation system was used as intraoperative guidance for screw placement. Results: Radiological and clinical results were good, with optimal bone reduction and patient's early return to daily activities. Discussion and conclusion: Surgical management remains debateable for isolated C1 lateral mass fractures. Different surgical approaches have been described for atlas fractures, such as transoral anterior C1-ring plate osteosynthesis, posterior osteosynthesis with a lateral mass screw rod, and posterior C1 to C2 fusion and C0 to C2 fusion. Minimally invasive operative treatment with lag screw and reduction of fracture's edges without occiput-C1 or C1-C2 stabilization could be the optimal treatment with good result and decreasing rate of pseudoarthrosis, allowing to avoid Halo-vest discomfort and complications.

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.

Infundibulum of Accessory Anterior Cerebral Artery: Rare, Likely Benign Malformation of Anterior Communicating Artery Complex to Keep in Mind.

BACKGROUND: Infundibular dilations (IDs) are funnel-shaped enlargements located at the origin of cerebral arteries. Neuroradiologists and neurosurgeons are familiar with IDs of the posterior communicating artery, which are relatively common. Other locations, being unexpected sites of IDs, can pose diagnostic and therapeutic challenges. CASE DESCRIPTION: In this paper, we describe a case of infundibulum of the accessory anterior cerebral artery, diagnosed with 3-dimensional reconstructions of computed tomography angiography, which is to our knowledge the first report of an ID of this anatomic variant. CONCLUSIONS: Anterior communicating artery represents a rare location for infundibular dilations. Differential diagnosis between them and true aneurysms can be sometimes challenging, especially when associated with anatomic variants; thus neurosurgeons and radiologists must be aware of these pathologic entities.

In vivo demonstration of blood-brain barrier impairment in Moyamoya disease.

BACKGROUND: Moyamoya disease (MMD) is a cerebrovascular disorder characterized by fragile vascular system. Previous studies suggested that the blood-brain barrier (BBB) destabilizing cytokine angiopoietin-2 plays a critical role in increasing vascular plasticity and endothelial disintegration in MMD. The aim of this study was to assess cerebrovascular integrity in vivo in patients affected by MMD. METHODS: We retrospectively analyzed 11 patients that underwent bypass for MMD (MMD group), 11 patients that underwent bypass for atherosclerotic cerebrovascular disease (ACVD-control group I), and 5 patients that underwent clipping for unruptured aneurysms (non-ischemic-control group II). Sodium fluorescein (NaFL) extravasation was evaluated during videoangiography when checking for bypass patency. A grading system (0, +, ++, +++) was used to define the extent of extravasation. Frequency and intensity of leakage was compared among different groups. RESULTS: NaFL extravasation appeared in 10/11 (91%) patients with MMD and in 8/11 (73%) patients with ACVD during bypass procedures. Extravasation was observed in none of the patients undergoing clipping for unruptured aneurysms. Although both chronic ischemic patient groups showed a comparably high incidence of NaFL extravasation, the MMD group was characterized by a much greater intensity of NaFL extravasation (grade +++ in 82%) than the ACVD group (grade +++ in 27%, p < 0.05). CONCLUSIONS: We demonstrate blood-brain barrier impairment in MMD patients for the first time in vivo. This may be due to mechanisms intrinsic to the unique pathology of MMD, probably explaining the higher association with hemorrhage and post-operative hyperperfusion.

An Evidence-based Approach to the Management of Children With Morquio A Syndrome Presenting With Craniocervical Pathology.

