Multiple Abdominal abscesses following ventriculoperitoneal shunt placement in an immunosuppressed patient: An illustrative case.

Background: Ventriculoperitoneal (VP) shunt placement is one of the most performed procedures in neurosurgery to treat various types of hydrocephalus (HC). Immediate or late postoperative complications may quite commonly occur, especially in immunosuppressed patients, who are predisposed to develop rare and difficult-to-treat conditions. Case Description: Herein, we report the case of a 41-year-old female patient with a prior history of acute myeloid leukemia, followed by a tetra-ventricular acute HC due to a spontaneous non-aneurysmal subarachnoid hemorrhage. After an urgent external ventricular drainage placement, she underwent careful testing of "shunt dependency," which ended with a VP shunt placement. After 2 months, she presented at the emergency department with worsening abdominal pain and fever. She underwent a computed tomography scan with contrast administration, which has shown abscesses in the abdominal cavity. An urgent surgical revision of the VP shunt and antibiotics administration followed this. After inflammatory markers normalization, due to the high risk of post-infective peritoneal adherence and consequent impairment of cerebrospinal fluid absorption, a ventriculoatrial shunt was considered the most appropriate solution. Conclusion: Abdominal abscesses are a rare but subtle complication after VP shunt placement. Their management depends on etiology, patient clinical characteristics, and manifestations. Prompt interventions have been shown to improve clinical outcomes and optimize quality of life in such delicate patients.

Large Skull Metastasis in Follicular Thyroid Carcinoma: A Comprehensive Case Presentation and Systematic Review.

BACKGROUND: Skull metastases from follicular thyroid carcinoma (FTC) are infrequent but clinically significant, often presenting with localized pain, neurologic deficits, and cranial nerve dysfunction. Early detection and accurate diagnosis pose challenges due to their asymptomatic nature in some cases. METHODS: A systematic literature review, conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, identified and analyzed 15 relevant studies focusing on large skull metastases in FTC. Data extraction and synthesis included clinical presentation, diagnostic methods, treatment strategies, and patient outcomes. RESULTS: The systematic review encompassed 20 patients with secondary skull metastases from FTC, offering insights into the clinical diversity of this rare condition. Clinical presentations varied, with localized pain (70% of cases) and headaches being predominant symptoms. Imaging techniques, including computed tomography (CT) and magnetic resonance imaging (MRI), played a pivotal role in diagnosis. Surgical resection was considered in select cases, achieving complete or near-complete tumor removal in 30 to 50% of patients. Radiotherapy, including external beam radiation therapy (EBRT) and stereotactic radiosurgery (SRS), provided local control and symptom relief in 70 to 80% of cases. Systemic therapies, such as tyrosine kinase inhibitors (TKIs), showed promise in disease stabilization or regression (45% of patients). Prognosis remained poor, with a median overall survival of 6 to 12 months, reflecting an advanced and aggressive disease state. CONCLUSION: Managing secondary skull metastases from FTC requires a comprehensive approach, including surgical intervention, radiotherapy, and potential systemic therapies. The rarity of these metastases underscores the need for further research to establish standardized treatment guidelines, explore molecular profiling, and investigate immunotherapy and combination therapies, offering hope for improved outcomes in this challenging clinical scenario.

Intraventricular Cerebral Metastases: A Comprehensive Systematic Review.

BACKGROUND/AIM: Intraventricular cerebral metastases (IVCM) are a rare but clinically significant subset of brain metastases. This systematic review aimed to provide a comprehensive analysis of IVCM by synthesizing current literature on epidemiology, clinical presentation, imaging features, pathophysiology, and treatment options. MATERIALS AND METHODS: A systematic literature search was conducted, identifying 11 relevant studies encompassing 11 studies encompassing 842 IVCM cases. Data regarding primary tumor origins, patient demographics, presenting symptoms, treatment modalities, and survival outcomes were analyzed. RESULTS: IVCM cases displayed a diverse range of primary tumor origins, with the kidney (27.4%), thyroid (21.6%), lung (19.8%), colon (11.7%), melanoma (8.4%), and breast ductal carcinoma (7.9%) being common sources. Patients presented with a wide spectrum of symptoms, including headaches (42.3%), nausea (31.5%), altered mental status (25.7%), neurological deficits (18.2%), and others. Treatment approaches varied, encompassing surgical resection (41.2%), radiation therapy (32.5%), chemotherapy (15.3%), and immunotherapy (7.9%). Overall survival was generally limited, with a mean duration of approximately 10.3 months (±8.7 months). The time to recurrence after treatment exhibited considerable variability. CONCLUSION: IVCM represents a challenging and underexplored metastatic disease. This systematic review underscores the need for further research to enhance our understanding of IVCM's pathophysiology and develop tailored diagnostic and treatment approaches. Such efforts are crucial to improving outcomes and the overall quality of life for patients facing this complex condition. The multidisciplinary nature of IVCM management, involving neurologists, neurosurgeons, oncologists, radiologists, and other healthcare professionals, is emphasized as essential for individualized patient care.

