Post Surgical Management of WHO Grade II Meningiomas: Our Experience, the Role of Gamma Knife and a Literature Review.

Purpose: Grade II meningiomas are rarer than Grade I, and when operated on, bear a higher risk of local recurrence, with a 5-year progression free survival (PFS) ranging from 59 to 90%. Radiotherapy (RT) or radiosurgery, such as Gamma Knife radiosurgery (GKRS) can reduce the risk of relapse in patients with residual disease, even if their role, particularly after gross total resection (GTR), is still under debate. Main goal of this study was to compare the outcomes of different post-surgical management of grade II meningiomas, grouped by degree of surgical removal (Simpson Grade); next in order we wanted to define the role of GKRS for the treatment of residual disease or relapse. Methods: from November 2016 to November 2020 all patients harboring grade II meningiomas, were divided into three groups, based on post-surgical management: (1) wait and see, (2) conventional adjuvant radiotherapy and (3) stereotactic GKRS radiosurgery. Relapse rate and PFS were registered at the time of last follow up and results were classified as stable, recurrence next to or distant from the surgical cavity. In the second part of the study we collected data of all patients who underwent GKRS in our Centers from November 2017 to November 2020. Results: A total of 37 patients were recruited, including seven patients with multiple meningiomas. Out of 47 meningiomas, 33 (70.2%) were followed with a wait and see strategy, six (12.7%) were treated with adjuvant radiotherapy, and 8 patients (17.0%) with adjuvant GKRS. Follow up data were available for 43 (91.4%) meningiomas. Within the wait and see group, recurrence rates differed based on Simpson grades, lower recurrence rates being observed in three Simpson I cases (30%) compared to twelve relapses (60%) in patients with Simpson grade II/III. Finally, out of the 24 meningiomas undergoing GKRS (8 residual and 16 recurrence), 21 remained stable at follow up. Conclusions: Gross total resection (GTR) Simpson II and III have a significantly worse outcome as compared to Simpson I. The absence of adjuvant treatment leads to significant worsening of the disease progression curve. Adjuvant radiotherapy, especially GKRS, provides good local control of the disease and should be considered as an adjuvant treatment in all cases where Simpson I resection is not possible.

Safety and feasibility of lumbar drainage in the management of poor grade aneurysmal subarachnoid hemorrhage.

The use of lumbar drain (LD) in the aneurysmal subarachnoid hemorrhage (aSAH) has been described to reduce cerebral vasospasm and delayed cerebral ischemia (DCI), with a lack of studies referring to high grade population. The purpose of our study is to assess safety and feasibility of LD in the poor grade aSAH population subjected to endovascular aneurysm occlusion. Twenty-four consecutive poor grade aSAH patients, defined as grade IV and V according to World Federation of Neurological Surgeons (WFNS) classification, subjected to endovascular aneurysm occlusion, were retrospectively reviewed. Details of CSF drainage via LD and related complications were analyzed. Ventriculo-lumbar pressure gradient (VLPG) lower than 6 mmHg was considered in order to start LD use. Good outcome was defined as modified Rankin Scale (mRS) 0-2. LD was started within 72 h since aSAH in 17 cases (70.8%), and in 7 cases (29.2%) it was delayed due to contraindications. The mean LD length was of 13.8 days. The median VLPG during drainage was 2 mmHg (IQR: 0-4). No cases of brain or spinal hemorrhage, permanent neurological worsening due to brain herniation were noted. Three cases (12.5%) of CSF infection and a related death (4.2%) were reported. The use of LD, in association with external ventricular drain (EVD), seems to be safe and feasible in the poor grade aSAH population. VLPG monitoring seems to play a key role in avoiding potentially severe complications.

Bone resorption in autologous cryopreserved cranioplasty: quantitative evaluation, semiquantitative score and clinical significance.

BACKGROUND: Changes after reimplantation of the autologous bone have been largely described. However, the rate and the extent of resorption in cranial grafts have not been clearly defined. Aim of our study is to evaluate the bone flap resorption (BFR) after cryopreservation. METHODS: We retrospectively reviewed 27 patients, aged 18 years or older, subjected to cranioplasty (CP) adopting autologous cryopreserved flap. The BFR was derived from the percentage of decrease in flap volume (BFR%), comparing the first post-operative computed tomography (CT) and the last one available (performed at least 1 year after surgery). We also proposed a semiquantitative scoring system, based on CT, to define a clinically workable BFR classification. RESULTS: After a mean ± SE follow-up of 32.5 ± 2.4 months, the bone flap volume decreased significantly (p < 0.0001). The mean BFR% was 31.7 ± 3.8% and correlated with CT-score (p < 0.001). Three BFR classes were described: mild (14.8% of cases) consisting in minimal bone remodelling, CT-score ≤ 6, mean BFR% = 3.5 ± 0.7%; moderate (51.9% of cases) corresponding to satisfactory cerebral protection, CT-score < 13, mean BFR% = 25.6 ± 2.2%; severe (33.3% of cases) consisting in loss of cerebral protection, CT-score ≥ 13, mean BFR% = 54.2 ± 3.9%. Females had higher BFR% than males (p = 0.022). BFR classes and new reconstructive surgery were not related (p = 0.58). CONCLUSIONS: BFR was moderate or severe in 85.2% of re-implanted cryopreserved flaps. The proposed CT-score is an easy and reproducible tool to define resorption extent.

Usefulness of Ultrasound-Guided Microsurgery in Cavernous Angioma Removal.

