Tuberculum sellae meningiomas: surgical outcomes in 65 patients, review of the literature and proposal for an anatomical and radiological classification.

Tuberculum sellae meningiomas (TSM) are challenging tumors due to their proximity to vital neurovascular structures. We propose a new classification system based on anatomical and radiological parameters. All patients treated for TSM, between January 2003 and December 2016, have been retrospectively reviewed. A systematic research was performed in PubMed database to review all studies comparing the performance of transcranial (TCA) and transphenoidal (ETSA) approaches. Overall, 65 patients were included in the surgical series. Gross total removal (GTR) was achieved in 55 patients (85%) and near total resection in 10 (15%). 54 patients (83%) showed a stability or an improvement of visual functions and 11 (17%) worsened. Postoperative complications were observed in seven patients (11%): CSF leak in one patient (1.5%); diabetes insipidus in two (3%); hypopituitarism in two (3%) third cranial nerve paresis and subdural empyema in one (1.5%). For the literature review, data about 10,833 patients (TCA N.=9159; ETSA N.=1674) were recorded; GTR was achieved in 84.1% (range 68-92%) of TCA and in 79.1% (range 60-92%) of ETSA; visual improvement (VI) occurred in 59.3% of TCA (range 25-84%) and in 79.3% of ETSA (range 46-100%); visual deterioration (VD) was registered in 12.7% of TCA (0-24%) and in 4.1% of ETSA (range 0-17%); a CSF-leak was observed in 3.8% of TCA (range 0-8%) while in ETSA in 18.6% of patients (range 0-62%); vascular injuries was reported in 4% (range 0-15%) of TCA and in 1.5% (range 0-5%) of ETSA. In conclusion, TSMs represent a unique category of midline tumors. The proposed classification system provides an intuitive and reproducible method in the choice of the most suitable approach.

Role of 1p/19q Codeletion in Diffuse Low-grade Glioma Tumour Prognosis.

BACKGROUND/AIM: In the latest 2021 WHO classification of central nervous system tumours (CNS), gliomas that present isocitrate dehydrogenase (IDH) mutations are defined as diffuse low-grade gliomas (DLGGs). IDH mutations are commonly observed in this tumour type. The Extent of Resection (EOR) positively influence survival; however, it is still debated whether the predictive value of EOR is independent of the 1p/19q co-deletion. We carried out a retrospective analysis on patients operated on for DLGG at the Sant'Andrea University Hospital Sapienza University of Rome, correlating the outcome with the presence of 1p/19q co-deletion and EOR. PATIENTS AND METHODS: The study examined 66 patients with DLGG who had undergone surgery for tumour resection between 2008 and 2018. Patients with DLGG were divided into two groups; diffuse astrocytoma (DA) in which 1p/19q codeletion is absent and oligodendroglioma (OG) in which 1p/19q codeletion is present. According to EOR, both groups were divided into two subgroups: subtotal resection (STR) and gross total resection (GTR). Three end-point variables were considered: overall survival (OS), progression-free survival (PFS) and time to malignant transformation (TMT). RESULTS: In the DA group, the GTR subgroup had an average OS of 81.6 months, an average PFS of 45.9 months and an average TMT of 63.6 months. After surgery, these patients had an average Karnofsky Performance Score (KPS) of 83.4. The STR subgroup had an average OS of 60.4 months, PFS was 38.7 months, and TMT was 46.4 months, post-operative KPS was 83.4. In contrast, in the OG group, the GTR averagely had 101.7 months of OS, 64.9 months of PFS, 80.3 months of TMT and an average post-operative KPS of 84.2, and the STR subgroup had an average of OS of 73.3 months, PFS of 48.2 months, TMT of 57.3 and an average postoperative KPS of 96.2. CONCLUSION: In patients affected by DLGGs, 1p/19q codeletion is significantly associated with prolonged survival and longer time-to-malignant transformation (TMT) compared to the absence of 1p/19q codeletion. Also, the extent of surgical resection (EOR) in DLGG patients has been confirmed as one of the main prognostic factors. However, its predictive value is substantially influenced by the presence of the 1p/19q codeletion.