The role of extended reality in eloquent area lesions: a systematic review.

OBJECTIVE: The surgical approach to lesions near eloquent areas continues to represent a challenge for neurosurgeons, despite all of the sophisticated tools currently used. The goal of surgery in eloquent areas is to maintain a good oncofunctional balance, that is, to preserve neurological function and ensure maximum tumor resection. Among all the available tools, extended reality (used to describe both virtual reality [VR] and mixed reality) is rapidly gaining a pivotal role in such delicate lesions, especially in preoperative planning, and recently, even during the surgical procedure. VR creates a completely new world in which only digital components are present. Augmented reality (AR), using software and hardware to introduce digital elements into the real-world environment, enhances the human experience. In addition, mixed reality, a more recent technique, combines VR and AR by projecting virtual objects into the real world, allowing the user to interact with them. METHODS: A systematic literature review of the last 23.5 years was conducted (January 2000-June 2023) to investigate and discuss all progress related to the emerging role and use of these new technologies (VR, AR, and mixed reality), particularly in eloquent area lesions as a pre- and/or intraoperative tool. RESULTS: Five hundred eighty-four published studies were identified. After removing duplicates and excluding articles that did not meet the inclusion criteria, 21 papers were included in the systematic review. The use of AR or VR was fully analyzed, considering their roles both intraoperatively and for surgical planning. CONCLUSIONS: The increasing use of such innovative technologies has completely changed the way to approach a lesion, using 3D visualization to foster a better understanding of its anatomical and vascular characteristics.

Improving mixed-reality neuronavigation with blue-green light: a comparative multimodal laboratory study.

OBJECTIVE: This study aimed to rigorously assess the accuracy of mixed-reality neuronavigation (MRN) in comparison with magnetic neuronavigation (MN) through a comprehensive phantom-based experiment. It introduces a novel dimension by examining the influence of blue-green light (BGL) on MRN accuracy, a previously unexplored avenue in this domain. METHODS: Twenty-nine phantoms, each meticulously marked with 5-6 fiducials, underwent CT scans as part of the navigation protocol. A 3D model was then superimposed onto a 3D-printed plaster skull using a semiautomatic registration process. The study meticulously evaluated the accuracy of both navigation techniques by pinpointing specific markers on the plaster surface. Precise measurements were then taken using digital calipers, with navigation conducted under three distinct lighting conditions: indirect white light (referred to as no light [NL]), direct white light (WL), and BGL. The research enlisted two operators with distinct levels of experience, one senior and one junior, to ensure a comprehensive analysis. The study was structured into two distinct experiments (experiment 1 [MN] and experiment 2 [MRN]) conducted by the two operators. Data analysis focused on calculating average and median values within subgroups, considering variables such as the type of lighting, precision, and recording time. RESULTS: In experiment 1, no statistically significant differences emerged between the two operators. However, in experiment 2, notable disparities became apparent, with the senior operator recording longer times but achieving higher precision. Most significantly, BGL consistently demonstrated a capacity to enhance accuracy in MRN across both experiments. CONCLUSIONS: This study demonstrated the substantial positive influence of BGL on MRN accuracy, providing profound implications for the design and implementation of mixed-reality systems. It also emphasized that integrating BGL into mixed-reality environments could profoundly improve user experience and performance. Further research is essential to validate these findings in real-world settings and explore the broader potential of BGL in a variety of mixed-reality applications.

The Use of Intraoperative Microvascular Doppler in Vascular Neurosurgery: Rationale and Results-A Systematic Review.

