Beyond nimodipine: advanced neuroprotection strategies for aneurysmal subarachnoid hemorrhage vasospasm and delayed cerebral ischemia.

The clinical management of aneurysmal subarachnoid hemorrhage (SAH)-associated vasospasm remains a challenge in neurosurgical practice, with its prevention and treatment having a major impact on neurological outcome. While considered a mainstay, nimodipine is burdened by some non-negligible limitations that make it still a suboptimal candidate of pharmacotherapy for SAH. This narrative review aims to provide an update on the pharmacodynamics, pharmacokinetics, overall evidence, and strength of recommendation of nimodipine alternative drugs for aneurysmal SAH-associated vasospasm and delayed cerebral ischemia. A PRISMA literature search was performed in the PubMed/Medline, Web of Science, ClinicalTrials.gov, and PubChem databases using a combination of the MeSH terms "medical therapy," "management," "cerebral vasospasm," "subarachnoid hemorrhage," and "delayed cerebral ischemia." Collected articles were reviewed for typology and relevance prior to final inclusion. A total of 346 articles were initially collected. The identification, screening, eligibility, and inclusion process resulted in the selection of 59 studies. Nicardipine and cilostazol, which have longer half-lives than nimodipine, had robust evidence of efficacy and safety. Eicosapentaenoic acid, dapsone and clazosentan showed a good balance between effectiveness and favorable pharmacokinetics. Combinations between different drug classes have been studied to a very limited extent. Nicardipine, cilostazol, Rho-kinase inhibitors, and clazosentan proved their better pharmacokinetic profiles compared with nimodipine without prejudice with effective and safe neuroprotective role. However, the number of trials conducted is significantly lower than for nimodipine. Aneurysmal SAH-associated vasospasm remains an area of ongoing preclinical and clinical research where the search for new drugs or associations is critical.

Differential tractography and whole brain connectometry in primary motor area gliomas resection: A feasibility study.

OBJECTIVE: Establish the evolution of the connectome before and after resection of motor area glioma using a comparison of connectome maps and high-definition differential tractography (DifT). METHODS: DifT was done using normalized quantitative anisotropy (NQA) with DSI Studio. The quantitative analysis involved obtaining mean NQA and fractional anisotropy (FA) values for the disrupted pathways tracing the corticospinal tract (CST), and white fiber network changes over time. RESULTS: We described the baseline tractography, DifT, and white matter network changes from two patients who underwent resection of an oligodendroglioma (Case 1) and an IDH mutant astrocytoma, grade 4 (Case 2). CASE 1: There was a slight decrease in the diffusion signal of the compromised CST in the immediate postop. The NQA and FA values increased at the 1-year follow-up (0.18 vs. 0.32 and 0.35 vs. 0.44, respectively). CASE 2: There was an important decrease in the immediate postop, followed by an increase in the follow-up. In the 1-year follow-up, the patient presented with radiation necrosis and tumor recurrence, increasing NQA from 0.18 in the preop to 0.29. Fiber network analysis: whole-brain connectome comparison demonstrated no significant changes in the immediate postop. However, in the 1-year follow up there was a notorious reorganization of the fibers in both cases, showing the decreased density of connections. CONCLUSIONS: Connectome studies and DifT constitute new potential tools to predict early reorganization changes in a patient's networks, showing the brain plasticity capacity, and helping to establish timelines for the progression of the tumor and treatment-induced changes.

Comparative Analysis of Antithrombotic Therapy Outcomes in Mild Traumatic Brain-Injury Patients: A Focus on Bleeding Risk and Hospital-Stay Duration.

