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.

Preoperative Angiographic Protocol for the Surgical Management of Spinal Dural Arteriovenous Fistulas: A Technical Nuance for Safe Minimally Invasive Surgery.

BACKGROUND: Interruption of the fistulous point is the goal of treatment of spinal dural arteriovenous fistulas (dAVFs). Microsurgery remains a highly efficient treatment in terms of complete occlusion with the lowest risk of recurrence rate. It is reported that the hardest step involves finding the fistulous site itself, potentially extending surgical access and time and increasing potential postoperative surgical-related complications. The accurate preoperative detection of the shunt and spinal level together is crucial for guiding optimal, fast, and safe microsurgical treatment. METHODS: We describe a preoperative angiographic protocol for achieving a safe and simple resection of spinal dural arteriovenous fistulas based on a 6-year institutional experience of 42 patients who underwent minimally invasive procedures. Two illustrative cases are included to support the technical descriptions. RESULTS: The suspected artery associated with the vascular malformation of interest is studied in our angiographic protocol through nonsubtracted selective acquisitions in lateral projection. The resulting frames are reconstructed with three-dimensional rotational angiography. The implementation of the preoperative angiographic protocol allowed 100% of intraoperative identification of the fistulous point in all cases with the use of a minimally invasive approach. CONCLUSIONS: Nowadays, neurosurgeons advocate for minimally invasive procedures and procedures with low morbidity risk for treatment of spinal dural arteriovenous fistulas. Our preoperative approach for accurate angiographic localization of the fistulous point through nonsubtracted and three-dimensional reconstructed angiography allowed us to achieve safe and definitive occlusion of the shunt.

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.

Assessing the impact of mixed reality-assisted informed consent: A study protocol.

Background: Informed consent is a crucial aspect of modern medicine, but it can be challenging due to the complexity of the information involved. Mixed reality (MR) has emerged as a promising technology to improve communication. However, there is a lack of comprehensive research on the impact of MR on medical informed consent. The proposed research protocol provides a solid foundation for conducting future investigations and developing MR-based protocols that can enhance patients' understanding and engagement in the decision-making process. Methods: This study will employ a randomized controlled trial design. Two arms will be defined: MR-assisted informed consent (MRaIC) as the experimental arm and conventional informed consent (CIC) as the control arm consent, with 52 patients in each group. The protocol includes the use of questionnaires to analyze the anxiety levels and the awareness of the procedure that the patient is going to perform to study the impact of MRaIC versus CIC before medical procedures. Results: The study will evaluate the impact of MR on patients' information comprehension, engagement during the process of obtaining informed consent, emotional reactions, and consent decisions. Ethical concerns will be addressed. Conclusion: This study protocol provides a comprehensive approach to investigate the impact of MR on medical informed consent. The findings may contribute to a better understanding of the effects of MR on information comprehension, engagement during the process of obtaining informed consent, psychological experience, consent decisions, and ethical considerations. The integration of MR technology has the potential to enhance surgical communication practices and improve the informed consent process.

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.

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.

Spinal Cord Stimulation Meets Them All: An Effective Treatment for Different Pain Conditions. Our Experience and Literature Review.

IntroductionSpinal Cord Stimulation (SCS) is an emerging minimally invasive technique which uses neuromodulation to manage different forms of intractable pain. SCS is a well-established option for the treatment of various pain conditions, and nowadays, indications are ever increasing.Materials and MethodsIn this study, we present our case series of 49 patients who underwent SCS at our Institution for the treatment of pain from different etiologies, and discuss our 10-year experience in SCS. For the purpose of this study, we also performed a systematic review of current indications and new perspectives in SCS.ResultsAmong our case series, patients were differentiated into two groups upon prior spinal surgery: patients who had undergone prior spinal surgery for back pain were defined as the "FBSS (failed back surgery syndrome) group," instead patient suffering from different types of pain but who had never undergone surgery were defined as the "naive group." As regards clinical response to SCS, 20 patients out of 36 (55.56%) were classified as responders in the FBSS group; in the "naïve" group, 10 patients out of 13 (76.92%) were classified as responders. Among the "not responders" group, several patients suffered from infections.Of the recent literature about SCS, 2124 records were screened and 37 studies were finally included in the qualitative synthesis for our systematic review.DiscussionIn case of FBSS, surgical revision is often associated with a high morbidity and corresponding low rates of success. Unfortunately, patients affected by chronic pain often become refractory to conservative treatments. Spinal Cord Stimulation (SCS) is nowadays considered as an effective therapy for several chronic and neuropathic pain conditions, such as failed back surgery syndrome. As regards the economic impact of SCS, implantation of an SCS system results in short-term costs increase, but the annual cumulative costs decrease during the following years after implantation, when compared to the costs of conventional management. Beyond the application for the treatment of FBSS, SCS has also been used for the treatment of other types of chronic non-oncological pain such as neuropathic pain and chronic back pain ineligible for surgical intervention. This evidence paved the way to establishing the potential role of SCS also for the treatment of oncological pain. However, the effectiveness and relative safety of SCS for cancer-related pain has not yet been adequately established.ConclusionsSpinal Cord Stimulation is a well-established treatment option in for FBSS. Beyond that, SCS has also been used for the treatment of "naive" patients, suffering from other types of chronic, both oncological and non-oncological, medical-refractory pain such as neuropathic pain and chronic back pain ineligible for surgical intervention.