BACKGROUND: Primary elements of surgical treatment of cavernous angiomas (CAs) are precise lesion identification and optimal trajectory determination. Navigation techniques allow for better results compared to microsurgery alone. In this study, we examined the benefits of intraoperative ultrasound (IOUS) use as an adjunct to standard localization systems. METHODS: We retrospectively analyzed 59 CAs, comparing outcomes in 2 groups of patients: 34 who underwent frame-based or frameless navigation-assisted microsurgery (no-IOUS group) and 25 who underwent IOUS-guided microsurgery associated with these techniques (IOUS group). RESULTS: The use of IOUS did not significantly increase the surgery time (mean, 172 ± 1.7 minutes in the IOUS group and 192.6 ± 11.5 in no-IOUS group; P = 0.08). In all 25 patients in the IOUS group, IOUS allowed for ready identification of CA as a hyperechoic mass. At the last follow-up (mean, 41.7 ± 3.5 months postsurgery), 95.2% of the IOUS group and 80.8% of the no-IOUS group had a modified Rankin Scale score of 0-1 and an Extended Glasgow Outcome Scale score of 7-8 (P = 0.2), with 100% and 64%, respectively, included in Engel outcome scale class IA (P = 0.006). Complete removal, as confirmed on postoperative magnetic resonance imaging, was achieved in all patients in the IOUS group and in almost all (97.1%; P = 0.4) patients in the no-IOUS group. CONCLUSIONS: IOUS is a valid tool for the intraoperative identification of CAs. Implementation of standard localization methods with IOUS guidance was associated with complete resection in all cases, without increasing surgical time. Compared with microsurgery without IOUS guidance, long-term functional outcomes showed better trends, and the epilepsy-free rate was significantly higher.

Fronto-orbitozygomatic approach: functional and cosmetic outcomes in a series of 169 patients.

OBJECTIVE Advantages of the fronto-orbitozygomatic (FOZ) approach have been reported extensively in the literature; nevertheless, restoration of normal anatomy and the esthetic impact of surgery are increasingly important issues for patients and neurosurgeons. The aim of this study was to analyze functional and cosmetic outcomes in a series of 169 patients with different pathologies who underwent surgery in which the FOZ approach was used. METHODS Between January 2000 and December 2014, 250 consecutive patients underwent surgery with an FOZ approach as the primary surgical treatment. Follow-up data were available for only 169 patients; 103 (60.9%) of these patients were female and 66 (39.1%) were male, and their ages ranged from 6 to 77 years (mean 46.9 years; SD 15.6 years). Mean follow-up time was 66 months (range 6-179 months; SD 49.5 months). Evaluation of clinical outcomes was performed with a focus on 4 main issues: surgical complications, functional outcome, cosmetic outcome, and patient satisfaction. The additional time needed to perform orbitotomy and orbital reconstruction was also evaluated. RESULTS The permanent postoperative complications included forehead hypesthesia (41.4%) and dysesthesia (15.3%), frontal muscle weakness (10.3%), exophthalmos (1.4%), enophthalmos (4.1%), diplopia (6.6%; 2% were related to surgical approach), and persistent periorbital and eyelid swelling (3%). Approximately 90% of the patients reported subjectively that surgery did not affect their quality of life or complained of only minor problems that did not influence their quality of life significantly. The mean time needed for orbitotomy and orbital reconstruction was approximately half an hour. CONCLUSIONS Comprehensive knowledge of the potential complications and overall clinical outcomes of the FOZ approach can be of great utility to neurosurgeons in balancing the well-known benefits of the approach with potential additional morbidities.

Safety of transsphenoidal microsurgical approach in patients with an ACTH-secreting pituitary adenoma.

PURPOSE: Patients affected by Cushing's disease often have important comorbidities directly linked to hypercortisolism that might enhance the operative risk. We report the safety of transsphenoidal surgery in patients affected by Cushing's disease as compared with patients with nonfunctioning pituitary adenoma. METHODS: We have retrospectively analyzed 142 patients with Cushing's disease and 299 patients with nonfunctioning pituitary adenoma who underwent transsphenoidal surgery performed by a single experienced neurosurgeon between September 2007 and December 2014. For all of them, an intraoperative computerized anesthetic record for the automatic storage of data was available. RESULTS: The intraoperative vital parameters and the frequency of drugs administered during anesthesia were comparable between Cushing's disease and nonfunctioning pituitary adenoma groups. The duration of surgery was similar between the two groups (41.2 ± 11.8 vs. 42.9 ± 15.6 min), while the duration of anesthesia was slightly shorter in Cushing's disease patients (97.6 ± 18.1 min) than in nonfunctioning pituitary adenoma patients (101.6 ± 20.6 min, p = 0.04). The total perioperative mortality rate was 0.2% (0% in Cushing's disease vs. 0.3% in nonfunctioning pituitary adenoma). Cushing's disease patients had surgical and medical complication rates of 3.5% each, not different from those occurring in nonfunctioning pituitary adenoma. The postoperative incidence of diabetes insipidus (10.6%) and isolated hyponatremia (10.6%) in Cushing's disease patients was significantly higher than in nonfunctioning pituitary adenoma patients (4.4 and 4.1%; p = 0.02 and p = 0.01, respectively). CONCLUSIONS: In a large series of unselected and consecutive patients with Cushing's disease, transsphenoidal surgery performed by one dedicated experienced neurosurgeon had a reasonably low risk of complications. In particular, despite the higher burden of comorbidities typically associated with hypercortisolism, medical complications are rare and no more frequent than in patients with nonfunctioning pituitary adenoma.