BACKGROUND: Traumatic brain injury (TBI) in the elderly is a noteworthy pathology due to the exponential increase in population age, and the effects of antiplatelet and anticoagulation on patients' outcomes are still a matter of dispute. The aim of the present study was to evaluate the impact of various antithrombotic agents on patients with mild TBI, focusing on the risk of intracranial bleeding (ICH) and length of hospitalization (LOS). METHODS: A retrospective analysis was conducted, including patients with a diagnosis of TBI admitted to the Emergency Department between 2021 and 2022. Patients were classified according to the concurrent antithrombotic therapy as aspirin (ASA), antiplatelets, direct oral anticoagulants (DOACs), and low-molecular-weight heparin (LMWH). The primary outcome was the ICH occurrence, while the secondary outcome was the LOS. The statistical analysis was performed via logistic regression models in R and STATA 13.1 software. Fisher's exact test was used for the statistical significance. RESULTS: 267 patients with mild TBI were included; 148 were not on antithrombotic agents, 43 were on aspirin, 33 on DOACs, 5 on LMWH, 22 on antiplatelets, and 16 on VKA. Out of the total, 9 patients experienced ICH, none of which were on DOACs, LMWH, or VKA, but 4-out of 65-were on antiplatelets, and 5-out of 148-were not on antithrombotic therapies. Patients not on antithrombotic therapy had the shortest LOS at 0.46 days, while those on VKA had the longest LOS at 1.19 days; similar trends were observed for patients on DOAC and LMWH. CONCLUSIONS: The results reveal that TBI patients on anticoagulants/antiplatelets had longer hospital stays compared with those on aspirin alone. Notably, VKA was the strongest predictor for an extended LOS. Regarding ICH, patients taking only aspirin were twice as likely to experience bleeding compared with those on anticoagulants/antiplatelets. However, to achieve statistically significant evidence, further research with a larger cohort of patients is needed.

Radiomics Multifactorial in Silico Model for Spatial Prediction of Glioblastoma Progression and Recurrence: A Proof-of-Concept.

BACKGROUND: Radiomics-based prediction of glioblastoma spatial progression and recurrence may improve personalized strategies. However, most prototypes are based on limited monofactorial Gompertzian models of tumor growth. The present study consists of a proof of concept on the accuracy of a radiomics multifactorial in silico model in predicting short-term spatial growth and recurrence of glioblastoma. METHODS: A radiomics-based biomathematical multifactorial in silico model was developed using magnetic resonance imaging (MRI) data from a 53-year-old patient with newly diagnosed glioblastoma of the right supramarginal gyrus. Raw and optimized models were derived from the MRI at diagnosis and matched to the preoperative MRI obtained 28 days after diagnosis to test the accuracy in predicting the short-term spatial growth of the tumor. An additional optimized model was derived from the early postoperative MRI and matched to the MRI documenting tumor recurrence to test spatial accuracy in predicting the location of recurrence. The spatial prediction accuracy of the model was reported as an average Jaccard index. RESULTS: Optimized models yielded an average Jaccard index of 0.69 and 0.26 for short-term tumor growth and long-term recurrence site, respectively. CONCLUSIONS: The present radiomics-based multifactorial in silico model was feasible, reliable, and accurate for short-term spatial prediction of glioblastoma progression. The predictive value for the spatial location of recurrence was still low, and refinements in the description of tissue reorganization in the peritumoral and resected areas may be critical to optimize accuracy further.

Occipital Sinus-Sparing Linear Paramedian Dural Incision: A Technical Note and Case Series for Median Suboccipital Approach.

BACKGROUND: Durotomies, traditionally used during the midline suboccipital approach, involve sacrificing the occipital sinus (OS) with consequent shrinking of the dura, risk of venous complications, difficulty performing watertight closure, and a higher rate of postoperative cerebrospinal fluid (CSF) leaks. The present technical note describes the OS-sparing linear paramedian dural incision, which leads to a decrease in the risk of complications during the median suboccipital approach in our case series. METHODS: The OS-sparing linear incision technique involves a dural incision placed 1 cm lateral to the OS. The angle of view of the microscope is frequently changed to overcome the narrowed exposure of the linear durotomy. Copious irrigation with saline prevents drying of the dura. A running watertight closure of the dura is performed. The overall results of 5 cases are reviewed. RESULTS: The cases were 3 tumors and 2 cavernomas. The OS was preserved in all 5, and no duraplasty was needed. The average dura closure time was 16.8 minutes. No CSF leak occurred, and no wound complications were observed. A gross total resection of the lesion was achieved in all the patients. The mean follow-up was 10.2 months, and there were no late complications related to the dura closure. CONCLUSIONS: In comparison to the types of durotomies conventionally used for the midline suboccipital approach, the OS-sparing linear paramedian dural incision entails lower risks of bleeding, venous complications, CSF leaks, and infections by avoiding duraplasty. Validation of this technical note on a larger patient cohort is needed.