An understimated maneuver for oculomotor nerve palsy due to posterior communicating artery aneurysm: the opening of the anterior petroclinoid ligament. A technical note.

Posterior communicating artery aneurysms (PcomAs) present with oculomotor nerve (OMN) palsy in 20-30% of cases, and the sudden onset of OMN palsy has to raise the suspicion of rupture, until proven otherwise. The surgical technique is described in a stepwise fashion. An illustrative case is reported: a 57-year-old female was admitted to our department with the diagnosis of a right sided-PcomA. Three months before the admission, when she harbored with the acute onset of complete ptosis, diplopia, orbital pain, impairment of the medial, upward, and downward gaze, with no pupil dysfunction. The origin of the Pcom and the neck of the aneurysm were easily identified and the aneurysm was clipped. Then, we followed the OMN and cut for less than 4 mm the above-lying anterior petroclinoid ligament (APL) to obtain nerve release. Although few cases are described in the literature, and ours represents a single case, we support that this maneuver should be introduced in the clinical practice of expert neurosurgeons dealing with vascular pathologies, such as the opening of the falciform ligament occurs for the decompression of the optical nerve.

Full-Thickness Craniodural Metastasis with Leptomeningeal Infiltration of Salivary Origin: A Radiological Lesson and a Technical Remark.

Calvarial metastases are a relatively rare entity, with an overall incidence of 3-4%. Among these cases, metastases arising from salivary gland cancers are even rarer; in fact, large studies regarding salivary gland tumors showed that brain metastases are observed in 0.8% of the cases. Generally, bone metastases have been described in proximity to primary tumors, while bloodstream-disseminated lesions are often located inside the brain parenchyma. During every surgical step, traction on lower-lying infiltrated tissues must be avoided in order to successfully remove the lesion. This case report presents the first ever case of a 67-year-old woman affected by submandibular gland undifferentiated adenocarcinoma metastasis with a full-thickness involvement of the calvarium, pachy- and leptomeninges.

Microsurgical clipping of Unruptured Intracranial Aneurysms (UIA) by a single surgeon's experience: why we should definitely preserve the neurosurgical skills in our health areas.

BACKGROUND: The long standing comparison between the endovascular and microsurgical treatment is still ongoing. While not any center avails of a neuroendovascular service, and not every aneurysm is suitable for endovascular treatment, the neurovascular technique is slowly disappearing from our territories, whereas in the current Literature, the role of the neurosurgical treatment is being re-appreciated. The objective of this paper is to discuss a single surgeon's clinical and radiological results with the microsurgical management of UIA. METHODS: We retrospectively reviewed the clinical and radiological records of patients treated for UIA, by a single surgeon,in the period ranging between 2015 and 2019. We recorded all the relevant anatomic features of the aneurysm, saliencies of the surgical treatment, such as the need for temporary clipping, intraoperative rupture or postoperative complications. The results of the clinical and radiological follow-up examinations were recorded either. RESULTS: Fifty-eight patient undergoing microsurgical clipping were included, harboring a total of 65 UIAs. CTA with 3D reconstructions was sufficient to reach a reliable preoperative planning in 46 patients (76%). A total of 94% of the cases were unchanged or neurologically unremarkable at follow-up. The presence of postoperative complications was associated to the neck size and predictor of a longer hospitalizations, as well as longer hospitalizations are associated to the patients' age, size of the aneurysms and surgical times. CONCLUSIONS: According to our experience, we believe that microsurgical clipping plays a critical role in the management of UIA, also on the ground of the encouraging results of the relevant Literature.

Time Trends in Outcomes After Aneurysmal Subarachnoid Hemorrhage Over the Past 30 Years.