Surgical treatment of neurovascular lesions like intracranial aneurysms, arteriovenous malformations and arteriovenous dural fistulas is still associated with high morbidity. Several recent studies are providing increasing insights into reliable tools to improve surgery and reduce complications. Inadvertent vessel compromise and incomplete occlusion of the lesion represent the most possible complications in neurovascular surgery. It is clear that direct visual examination alone does not allow to identify all instances of vessel compromise. Various modalities, including angiography, microvascular Doppler and neurophysiological studies, have been utilized for hemodynamics of flow vessels in proper clipping of the aneurysm or complete obliteration of the lesion. We intended to review the current knowledge about the intraoperative microvascular Doppler (iMDS) employment in the most updated literature, and explore the most recent implications not only in intracranial aneurysms but also in neurovascular lesions like arteriovenous malformations (AVMs) and arteriovenous dural fistulas (AVDFs). According to the PRISMA guidelines, systematic research in the most updated platform was performed in order to provide a complete overview about iMDS employment in neurovascular surgery. Twelve articles were included in the present paper and analyzed according to specific research areas. iMDS employment could represent a crucial tool to improve surgery in neurovascular lesions. The safety and effectiveness of the surgical treatment of neurovascular lesions like intracranial aneurysm and other neurovascular lesions like AVMs and AVDFs requires careful and accurate consideration regarding the assessment of anatomy and blood flow. Prognosis may depend on suboptimal or incomplete exclusion of the lesion.

Corticocortical Evoked Potentials in Eloquent Brain Tumor Surgery. A Systematic Review.

Eloquent brain tumor surgery involves the delicate task of resecting tumors located in regions of the brain responsible for critical functions, such as language, motor control, and sensory perception. Preserving these functions is of paramount importance to maintain the patient's quality of life. Corticocortical evoked potentials (CCEPs) have emerged as a valuable intraoperative monitoring technique that aids in identifying and preserving eloquent cortical areas during surgery. This systematic review aimed to assess the utility of CCEPs in eloquent brain tumor surgery and determine their effectiveness in improving patient outcomes. A comprehensive literature search was conducted using electronic databases, including PubMed/Medline and Scopus. The search strategy identified 11 relevant articles for detailed analysis. The findings of the included studies consistently demonstrated the potential of CCEPs in guiding surgical decision making, minimizing the risk of postoperative neurological deficits, and mapping functional connectivity during surgery. However, further research and standardization are needed to fully establish the clinical benefits and refine the implementation of CCEPs in routine neurosurgical practice.

Pedicle Screw Placement Aided by C-Arm Fluoroscopy: A "Nevermore without" Technology to Pursue Optimal Spine Fixation.

The surgical technique and the intraoperative technology that support spinal pedicle screw placement have consistently evolved over the past decades to decrease the misplacement rate of pedicle screws. We retrospectively evaluated our case series by analyzing the period 2016-2020. Patients undergoing pedicle screw fixation for cervical, thoracic, or lumbar spine degenerative diseases have been included. Surgery was carried out with the aid of intraoperative 3D C-arm fluoroscopy to assess and optimize screw placement and/or correct possible mispositioning. Each patient underwent a postoperative CT scan. Our aim was to evaluate the safety and accuracy of pedicle screw placement and estimate the variation in mispositioning rates. We carried out 329 surgical procedures, as follows: 70 cervical, 78 thoracic spine, and 181 lumbar spine surgeries. An excellent overall pedicle screw positioning was obtained, with slight differences between the cervical (98.6%), thoracic (100%), and lumbar (98.9%) tracts. Accordingly, only three patients required a revision surgery owing to mispositioning (0.91%). In particular, intraoperative C-arm fluoroscopy significatively improved the accuracy of thoracic screw positioning, as shown by postoperative CT scans. Our experience proves the crucial role of intraoperative C-arm fluoroscopy in pursuing optimal technical results and improving patient outcomes at follow-up.

Fluoroscopy-Assisted Freehand Versus 3D-Navigated Imaging-Assisted Pedicle Screw Insertion: A Multicenter Study.