Impact of augmented reality fiber tractography on the extent of resection and functional outcome of primary motor area tumors.

OBJECTIVE: This study aimed to evaluate the impact of augmented reality intraoperative fiber tractography (AR-iFT) on extent of resection (EOR), motor functional outcome, and survival of patients with primary motor area (M1) intra-axial malignant tumors. METHODS: Data obtained from patients who underwent AR-iFT for M1 primary tumors were retrospectively analyzed and compared with those from a control group who underwent unaugmented reality intraoperative fiber tractography (unAR-iFT). A full asleep procedure with electrical stimulation mapping and fluorescein guidance was performed in both groups. The Neurological Assessment in Neuro-Oncology (NANO), Medical Research Council (MRC), and House-Brackmann grading systems were used for neurological, motor, and facial nerve assessment, respectively. Three-month postoperative NANO and MRC scores were used as outcome measures of the safety of the technique, whereas EOR and survival curves were related to its cytoreductive efficacy. In this study, p < 0.05 indicated statistical significance. RESULTS: This study included 34 and 31 patients in the AR-iFT and unAR-iFT groups, respectively. The intraoperative seizure rate, 3-month postoperative NANO score, and 1-week and 1-month MRC scores were significantly (p < 0.05) different and in favor of the AR-iFT group. However, no difference was observed in the rate of complications. Glioma had incidence rates of 58.9% and 51.7% in the study and control groups, respectively, with no statistical difference. Metastasis had a slightly higher incidence rate in the control group, without statistical significance, and the gross-total resection and near-total resection rates and progression-free survival (PFS) rate were higher in the study group. Overall survival was not affected by the technique. CONCLUSIONS: AR-iFT proved to be feasible, effective, and safe during surgery for M1 tumors and positively affected the EOR, intraoperative seizure rate, motor outcome, and PFS. Integration with electrical stimulation mapping is critical to achieve constant anatomo-functional intraoperative feedback. The accuracy of AR-iFT is intrinsically limited by diffusion tensor-based techniques, parallax error, and fiber tract crowding. Further studies are warranted to definitively validate the benefits of augmented reality navigation in this surgical scenario.

Supracerebellar "Flyover" Approach to Dumbbell Falcotentorial Meningioma Encasing the Galenic Venous System.

Falcotentorial meningiomas involve the tentorial apex and straight sinus, posing challenges when encasing the galenic venous system.1 Microneurosurgery is considered the best treatment option for large falcotentorial meningiomas because it provides a definitive cure.2 In contrast, Gamma Knife surgery mainly allows the control of smaller or residual tumors after microsurgical resection.3 Approach selection between interhemispheric supratentorial versa supracerebellar transtentorial is dictated by the displacement of the Galen vein.1,4-8Video 1 describes the critical surgical steps of the supracerebellar "flyover" approach for a Bassiouni type II dumbbell falcotentorial meningiomas encasing the galenic venous system. Preoperative embolization was ruled out due to potential additional morbidity and mortality risks.9,10 A perimedian supracerebellar infratentorial transtentorial approach was performed with the patient in ¾ prone Concorde position. After early devascularization and division of the tentorium, the meningioma was internally debulked while preserving the arachnoid plane. The posterior choroidal arteries, internal cerebral veins, basal veins of Rosenthal, and vein of Galen were carefully dissected, and the tumor was completely resected. The patient was discharged on postoperative day 3 with no deficits. Postoperative magnetic resonance imaging confirmed a Simpson grade 1 resection. Pathology revealed a grade 2 meningioma. The patient remained asymptomatic with no recurrence at a 10-year follow-up. The reported case demonstrates that the most critical factor in the choice of approach to midline dumbbell falcotentorial meningiomas is the relationship of the tumor to the galenic venous system and its tributaries.

Intraoperative Augmented Reality Fiber Tractography for Primary Motor Area Glioma Resection.