STUDY DESIGN: Retrospective case series OBJECTIVE.: The aim of this study was to review clinical and radiological outcomes of craniovertebral surgery in children with Morquio A syndrome (Mucopolysaccharidosis type IVA) and develop an evidence-based management algorithm. SUMMARY OF BACKGROUND DATA: Myelopathy secondary to craniovertebral pathology is a common cause of neurological disability in Morquio A syndrome. Previously unresolved surgical controversies include the value of surveillance, surgical indications, and operative technique. METHODS: A retrospective case-based review of children with Morquio A syndrome and craniovertebral pathology seen in a tertiary referral pediatric center from 1992 to 2016 was performed. Patients treated nonoperatively and operatively were included. Medical records and imaging were reviewed to determine clinical and radiological findings at initial assessment, before cervical spine surgery, early postoperative period, and final follow-up. The clinical outcomes of interest were neurological status and mobility at follow-up, complications, and need for further surgery. RESULTS: Twenty-seven patients were included. Surgical indications were radiological evidence of cervicomedullary compression alone (six cases) or with clinical evidence of myelopathy (12 cases). Eighteen patients (median age 6.2 years, range 3.5-15.9 years) underwent surgery, with median follow-up of 8.5 years. Occiput to upper cervical spine fusion with C1 decompression was performed in all cases with the addition of autologous calvarial graft in young patients (12 cases) and occipital-cervical plate fixation in older children (six cases). Neurological improvement occurred in 38% of cases but by one functional level only. Six of nine conservatively treated patients remained independent walkers. CONCLUSION: Surgery for craniovertebral pathology is required in the majority of children with Morquio A syndrome. Close clinical and radiological surveillance is essential for timely intervention. Occiput to cervical fusion is safe and feasible even in young patients and improves clinical and radiological parameters. LEVEL OF EVIDENCE: 4.

Fluorescein videoangiography during extracranial-to-intracranial bypass surgery: preliminary results.

BACKGROUND: Over the last years, intraoperative use of fluorescein is gaining ground in the field of neurosurgery, due to development of a microscope-integrated YELLOW 560 module, with reported experiences in brain malignancies, aneurysms, and arteriovenous malformation surgery. The aim of this study is to determine the feasibility and value of fluorescein videoangiography during bypass procedures. METHODS: The authors enrolled 11 patients who underwent extracranial-to-intracranial bypass for moyamoya disease, atherosclerotic steno-occlusive cerebrovascular disease, and flow replacement during a giant middle cerebral artery (MCA) aneurysm treatment. Patients underwent fluorescein videoangiography using microscope-integrated fluorescence module. RESULTS: In all 11 cases, good bypass patency was intraoperatively demonstrated through fluorescein videoangiography and confirmed by post-operative digital subtraction angiography or computed tomographic angiography. The technique seems to be less sensible than standard indocyanine green videoangiography in terms of flow velocity assessment during first pass and does not benefit from a dedicated software to perform hemodynamic parameter analysis (i.e., FLOW 800). Fluorescein videoangiography was able to show a higher number of vessels than indocyanine green videoangiography, providing an extremely well-defined view of cortical vascular network, also in deeper cortical areas. In case of deep-seated anastomosis, it allowed real-time manipulation of neurovascular structures, making it possible a safe analysis of vessels in deep surgical field during videoangiography observation. CONCLUSIONS: Fluorescein videoangiography is a cost-effective, easy-to-use, fast and safe intraoperative tool and is useful to assess graft patency and extent of cortical vascular network also in deeper cortical areas. In case of deep-seated anastomosis, it provides the great advantage of performing real-time manipulation of neurovascular structures during videoangiography observation. It could represent a valuable complementary or alternative technique to assess intraoperative bypass function.

Decision Making in Surgery for Nonsaccular Posterior Inferior Cerebellar Artery Aneurysms With Special Reference to Intraoperative Assessment of Collateral Blood Flow and Neurophysiological Function.

BACKGROUND: Posterior inferior cerebellar artery (PICA) aneurysms represent a challenging pathology. PICA sacrifice is often necessary, due to the high proportion of nonsaccular aneurysms that can be found in this location. Several treatments are available, but the infrequency of these aneurysms and the increasing number of endovascular techniques have limited the development of a standardized algorithm for cases in which open surgery is indicated. OBJECTIVE: We present our series of nonsaccular PICA aneurysms, in the attempt to define an algorithm for their surgical management. METHODS: We retrospectively reviewed the operation database, identifying patients harboring nonsaccular PICA aneurysms who were surgically treated at our institution from 2007 to 2016. RESULTS: During a 9-yr period, 17 patients harboring 18 nonsaccular PICA aneurysms were surgically treated at our institution. Fourteen (7.7%) aneurysms were located within the proximal PICA (including those located at the vertebral artery-PICA junction), and 4 were located distally. We performed PICA revascularization in 8 (57.1%) cases of proximal aneurysms (n = 4, PICA-PICA bypass; n = 4, occipital artery-PICA bypass). We based our decision whether to perform bypass on intraoperative test occlusion with indocyanine green (ICG) videoangiography and neurophysiological monitoring. In no cases, bypass was necessary for distal aneurysms. CONCLUSION: For nonsaccular PICA aneurysms, in which vessel occlusion is often necessary, it is possible to adopt a selective use of revascularization techniques. Intraoperative occlusion test with ICG videoangiography and neurophysiological monitoring provides reliable indications, allowing real-time assessment of collateral circulation.