INTRODUCTION: Pedicle screw placement is a widely accepted surgical procedure for spinal fixation. Despite increases in knowledge about and expertise in pedicle screw insertion techniques, overall reported screw misplacement rates are still high. Spinal neuronavigation and intraoperative computed tomography (CT) imaging improves the accuracy and safety of pedicle screw placement through the continuous monitoring of screw trajectory. The purpose of this study is to compare pedicle screw placement under an O-arm intraoperative imaging system assisted by the StealthStation navigation system with screw placement under conventional fluoroscopy (C-arm). METHODS: For 222 patients, 1288 implanted pedicle screws in total were evaluated between 2018 and 2020. All patients underwent pedicle screw placement in the thoracic and lumbosacral regions through a posterior approach. Moreover, 107 patients (48.2%), 48 men and 59 women, underwent freehand screw placement under conventional fluoroscopy (C-arm group), whereas 115 patients (51.8%), 53 men and 62 women, underwent pedicle screw insertion under O-arm guidance with the help of the StealthStation neuronavigation system (Medtronic Navigation, Louisville, CO, USA) (O-arm group). Data were recorded and retrospectively analyzed. The accuracy of pedicle screw placement was postoperatively examined by using CT imaging and analyzed according to the Gertzbein-Robbins classification. RESULTS: Of the 1288 pedicle screws, 665 (51.6%) were placed with C-arm image-guided assistance with a mean of 6.21 ± 2.1 screws per patient and 643 (48.4%) with O-arm image-guided assistance with a mean of 5.59 ± 1.6 screws. The average time for the screw placement procedure was 3:57 ± 1:07 h in the C-arm group and 4:21 ± 1:41 h in the O-arm group. A correct screw placement was detected in 92.78% of patients in the C-arm group and in 98.13% of patients in the O-arm group. Medial cortical breach was shown in 13 Grade B screws (1.95%), 19 Grade C (2.86%), 14 Grade D (2.11%), and two Grade E (0.3%) in the C-arm group, whereas this was shown in 11 Grade B screws (1.71%) and one Grade C (0.16%) in the O-arm group. Lateral breach occurred in eight screws in both groups. Anterior vertebral body breach was shown in eight screws in the C-arm group, whereas it was shown in four screws in the O-arm group. Reoperation for screw misplacement was mandatory in five patients in the C-arm group and two patients in the O-arm group. CONCLUSION: Pedicle screw placement under an O-arm intraoperative imaging system assisted by spinal navigation showed greater accuracy compared with placement under conventional fluoroscopic control, thus avoiding the onset of major postoperative complications. Notably, a reduction in medial and anterior breaches has been demonstrated.

The Role of Augmented Reality Neuronavigation in Transsphenoidal Surgery: A Systematic Review.

In the field of minimally invasive neurosurgery, microscopic transsphenoidal surgery (MTS) and endoscopic transsphenoidal surgery (ETS) have been widely accepted as a safe approach for pituitary lesions and, more recently, their indications have been extended to lesions at various skull base regions. It is mandatory during transsphenoidal surgery (TS) to identify key anatomical landmarks in the sphenoid sinus and distinguish them from the lesion. Over the years, many intraoperative tools have been introduced to improve the neuronavigation systems aiming to achieve safer and more accurate neurosurgical interventions. However, traditional neuronavigation systems may lose the accuracy of real-time location due to the discrepancy between the actual surgical field and the preoperative 2D images. To deal with this, augmented reality (AR)-a new sophisticated 3D technology that superimposes computer-generated virtual objects onto the user's view of the real world-has been considered a promising tool. Particularly, in the field of TS, AR can minimize the anatomic challenges of traditional endoscopic or microscopic surgery, aiding in surgical training, preoperative planning and intra-operative orientation. The aim of this systematic review is to analyze the potential future role of augmented reality, both in endoscopic and microscopic transsphenoidal surgeries.

An Insight into the Prospects and Drawbacks of Stem Cell Therapy for Spinal Cord Injuries: Ongoing Trials and Future Directions.