The implementation of intraoperative augmented reality fiber tractography (iAR-FT) into the surgical workflow for high-grade supratentorial gliomas has been shown to be effective and safe in maximizing the extent of resection and progression-free survival through the surgeon's enhanced 3-dimensional awareness of the spatial localization of fiber tracts.1-3 Primary motor area tumors present special challenges due to the high eloquence of the precentral gyrus and risk of postoperative onset or worsening of motor deficits, as well as limited postoperative plasticity.4 Although essential, electrical stimulation mapping (ESM) techniques have a number of limitations with respect to primary motor pathways, including a higher risk of intraoperative stimulation-evoked seizures, a risk of false negatives in the presence of preoperative deficits, a nonnegligible risk of permanent deterioration even in the presence of negative stimulation maps, and, most importantly, limited spatial resolution.4-8 The rationale for integrating ESM and iAR-FT is to compensate for the limitations of the former in terms of morphologic and spatial representation of fiber tracts. The benefits of coupling iAR-FT with ESM techniques allow for continuous integrated anatomical-functional feedback during surgery. In Video 1 we describe the key technical aspects and benefits of iAR-FT-assisted surgery for maximal safe gross total resection of a primary motor area grade IV astrocytoma.

Preoperative tractography algorithm for safe resection of tumors located in the descending motor pathways zone.

Background: Diffusion tensor imaging (DTI) tractography facilitates maximal safe resection and optimizes planning to avoid injury during subcortical dissection along descending motor pathways (DMPs). We provide an affordable, safe, and timely algorithm for preoperative DTI motor reconstruction for gliomas adjacent to DMPs. Methods: Preoperative DTI reconstructions were extracted from a prospectively acquired registry of glioma resections adjacent to DMPs. The surgeries were performed over a 7-year period. Demographic, clinical, and radiographic data were extracted from patients' electronic medical records. Results: Nineteen patients (12 male) underwent preoperative tractography between January 1, 2013, and May 31, 2020. The average age was 44.5 years (range, 19-81 years). A complete radiological resection was achieved in nine patients, a subtotal resection in five, a partial resection in three, and a biopsy in two. Histopathological diagnoses included 10 patients with high-grade glioma and nine with low-grade glioma. A total of 16 perirolandic locations (10 frontal and six frontoparietal) were recorded, as well as two in the insula and one in the basal ganglia. In 9 patients (47.3%), the lesion was in the dominant hemisphere. The median preoperative and postoperative Karnofsky Performance Scores were 78 and 80, respectively. Motor function was unchanged or improved over time in 15 cases (78.9%). Conclusion: This protocol of DTI reconstruction for glioma removal near the DMP shows good results in low-term neurological functional outcomes.

Comparative Analysis of Surgical Working Corridors for Meckel Cave Trigeminal Schwannomas: A Quantitative Anatomic Study.

BACKGROUND AND OBJECTIVES: Volumetric analysis of the working corridors of the interdural approach to the Meckel cave may lead to a selection of routes which are anatomically more advantageous for trigeminal schwannoma resection. The herein-reported anatomic study quantitively compares the infratrochlear (IT) transcavernous, anteromedial (AM), and anterolateral (AL) corridors, highlighting their feasibility, indications, advantages, and limitations. METHODS: Anatomic boundaries and depth of Meckel cave, porus trigeminus, IT transcavernous, AM, and AL corridors were identified in 20 formalin-fixed latex-injected cadaveric heads and were subsequently measured. The corridor areas and volumes were derived accordingly. Each opening angle was also calculated. Angles and volumes were compared using analysis of variance. Statistical significance was set at a P -value <.05. RESULTS: The IT transcavernous corridor volume was greater than that of the AM and AL. The opening angle of the AM middle fossa triangle was wider than the other 2. CONCLUSION: The IT corridor can be advantageous for Meckel cave schwannomas invading the cavernous sinus and those with a notable extension into the posterior fossa because the transcavernous approach maximizes the working space into the retrosellar area. The AM middle fossa corridor is strategic in schwannomas confined to the Meckel cave with a minor extension into the posterior fossa. It raises the chance of total resection with a single approach involving the porus trigeminus opening.

Surgical corridors to foramen magnum meningiomas: a mini-review.