Effects of nerve growth factor in experimental model of focal microgyria.

AIM: The effects on neural repair of intraparenchymal nerve growth factor (NGF) administration were evaluated in neonate Wistar rats with experimentally induced focal microgyria. METHODS: A freezing focal polymicrogyric lesion was induced on the frontal cortex in 35 newborn Wistar rats on postnatal day 1. NGF was administered in 15 cases, with 20 pups as controls. Animals were sacrificed at 72 h and 7 days after NGF administration. Real-time PCR was used for the quantification of the expression of TrkA, p75, and doublecortin (DCX) at the level of the cortical lesion in seven different groups of animals: control 72 h (n = 5), control 7 days (n = 5), microgyria 72 h (n = 5), microgyria 7 days (n = 5), microgyria + NGF 72 h (n = 5), microgyria + NGF 7 days (n = 5), and control + NGF (n = 5). RESULTS: A significant increase in TrkA expression was found in the microgyria + NGF 7 days group compared to the others. TrkA upregulation was already visible 72 h after NGF administration. Unlike TrkA, p75 expression increased in animals subjected to the experimental focal microgyria and decreased markedly after NGF administration. DCX expression in injured animals was observed to increase strongly 7 days after NGF administration compared with other groups. CONCLUSIONS: NGF administration interferes with neural repair mechanisms at the polymicrogyric lesion site by means of TrkA and DCX upregulation which possibly counteracts the process of apoptosis caused by the brain injury.

Ollier disease.

BACKGROUND: Ollier disease is a rare, nonfamilial disorder characterized by multiple enchondromatosis with an asymmetric distribution and areas of dysplastic cartilage. Clinical manifestations usually start with local pain, bone swelling, and palpable bony masses, often associated with bone deformity. Intracranial enchondromas arise from the skull base because of its cartilage embryological derivation. Headache and cranial nerve palsy are the most prominent clinical findings. The only effective treatment is represented by surgery that allows to resect the tumors and to treat their complications, such as pathological fractures, growth defect, and neurological symptoms. METHOD: We report on a 12-year-old boy affected with Ollier disease and operated on for a skull base enchondroma. The tumor was partially removed through a right pterional approach to the cavernous sinus. Serial postoperative magnetic resonance imaging showed an increasing residual tumor and the patient underwent radiation therapy. CONCLUSION: Surgery remains the main therapy for intracranial enchondromas. Radiotherapy is required in case of sarcomatous evolution or when a gross total tumor resection is not feasible, as in the present case.

Thyroid neoplasm after central nervous system irradiation for medulloblastoma in childhood: report of two cases.

OBJECTIVE: Surgical excision combined with radio-chemotherapy represents the gold standard of therapy of medulloblastoma. The effectiveness of such a combined treatment has encouraged the use of radiotherapy even in young paediatric patients, in spite of the many adverse effects reported in literature, and, in particular, the increased risk of a second radioinduced malignancy. Irradiation is the well-known risk factor for development of benign and malignant thyroid tumours. Children are more exposed to this risk because of their thyroid gland is more sensitive to carcinogenic effect of ionising radiation. CASE REPORT: Two children underwent radiotherapy for the treatment of a medulloblastoma when they were 3 and 4 years old, respectively. At the age of 20 and 23, both of them underwent the surgical excision of a papillary thyroid carcinoma, 20 and 17 years after the radiotherapeutic treatment, respectively. CONCLUSIONS: Radioinduced thyroid tumours are a well-recognised nosographic entities due to the particular sensitivity of this gland to ionising radiations. However, only a few papers on radioinduced thyroid neoplasms after CNS irradiation have been published in the literature. We report on two additional cases of thyroid neoplasms following childhood CNS irradiation for the treatment of a posterior fossa medulloblastoma.