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.

New Trend in Craniovertebral Junction Surgical Strategy: Technical Note for the Treatment of Hangman's Fractures Through a Minimally Invasive Approach.

INTRODUCTION: The reduction, stabilization, and maintenance of alignment are the main goals in the surgical treatment of unstable hangman's fractures. The choice of the surgical strategy remains poorly standardized; anterior and/or posterior fusion could be performed; and none of the available clinical studies in the literature have shown significant differences in outcomes or complication rates. Vertebral anatomy, age, comorbidities, patient factors, and surgical experience may guide the treatment choice. METHODS: We present a case of a polytraumatized young woman with an unstable hangman's fracture type II, according to Levine-Edwards classification. We treated the fracture by using a plate with four holes to fix C2-C3 without discectomy and body fusion. RESULTS: We performed a small incision, such as those used for the fixation of odontoid screws, where the working angle allowed us to easily and quickly position the plate by using a minimally invasive approach. CONCLUSION: The stabilization alone, without discectomy and body fusion with the cage, in the same way favored the natural healing of the bone fracture. In our opinion, in some select cases, fixation of C2-C3 alone through a minimally invasive approach allows for bone healing with fewer risks and an easier surgery.

Spinal Dural Arteriovenous Fistulas: A Retrospective Analysis of Prognostic Factors and Long-Term Clinical Outcomes in the Light of the Recent Diagnostic and Technical Refinements.

Spinal dural arteriovenous fistulas (dAVFs) are abnormal connections between the meningeal branches of segmental arteries and a radiculomedullary veins that result in a progressive myelopathy thanks to perimedullary coronal venous plexus congestion. Usually, dAVFs show nonspecific symptoms, thus leading to late clinical suspicion and a difficult MRI diagnosis.Several authors have tried to identify prognostic factors before treatment, but published studies results are often inconsistent and sometimes contradictory.In this study, we reviewed our recent experience of 30 dAVF patients where we collected all demographic, clinical and angioarchitectural features as well as radiological and treatment-related characteristics. The thoracic spine was the most common location, constituting 53.3% of cases, followed by the lumbar roots, comprising 30%. About 83% of patients showed motor deficits, urinary disturbances were present in 70%, and bowel symptoms in 50%.We treated 86.7% of patients with microsurgery and 13.3% with endovascular occlusion with a mean interval between clinical onset and intervention of 10.8 ± 14.2 months.A significant clinical improvement was observed at follow-up in 80% of patients, with a significant reduction in mean G-score, U-score and F-score at a mean follow-up of 105.89 ± 191.9 months.However, none among the principal demographic, clinical and radiological characteristics showed significant prognostic value to the clinical improvement observed at follow-up.

Nuance in Craniovertebral Junction Surgical Approach for Posterior C1-C2 Harms Stabilization: "Window Transposition" of the External Vertebral Venous Plexus for Bloodless C1 Lateral Mass Screw Insertion: Anatomical Aspects and Technical Notes.

Atlas and axis instrumentation may be necessary in cases of several craniocervical junction pathologies. According to the Harms technique, C1-C2 polyaxial screws are inserted respectively in the C1 lateral masses and in C2 pedicles. C1 lateral mass screw insertion requires the careful subperiosteal dissection of the posterior elements of C1, the identification of the screw entry point by the downward distraction of C2 nerve root, and the cautious sparing of the overlying posterior external vertebral venous plexus (peVVP), whose bleeding, obstructing the surgical field, is sometimes barely controlled by hemostatic agents and swabbing. The authors describe in detail the anatomical aspects of an alternative surgical technique developed for the microsurgical transposition of the C1-C2 interposed external vertebral venous plexus in the case of Harms C1-C2 screw stabilization. The longitudinal median incision of the atlantoaxial membrane, followed by bilateral subperiosteal dissection and microsurgical section respectively at the inferior borders of the C1 laminae and at the superior borders of the C2 laminae, allows, as a "window opening," the symmetrical mediolateral transposition of the peVVP. This procedure provides a faster and cleaner anatomical exposition of the posterior surface of the C1 lateral mass and the C2 isthmus, preventing troublesome intraoperative venous bleeding that hinders C1 lateral mass screw insertion.