Gross-total resection of foramen magnum meningiomas remains the gold standard of treatment and should be performed whenever possible. The transcondylar approach (and its variations) represents the most used approach for meningiomas located in the lateral or anterior borders of the foramen magnum. Endoscopic transclivus approaches represent a useful option in selected cases of anterior midline foramen magnum meningiomas, to be performed in centers with advanced experience in endoscopic skull base surgery, with the caveats of increased risk of postoperative cerebrospinal fluid leak. Alternatively, radiosurgery remains an option for well-selected cases, especially for the management of asymptomatic patients with small enlarging tumors. Advances in molecular profiling, as well as genetic analysis, may guide adjuvant treatment.

Understanding the molecular profiling of diffuse gliomas classification: A brief overview.

Background: Gliomas represent almost 30% of all primary brain tumors and account for 80% of malignant primary ones. In the last two decades, significant progress has been made in understanding gliomas' molecular origin and development. These advancements have demonstrated a remarkable improvement in classification systems based on mutational markers, which contribute paramount information in addition to traditional histology-based classification. Methods: We performed a narrative review of the literature including each molecular marker described for adult diffuse gliomas used in the World Health Organization (WHO) central nervous system 5. Results: The 2021 WHO classification of diffuse gliomas encompasses many molecular aspects considered in the latest proposed hallmarks of cancer. The outcome of patients with diffuse gliomas relies on their molecular behavior and consequently, to determine clinical outcomes for these patients, molecular profiling should be mandatory. At least, the following molecular markers are necessary for the current most accurate classification of these tumors: (1) isocitrate dehydrogenase (IDH) IDH-1 mutation, (2) 1p/19q codeletion, (3) cyclin-dependent kinase inhibitor 2A/B deletion, (4) telomerase reverse transcriptase promoter mutation, (5) α-thalassemia/ mental retardation syndrome X-linked loss, (6) epidermal growth factor receptor amplification, and (7) tumor protein P53 mutation. These molecular markers have allowed the differentiation of multiple variations of the same disease, including the differentiation of distinct molecular Grade 4 gliomas. This could imply different clinical outcomes and possibly impact targeted therapies in the years to come. Conclusion: Physicians face different challenging scenarios according to the clinical features of patients with gliomas. In addition to the current advances in clinical decision-making, including radiological and surgical techniques, understanding the disease's molecular pathogenesis is paramount to improving the benefits of its clinical treatments. This review aims to describe straightforwardly the most remarkable aspects of the molecular pathogenesis of diffuse gliomas.

Photo-Stacking Technique for Neuroanatomical High-Definition Photography and 3-Dimensional Modeling.

BACKGROUND: Three-dimensional (3D) neuroanatomical knowledge is vital in neurosurgery. Technological advances improved 3D anatomical perception, but they are usually expensive and not widely available. The aim of the present study was to provide a detailed description of the photo-stacking technique for high-resolution neuroanatomical photography and 3D modeling. METHODS: The photo-stacking technique was described in a step-by-step approach. The time for image acquisition, file conversion, processing, and final production was measured using 2 processing methods. The total number and file size of images are presented. Measures of central tendency and dispersion report the measured values. RESULTS: Ten models were used in both methods achieving 20 models with high-definition images. The mean number of acquired images was 40.6 (14-67), image acquisition time 51.50 ± 18.8 s, file conversion time 250 ± 134.6 s, processing time 50.46 ± 21.46 s and 41.97 ± 20.84 s, and 3D reconstruction time was 4.29 ± 0.74 s and 3.89 ± 0.60 s for methods B and C, respectively. The mean file size of RAW files is 1010 ± 452 megabyte (MB) and 101.06 ± 38.09 MB for Joint Photographic Experts Group files after conversion. The mean size of the final image means size is 71.9 ± 0.126 MB, and the mean file size of the 3D model means is 37.4 ± 0.516 MB for both methods. The total equipment used was less expensive than other reported systems. CONCLUSIONS: The photo-stacking technique is a simple and inexpensive method to create 3D models and high-definition images that could prove valuable in neuroanatomy training.

The Party Wall: Redefining the Indications of Transcranial Approaches for Giant Pituitary Adenomas in Endoscopic Era.