OBJECTIVE: To analyze trends in mortality rates, functional outcomes, and treatment in patients with aneurysmal subarachnoid hemorrhage (aSAH) over the past 3 decades. PATIENTS AND METHODS: We conducted a retrospective review of consecutive patients with aSAH treated at Mayo Clinic in Rochester, Minnesota, between January 1, 1985, and December 31, 2014. RESULTS: A total of 1173 patients identified were grouped by decade of treatment: 1985 to 1994, n=274; 1995 to 2004, n=461; and 2005 to 2014, n=438. Overall, the use of endovascular techniques increased progressively from 5.1% (14) in 1985 to 1994 to 65.5% (287) in 2005 to 2014. This corresponded to a progressive decrease in the rate of clipping from 78.8% (216) in 1985 to 2004 to 21.5% (94) in 2005 to 2014 (P<.001). The percentage of patients admitted with poor clinical grade also increased from 22.3% (61) in 1985 to 1994 to 24.1% (111) in 1995 to 2004 and 29.5% (129) in 2005 to 2014 (P=.06). The in-hospital mortality rate decreased from 22.6% (62) in 1985 to 1994 to 16.3% (75) in 1995 to 2004 and remained relatively constant at 16.7% (73) in 2005 to 2014. Good functional outcome at 3- to 6-month follow-up improved significantly from 64.8% (173) in 1985 to 1994 to 72% (332) in 1995 to 2004 and 78.8% (345) in 2005 to 2014 (P<.001). CONCLUSION: Outcomes in patients with aSAH have markedly improved over the past 3 decades, in terms of both in-hospital survival and functional recovery of survivors. Higher rates of endovascular coiling over time paralleled these improvements in clinical outcomes. More detailed investigation is necessary to determine whether this or other factors may directly explain the favorable trends in survival and functional recovery over time.

Surgical approach to posterior inferior cerebellar artery aneurysms.

BACKGROUND: The far-lateral is a standardised approach to clip aneurysms of the posterior inferior cerebellar artery (PICA). Different variants can be adopted to manage aneurysms that differ in morphology, topography, ruptured status, cerebellar swelling and surgeon preference. METHOD: We distinguished five paradigmatic approaches aimed to manage aneurysms that are: proximal unruptured; proximal ruptured requiring posterior fossa decompression (PFD); proximal ruptured not requiring PFD; distal unruptured; distal ruptured. CONCLUSIONS: Preoperative planning in the setting of PICA aneurysm surgery is of paramount importance to perform an effective and safe procedure, to ensure an adequate PFD and optimal proximal control before aneurysm manipulation.

Vertebroplasty and delayed subdural cauda equina hematoma: Review of literature and case report.

Vertebroplasy is considered an alternative and effective treatment of painful oncologic spine disease. Major complications are very rare, but with high morbidity and occur in less than 1% of patients who undergo vertebroplasty. Spinal subdural hematoma (SDH) is an extremely rare complication, usual developing within 12 h to 24 h after the procedure. We report the case of a tardive SDH in an oncologic patient who underwent VP for Myxoid Liposarcoma metastasis. Trying to explain the pathogenesis, we support the hypothesis that both venous congestion of the vertebral venous plexus of the vertebral body and venous congestion due to a traumatic injury can provoke SDH. To our best knowledge, only 4 cases of spinal subdural hematoma following a transpedicular vertebroplasty have been previously described in International literature and only one of them occurred two weeks after that surgical procedures. Percutaneous verteboplasty is a well-known treatment of pain oncologic spine disease, used to provide pain relief and improvement of quality life and is considered a simple surgical procedure, involving a low risk of complications, but related to high morbidity, such as SDH. Therefore it has to be performed by experienced and skilled surgeons, that should also recognize possible risk factors, making SDH more risky.

How I do it: surgical ligation of craniocervical junction dural AV fistulas.

BACKGROUND: Dural arteriovenous fistulas (DAVFs) of the craniocervical junction are uncommon vascular lesions, which often require surgical treatment even in the endovascular era. METHODS: Most commonly, the fistula is placed laterally, and surgical ligation is performed through a lateral suboccipital craniotomy. After dural opening, the area is inspected, and the arterialized vein is identified emerging from the dura, often adjacent to the entry point of the vertebral artery, and ligated. CONCLUSIONS: A far lateral craniotomy is the authors' preferred surgical approach for accessing and treating dural arteriovenous fistulas of the craniocervical junction that cannot be reached endovascularly.

The paramedian supracerebellar infratentorial approach.

