Pedicled multifidus muscle flaps to treat dural tears due to penetrating spinal stab wounds: Two case reports and a literature review.

Background: Penetrating spinal injuries occasionally lead to dural tears (DT) and cerebrospinal fluid (CSF) leaks that risk both infectious and neurological complications. Here, we reviewed two cases and the literature regarding the safety/efficacy and limitations of repairing traumatic DT utilizing pedicled multifidus muscle flaps. Case Description: Two males, ages 73 and 50, presented with Brown-Sequard syndromes and DT/CSF fistulas attributed to knife-induced spinal injuries at the D3-D4 and D11-D12 levels. Intraoperatively, DT was repaired utilizing pedicle multifidus muscle flaps. Postoperatively, both patients demonstrated partial recovery of neurological function along with no residual symptoms/signs of DT/CSF fistulas. Conclusion: Penetrating traumatic spinal injuries may result in DT/CSF fistulas that can be adequately repaired utilizing pedicle multifidus muscle flaps.

Utility and Feasibility of a Low-Cost System to Simulate Clipping Strategy for Cerebral Aneurysms Using Three-Dimensional Computed Tomography Angiography with Virtual Craniotomy.

OBJECTIVE: To assess utility and feasibility of a low-cost system to simulate clipping strategy for cerebral aneurysms using patient-specific surgically oriented three-dimensional (3D) computed tomography angiography with virtual craniotomy. METHODS: From 2017 to 2021, 53 consecutive patients scheduled for aneurysm clipping underwent preoperative planning using 3D computed tomography angiography with virtual craniotomy. The model was oriented in the surgical position to observe the anatomy through surgical corridors. Clipping was planned considering 3 parameters: shape of the clip, clip type (standard vs. fenestrated), and clipping strategy (simple vs. multiple). We used a scoring system (0-3) to assess the concordance of virtual planning with real surgery by assigning 1 point for each correctly predicted parameter. Qualitative assessment of 3D models was a secondary end point. RESULTS: In 51 patients, 3D images perfectly matched the real anatomy shown in surgical videos. Concordance scores of 0, 1, 2, and 3 occurred with a frequency of 5%, 14%, 38%, and 43%, respectively. Concerning the shape of the clip, clip type, and clipping strategy, the concordance occurred in 73%, 80%, and 59%, respectively. Compared with simple clipping, strategies with multiple clippings were more difficult to predict correctly. Concordance scores of 0, 1, 2, and 3 occurred with a frequency of 5.7%, 5.7%, 31.4%, and 57.1%, respectively, in simple clipping and 4.8%, 28.6%, 47.6%, and 19%, respectively, in multiple clipping. CONCLUSIONS: In our experience, use of 3D computed tomography angiography with virtual craniotomy is an easy and useful solution to plan clipping strategy. The surgeon's awareness of the surgical anatomy is improved. Although this method has some technical limitations, it represents a low-cost alternative if complex and expensive simulation systems are not available.

Atypical and aggressive diffuse leptomeningeal glioneuronal tumor in a young adult: A case report and review of the literature.

Background: DLGNT is a rare tumor, commonly diagnosed in pediatric age; in most cases, the pathology presents a slow and indolent evolution. We present a case report of a young adult affected by DLGNT characterized by aggressive and atypical behavior. Case Description: A 21-year-old male presented with mild paraparesis and hypoesthesia with a D2 level. MRI scan of the brain and spine showed a dorsal intramedullary lesion; a diffuse craniospinal leptomeningeal thickening was also present. After a week, the neurological status deteriorated rapidly with paraparesis worsening and onset of acute hydrocephalus. The patient underwent external ventricular drain positioning; a C7-D4 laminectomy was subsequently performed with partial tumor resection. Histological examination revealed a DLGNT with aggressive aspects (Ki67 30%). Postoperatively, the patient showed an immediate mild worsening of the lower limbs deficit. After a few days, severe further neurological deterioration occurred with progressive motor deficit to the upper limbs and ultimately respiratory failure. Mechanical ventilation was necessary and the patient was transferred to the ICU; during the following weeks, he developed tetraplegia and underwent ventriculoperitoneal shunt positioning. By the time, the histological diagnosis was available, the clinical status would not allow radiotherapy or chemotherapy. The patient deceased approximately 90 days after hospitalization due to respiratory complications. Conclusion: DLGNT is a rare tumor; diagnosis requires a high index of suspicion and confirmation with biopsy. Although most cases have an indolent course, some patients may have aggressive forms. High proliferation index, hydrocephalus occurrence, and massive craniospinal leptomeningeal spread appear to be associated with worse prognosis.

Comparison of two different titanium cranioplasty methods: Custom-made titanium prostheses versus precurved titanium mesh.

BACKGROUND: The aim of this study was to compare the results of two different titanium cranioplasties for reconstructing skull defects: standard precurved mesh versus custom-made prostheses. METHODS: Retrospective analysis of 23 patients submitted to titanium cranioplasty between January 2014 and January 2019. Ten patients underwent delayed cranioplasty using custom-made prostheses; and 13 patients were treated using precurved titanium mesh (ten delayed cranioplasties, and three single-stage resection- reconstructions). Demographic, clinical, and radiological data were recorded. Results and complications of the two methods were compared, including duration of surgery, cosmetic results (visual analog scale for cosmesis [VASC]), and costs of the implants. RESULTS: Complications: one epidural hematoma in the custom-made group, one delayed failure in precurved group due to wound dehiscence with mesh exposure. There were no infections in either group. All custom-made prostheses perfectly fitted on the defect; eight of 13 precurved mesh prostheses incompletely covered the defect. Custom-made cranioplasty obtained better cosmetic results (average VASC 94 vs. 68), shorter surgical time (141min vs. 186min), and -fewer screws was needed to fix the prostheses in place (6 vs. 15). However, satisfactory results were obtained using precurved mesh in cases of small defects and in single-stage reconstruction. Precurved mesh was found to be cheaper (€1,500 vs. €5,500). CONCLUSION: Custom-made cranioplasty obtained better results and we would suggest that this should be a first choice, particularly for young patients with a large cranial defect. Precurved mesh was cheaper and useful for single-stage resection-reconstruction. Depending on the individual conditions, both prostheses have their place in cranioplasty therapies.