The evolution of endoscopic trans-sphenoidal surgery raises the question of the role of transcranial surgery for pituitary tumors, particularly with the effectiveness of adjunct irradiation. This narrative review aims to redefine the current indications for the transcranial approaches for giant pituitary adenomas in the endoscopic era. A critical appraisal of the personal series of the senior author (O.A.-M.) was performed to characterize the patient factors and the tumor's pathological anatomy features that endorse a cranial approach. Traditional indications for transcranial approaches include the absent pneumatization of the sphenoid sinus; kissing/ectatic internal carotid arteries; reduced dimensions of the sella; lateral invasion of the cavernous sinus lateral to the carotid artery; dumbbell-shaped tumors caused by severe diaphragm constriction; fibrous/calcified tumor consistency; wide supra-, para-, and retrosellar extension; arterial encasement; brain invasion; coexisting cerebral aneurysms; and separate coexisting pathologies of the sphenoid sinus, especially infections. Residual/recurrent tumors and postoperative pituitary apoplexy after trans-sphenoidal surgery require individualized considerations. Transcranial approaches still have a critical role in giant and complex pituitary adenomas with wide intracranial extension, brain parenchymal involvement, and the encasement of neurovascular structures.

Surgical management of symptomatic hemangioma of the geniculate ganglion: fascicular-sparing resection or grafting?

Geniculate ganglion hemangioma (GGH) is rarely presented in the neurosurgical literature. It extends extradurally on the middle fossa floor and displaces the intratemporal part of the facial nerve. Surgical treatment is advisable at early symptoms. Proposed techniques include fascicular-sparing resection or nerve interruption with grafting. No definitive conclusions exist about the superiority of a certain technique in preserving facial nerve integrity and function. Through the description of a surgically managed symptomatic GGH, we herein discuss literature data about the surgical results of fascicular-sparing resection versus grafting. A PRISMA-based literature search was performed on the PubMed database. Only articles in English and published since 1990 were selected and furtherly filtered based on the best relevance. Statistical comparisons were performed with ANOVA. One hundred sixteen GGHs were collected, 56 were treated by fascicular-sparing resection, and 60 were treated by grafting. The facial function was improved, or unchanged, in 53 patients of the fascicular-sparing group and 30 patients of the grafting one. Sixty-five patients achieved a good (House-Brackmann (HB) grade III) postoperative facial outcome, of which 47 and 18 belonged to the fascicular-sparing and grafting group, respectively. Greater efficacy of the fascicular-sparing technique in the achievement of a better facial outcome was found (p = 0.0014; p = 0.0022). A surgical resection at the earliest symptoms is critical to preserve the facial nerve function in GGHs. Fascicular-sparing resection should be pursued in symptomatic cases with residual facial function (I-III HB). Conversely, grafting has a rationale for higher HB grades (V-VI). Broader studies are required to confirm these findings and turn them into new therapeutic perspectives.

Microneurosurgical anatomy of the basal cisterns: A brief review for cisternostomy.

Background: Cisternostomy is a surgical technique thought of and developed as an option for severe brain trauma treatment. It demands a particular knowledge and skill to microsurgically approach basal cisterns and effectively manipulate their contents. To perform this procedure safely, the anatomy and pathophysiology must be clearly understood. Methods: Detailed microscopic dissection and anatomical review were done, after a detailed reading of facts and recent publications about cisternostomy. Cisternal pathways and landmark planning are described and augmented using a new method to show de arachnoid borders. Finally, a brief discussion is written as a synopsis. Results: Cisternostomy requires thorough microscopic knowledge and microsurgical skills. This paper intends to provide information to understand better the anatomy related, thus, easing the learning curve. The technique used to show arachnoid borders, complementing cadaveric and surgical images, was useful for this purpose. Conclusion: To perform this procedure safely, it is mandatory to handle microscopic details of cistern anatomy. Reaching a core cistern is necessary to assure effectiveness. This procedure needs, as well, surgical step-by-step landmark planning and performing. Cisternostomy could be a life-saving procedure and a new powerful tool for severe brain trauma treatment. Evidence is being collected to support its indications.

Virtual preoperative planning and 3D tumoral reconstruction with Horos open-source software.