Spinal cord injury (SCI) is a devastating neurological disorder that has a substantial detrimental impact on a person's quality of life. The estimated global incidence of SCI is 40 to 80 cases per million people and around 90% of cases are traumatic. Various etiologies can be recognized for SCI, and post-traumatic SCI represents the most common of these. Patients worldwide with SCI suffer from a persistent loss of motor and sensory function, which affects every aspect of their personal and social lives. Given the lack of effective treatments, many efforts have been made to seek a cure for this condition. In recent years, thanks to their ability to regenerate tissue and repair lost or damaged cells, much attention has been directed toward the use of stem cells (embryonic, induced pluripotent, mesenchymal, hematopoietic), aimed at restoring the functional integrity of the damaged spinal cord and improving a functional recovery including sensory and motor function. In this paper, we offer an overview of the benefits and drawbacks of stem cell therapy for SCI based on clinical evidence. This report also addresses the characteristics of various stem cell treatments, as well as the field's likely future. Each cell type targets specific pathological characteristics associated with SCI and demonstrates therapeutic effects via cell replacement, nutritional support, scaffolds, and immunomodulation pathways. SCI accompanied by complex pathological processes cannot be resolved by single treatment measures. Stem cells are associated with the adjustment of the expression of neurotrophic factors that help to achieve better nutrition to damaged tissue. Single-cell treatments have been shown in some studies to provide very minor benefits for SCI in multiple preclinical studies and a growing number of clinical trials. However, SCI damage is complex, and many studies are increasingly recognizing a combination approach such as physical therapy, electrical stimulation, or medication therapy to treatment.

Remote intracerebral hemorrhage following craniotomy for an intracerebral hematoma: A case report.

Remote intracerebral hemorrhage (RICH) is a rare yet highly consequential complication that can occur after a craniotomy performed for the evacuation of an intracerebral hemorrhage (ICH). In this case report, we present the clinical details of a 74-year-old female patient who underwent a supratentorial craniotomy to address an ICH, and subsequently developed RICH. A 74-year-old woman was admitted to our department with a severe headache, onset of dysarthria, and left-sided brachio-crural hemiparesis. The patient had a history of arterial hypertension and a previous cerebral ischemia incident 2 years prior, potentially due to cerebral amyloid angiopathy. Despite the immediate surgical intervention and intensive care, she succumbed to respiratory distress after developing a contralateral ICH. RICH following craniotomy for an intracerebral hematoma is a rare but potentially devastating complication. Close monitoring, prompt recognition of neurological deterioration, and timely intervention are imperative to optimize patient outcomes. Further research is needed to better understand the underlying mechanisms and risk factors associated with this complication, allowing for improved prevention and management strategies in the future.

Relationship Between Mediterranean Diet, Cardiovascular Risk Factors, and Meningiomas: A Retrospective Study.

BACKGROUND/AIM: The Mediterranean diet may be deemed as the best combination of nutrients to play a protective role against cancer. Previous studies have demonstrated how a healthy lifestyle, and the adherence to the Mediterranean diet might affect the onset of most common cancers, focusing less on their relationship with central nervous system (CNS) tumoral pathologies, especially benign ones, such as meningiomas. PATIENTS AND METHODS: This was a retrospective multicenter study, involving 52 patients who underwent meningioma resection and a group of 100 subjects not affected by brain tumors. This preliminary study aimed to investigate whether the non-adherence to a dietary pattern, such as the Mediterranean diet, and pre-existing cardiovascular risk factors can affect the onset of cranial meningiomas. RESULTS: Patients affected by meningioma had a significantly lower mean Mediterranean Diet Score (MDS), and a similar distribution of the main cardiovascular risk factors. CONCLUSION: A larger patient cohort is required to corroborate our findings. However, these promising results open up a new avenue for further exploration of the role of the Mediterranean diet in the development of meningiomas.

Assessing the Training in Neurosurgery with the Implementation of VITOM-3D Exoscope: Learning Curve on Experimental Model in Neurosurgical Practice.

(1) Background: Innovation and continuous demand in the field of visual enhancing technologies and video streaming have led to the discovery of new systems capable of improving visualization and illumination of the surgical field. The exoscope was brought into neurosurgical routine, and nearly ten years later, modern 3D systems have been introduced and tested, giving encouraging results. (2) Methods: In order to evaluate the surgeon's confidence with the exoscope and their increasing ability in terms of time spent and quality of the final achievement since their first encounter with the technique, an experimental trial on 18 neurosurgeons from a single Institution was performed to evaluate the learning curve for the use of the VITOM-3D exoscope in neurosurgical practice on a model of brain and dura mater. (3) Results: A significant improvement in the quality of the performance, number of errors made, and reduction in the time was found after the third iteration of the task, by when almost all the participants felt more comfortable and confident. No significant differences between senior neurosurgeons and resident neurosurgeons were reported. (4) Conclusions: Our results show that three iterations are enough to gain confidence with the exoscope from its first use, regardless of previous experience and training with an operating microscope.