BACKGROUND: Lesions of the superior cerebellar surface, pineal region, lateral and dorsal midbrain and mesial temporal lobe are challenging to treat and often require neurosurgical intervention. METHODS: The paramedian variation of the supracerebellar infratentorial approach utilizes the downward slope of the cerebellum to facilitate exposure and the lower density of cerebellar bridging veins away from the midline decreases the need to sacrifice larger venous channels. We also discuss our experiences with the approach, and some of the drawbacks and nuances that we have encountered as it has evolved over the years. CONCLUSIONS: This approach is versatile and effective and the authors' surgical approach of choice for resecting these challenging lesions.

Clipping in Awake Surgery as End-Stage in a Complex Internal Carotid Artery Aneurysm After Failure of Multimodal Endovascular and Extracranial-Intracranial Bypass Treatment.

BACKGROUND: Intracranial carotid artery aneurysm can be treated via microsurgical or endovascular techniques. The optimal planning is the result of the careful patient selection through clinical, anatomic, and angiographic analysis. CLINICAL PRESENTATION: We present a case of ruptured internal carotid artery (ICA) aneurysm that became a complex aneurysm after failure of multi-endovascular and surgery treatment. We describe complete trapping in awake craniotomy after failure of coiling, stenting, and bypassing. CONCLUSIONS: ICA aneurysms could become complex aneurysms following multi-treatment failure. Endovascular approaches to treat ICA aneurysms include coiling, stenting, flow diverter stenting, and stenting-assisted coiling technique. The role of surgery remains relevant. To avoid severe neurologic deficits, recurrence, and the need of retreatment, a multidisciplinary discussion with experienced endovascular and vascular neurosurgeons is mandatory in such complex cases.

Reversible Edema-Like Changes Along the Optic Tract Following Pipeline-Assisted Coiling of a Large Anterior Communicating Artery Aneurysm.

Aneurysmal volume expansion after endovascular treatment is caused by intra-aneurysmal thrombosis in the early postembolization period. Although postembolization mass effect on cranial nerves and other adjacent structures has been previously reported, we are unaware of reports involving the anterior visual pathway. A 66-year-old woman with a 2-week history of blurred vision without headache was found to have a large, unruptured anterior communicating artery aneurysm. One month after endovascular treatment of the aneurysm with coiling and flow diversion, the patient developed decreased vision in her right eye and a left homonymous hemianopia. Magnetic resonance imaging demonstrated compression of the right optic nerve, chiasm, and edema of the right optic tract. The patient was treated with a course of high dose corticosteroids, and over the course of several weeks, her vision improved and the optic tract edema resolved. We alert clinicians to this rare but potentially reversible visual complication of endovascular treatment of intracranial aneurysms.

Unruptured internal carotid artery bifurcation aneurysms: general features and overall results after modern treatment.

BACKGROUND: Internal carotid artery bifurcation aneurysms (ICAbifAs) present unique challenges to endovascular and surgical operators, and little is known about their natural history. We reviewed our institution's experience with ICAbifAs studying outcomes of surgical and endovascular management and natural history. METHODS: Consecutive patients with unruptured ICAbifAs evaluated and/or treated over an 8-year interval were studied. Baseline demographics, neurovascular risk factors, aneurysm location and size, clinical presentation, treatment recommendations, and outcomes were prospectively collected and retrospectively analyzed. Continuous variables were compared with Student's t test and categorical variables with Chi-square tests. RESULTS: Fifty-nine patients with 61 unruptured ICAbifAs were included. Seven aneurysms were treated surgically (11.5 %), 22 underwent endovascular treatment (36 %), and 32 were managed conservatively (52.5 %). In the surgical group, short- and long-term complete aneurysm occlusion rates were 100 % with no cases of perioperative or long-term permanent morbidity or treatment-related mortality. In the endovascular group, two patients (11.7 %) with giant aneurysms had perioperative thromboembolic events with transient morbidity. There was one case of aneurysm rupture at follow-up in a giant aneurysm treated with partial coil embolization. Complete/near-complete occlusion rates were 63 %. There was one case of aneurysm rupture after 114 aneurysm-years of follow-up in the conservative management group (0.89 %/year), but no ruptures were observed in small aneurysms selected for conservative management. CONCLUSIONS: Unruptured small ICAbifAs have a benign natural history. In patients selected for treatment, excellent results can be achieved in the vast majority of patients with judicious use of endovascular and surgical therapy.