Background: Presurgical three-dimensional (3D) reconstructions allow spatial localization of cerebral lesions and their relationship with adjacent anatomical structures for optimal surgical resolution. The purpose of the present article is to present a method of virtual preoperative planning aiming to enhance 3D comprehension of neurosurgical pathologies using free DICOM image viewers. Case Description: We describe the virtual presurgical planning of a 61-year-old female presenting a cerebral tumor. 3D reconstructions were created with the "Horos®" Digital Imaging and Communications in Medicine viewer, utilizing images obtained from contrast-enhanced brain magnetic resonance imaging and computed tomography. The tumor and adjacent relevant structures were identified and delimited. A sequential virtual simulation of the surgical stages for the approach was performed with the identification of local gyral and vascular patterns of the cerebral surface for posterior intraoperative recognition. Through virtual simulation, an optimal approach was gained. Accurate localization and complete removal of the lesion were achieved during the surgical procedure. Virtual presurgical planning with open-source software can be utilized for supratentorial pathologies in both urgent and elective cases. Virtual recognition of vascular and cerebral gyral patterns is helpful reference points for intraoperative localization of lesions lacking cortical expression, allowing less invasive corticotomies. Conclusion: Digital manipulation of cerebral structures can increase anatomical comprehension of neurosurgical lesions to be treated. 3D interpretation of neurosurgical pathologies and adjacent anatomical structures is essential for developing an effective and safe surgical approach. The described technique is a feasible and accessible option for presurgical planning.

Surgical management of thoracolumbar junction fractures: An evidence-based algorithm.

Background: The management of thoracolumbar junction (TLJ) fractures, involving the restoring anatomical stability and biomechanics properties, still remains a challenge for neurosurgeons.Despite the high frequency of these injuries, specific treatment guidelines, set on biomechanical properties, have not yet been assumed. The present study is meant to propose an evidence-based treatment algorithm. The primary aim for the protocol validation was the assessment of postoperative neurological recovery. The secondary objectives concerned the evaluation of residual deformity and rate of hardware failure. Technical nuances of surgical approaches and drawbacks were further discussed. Methods: Clinical and biomechanical data of patients harboring a single TLJ fracture, surgically managed between 2015 and 2020, were collected. Patients' cohorts were ranked into 4 groups according to Magerl's Type, McCormack Score, Vaccaro PLC point, Canal encroachment, and Farcy Sagittal Index. The outcome measures were the early/late Benzel-Larson Grade and postoperative kyphosis degree to estimate neurological status and residual deformity, respectively. Results: 32 patients were retrieved, 7, 9, 8, and 8 included within group 1, 2, 3, and 4, respectively. Overall neurological outcomes significantly improved for all patients at every follow-up stage (p â€‹< â€‹0.0001). Surgeries gained a complete restoration of post-traumatic kyphosis in the entire cohort (p â€‹< â€‹0.0001), except for group 4 which experienced a later worsening of residual deformity. Conclusions: The choice of the most appropriate surgical approach for TLJ fractures is dictated by morphological and biomechanical characteristics of fracture and the grade of neurological involvement. The proposed surgical management protocol was reliable and effective, although further validations are needed.

Micromirrors in Neurosurgery: Technical Overview and Benefits Assessment.

AIM: To weight the benefits and limitations of intraoperative use of micromirrors in neurosurgery. MATERIAL AND METHODS: Surgical cases where micromirrors were employed were retrospectively selected from the surgical database of five different surgeons in different hospitals. Complications directly attributable to the micromirrors were assessed intraoperatively and confirmed with postoperative neuroimaging studies. RESULTS: Fourteen patients were selected. The site of the lesion was as follows: posterior fossa (43%), frontal lobe (22%), temporal lobe (14%), parietal lobe (7%), insula (7%), and basal ganglia (7%). Five tumors (35%) were gliomas, 3 (21%) epidermoid, and 3 (21 %) supratentorial metastases. Two patients underwent microvascular decompression for neurovascular conflict, and 1 harbored a brain arteriovenous malformation. A gross total resection was achieved in all the tumors and the AVM, while an effective decompression was successfully performed in both patients with conflict. No complications directly attributable to the use of the micromirror occurred. A relatively easy learning curve was noted. CONCLUSION: Micromirrors proved to be useful in enhancing the visualization of neurovascular structures and pathology residuals within deep-seated surgical fields without the need for fixed brain retraction. Their cost-effectiveness and easy learning curve constitute solid reasons for advocating a revitalization of this ?old but gold? tool in neurosurgery.