Diffuse idiopathic skeletal hyperostosis: A functional enemy of vertebral stability - Case series and surgical consideration of craniovertebral junction involvement.

Context: Diffuse idiopathic skeletal hyperostosis (DISH) or Forestier's syndrome may reduce vertebral mobility, thus affecting the stability of adjacent vertebral segments and promoting spinal stenosis, vertebral dislocation, and unstable fracture secondary to low-energy trauma. Aims: This study aimed to contribute with a case series of three patients affected by DISH undergone surgery with occipitocervical fixation for craniovertebral junction (CVJ) instability since the poor literature about CVJ instability and surgery in patients affected by DISH. Settings and Design: This was a multicentric case series. Subjects and Methods: Literature about CVJ instability and surgery in patients affected by DISH is poor. Thus, we present a case series of three patients affected by DISH, who underwent surgery with occipitocervical fixation with different clinical and radiological patterns. Results: CVJ represents one of the most mobile joints of the spine and is at greater risk for instability. Moreover, instability itself may act as primum movens for several degenerative conditions such as cervical spondylosis, ossification of the posterior longitudinal ligament, and cervical deformities. On the contrary, DISH itself may worsen CVJ instability because of subaxial spine stiffness. In case of DISH, the rigid unit formed by several ossified vertebral bodies acts as a long lever arm, increasing the forces applied to the hypermobile CVJ and reducing the dynamic buffer capability of ossified spine. On the other hand, vertebral instability increases the odds of fractures. In such cases, CVJ posterior instrumentation and fusion is an effective and feasible surgical technique, aimed to restore vertebral stability and to halt the progression of spinal stenosis. Conclusions: Due to the altered dynamics cervical spine along with the possible comorbidities, treatment indication and surgery for patients affected by DISH must be tailored case by case.

Role of Mediterranean diet in the development and recurrence of meningiomas: a narrative review.

Several studies through the years have proven how an unhealthy nutrition, physical inactivity, sedentary lifestyle, obesity, and smoking represent relevant risk factors in cancer genesis. This study aims to provide an overview about the relationship between meningiomas and food assumption in the Mediterranean diet and whether it can be useful in meningioma prevention or it, somehow, can prevent their recurrence. The authors performed a wide literature search in PubMed and Scopus databases investigating the presence of a correlation between Mediterranean diet and meningiomas. The following MeSH and free text terms were used: "Meningiomas" AND "Diet" and "Brain tumors" AND "diet." Databases' search yielded a total of 749 articles. After duplicate removal, an abstract screening according to the eligibility criteria has been performed and 40 articles were selected. Thirty-one articles were excluded because they do not meet the inclusion criteria. Finally, a total of 9 articles were included in this review. It is widely established the key and protective role that a healthy lifestyle and a balanced diet can have against tumorigenesis. Nevertheless, studies focusing exclusively on the Mediterranean diet are still lacking. Thus, multicentric and/or prospective, randomized studies are mandatory to better assess and determine the impact of food assumptions in meningioma involvement.

The Role of Aquaporins in Epileptogenesis-A Systematic Review.

Aquaporins (AQPs) are a family of membrane proteins involved in the transport of water and ions across cell membranes. AQPs have been shown to be implicated in various physiological and pathological processes in the brain, including water homeostasis, cell migration, and inflammation, among others. Epileptogenesis is a complex and multifactorial process that involves alterations in the structure and function of neuronal networks. Recent evidence suggests that AQPs may also play a role in the pathogenesis of epilepsy. In animal models of epilepsy, AQPs have been shown to be upregulated in regions of the brain that are involved in seizure generation, suggesting that they may contribute to the hyperexcitability of neuronal networks. Moreover, genetic studies have identified mutations in AQP genes associated with an increased risk of developing epilepsy. Our review aims to investigate the role of AQPs in epilepsy and seizure onset from a pathophysiological point of view, pointing out the potential molecular mechanism and their clinical implications.