Pituitary Stalk Hemangioblastoma: Complete Resection through Orbitozygomatic Approach with Extradural Anterior Clinoidectomy.

Background Pituitary stalk hemangioblastomas (PSHBLs) are rare vascular tumors and their surgical removal is challenging due to the proximity with several fundamental anatomic structures including the pituitary stalk, third ventricle, hypothalamus, and optic pathways. To date, only few descriptions of transcranial and transsphenoidal approaches for PSHBLs have been reported in the literature and none in video, with suboptimal outcomes in terms of pituitary function preservation. Here, we describe the use of orbitozygomatic (OZ) craniotomy with extradural anterior clinoidectomy (EAC) for the removal of a PSHBL with preservation of the pituitary stalk. Case Description A 60-year-old woman with a sporadic symptomatic HBL of the pituitary stalk, with the typical features of avid contrast enhancement on T1- and flow voids on T2-weighted magnetic resonance imaging (MRI) images, underwent a right OZ craniotomy with EAC. The choice of the approach was guided by the necessity of exposing the floor of the 3rd ventricle and infundibulum, where the origin of the pituitary stalk is better appreciated and preserved, without brain retraction. EAC was deemed important due to the necessity of widening the right carotico-oculomotor and opticocarotid triangles and gaining access to the ophthalmic segment of the internal carotid artery, origin of the superior hypophyseal artery, and the tumor supply. The postoperative MRI confirmed gross tumor removal with preservation of the pituitary stalk and no tumor recurrence after 2 years of follow-up. Conclusion OZ craniotomy coupled with EAC facilitates surgical removal of PSHBLs thus augmenting the chances of pituitary function preservation. The link to the video can be found at https://youtu.be/hH65W937RGY .

Preliminary results of a novel pure endoscopic procedure in the treatment of degenerative lumbar spinal disorders: double endoscopic technique.

BACKGROUND: With increased experience and the availability of new technical instrumentations, the surgical endoscopic indications for lumbar spinal pathologies have moved from simple prolapsed disk to canal stenosis. The available endoscopes come in two different sizes (10 mm and 6.3 mm in diameter); however, one is too bulky to use inside the spinal canal and the other is too small to achieve a fast bone decompression. In order to overcome such problems, we developed and used a different surgical technique called: double endoscopic technique. METHODS: Using this approach, we operated and prospectively collected clinical information on 17 patients (Group A) suffering from a mixed (ligament-bone hypertrophy and prolapsed disk) single segmental lumbar canal stenosis. At a median of 13 months from surgery, all the patients in this group had a very good outcome with an improvement of the VAS and ODI. RESULTS: These clinical results were compared with those from another group of patients who had undergone surgery in the same unit but using standard MIS technique (Group B). Both groups were similar in terms of number, age, symptoms and stenosis location. We compared the pre- and postoperative VAS and ODI values, the amount of postoperative pain killers used during the first week postsurgery, the length of in-hospital stays as well as the blood loss during surgery. CONCLUSIONS: Although our aim was only to present a novel surgical endoscopic technique, the results, with all the study limitations including small numbers and short follow-up, have shown that this procedure is safe and effective, yielding an outcome comparable to the standard MIS approach. Furthermore, it is less disruptive towards the involved anatomy, it gives less postoperative pain, it requires a smaller skin incision, and the blood loss is negligible. Thus, this technique may guarantee a faster clinical recovery.

Subarachnoid hemorrhage in the eighties: to treat or not to treat.

BACKGROUND: Life expectancy has in the last few years increased and, as a consequence, also the number of elderly patients admitted to an Emergency Department with aneurysmal subarachnoid hemorrhage. We wanted to detect any difference in term of outcomes and adverse events between two groups of patients of different age, in relation to types of treatment and clinical status at presentation. METHODS: We selected and analyzed two groups of patients (group A and group B) among 458 retrospectively collected cases admitted to two neurosurgical centers with a diagnosis of aneurysmal subarachnoid hemorrhage over a 7.5-year period. Group A included 46 patients equal or older than 80 years and group B all the rest. Data were collected on age, sex, aneurysm location, size, comorbidities, clinical condition at presentation and at follow-up. RESULTS: In group A, 19 patients underwent surgery, 16 were embolized, 7 were treated conservatively and 4 died very soon after admission. After a median follow-up of 12 months 45.7% of patients had a good outcome, 24% were in poor conditions and 21.7% had died. When we compared these results with the youngest group, we found some important statistically significant differences. Older patients were more prone to have surgical and medical related complications, whereas endovascular treatment seemed to be a more sustainable treatment in the elderly age group. CONCLUSIONS: Elderly patients suffering from aneurysmal subarachnoid hemorrhage should be considered for treatment despite age, with endovascular embolization as the most preferable option. Without the treatment, the natural history can be very poor.

Lumbar canal stenosis: can we treat it endoscopically?

BACKGROUND: The common treatment for lumbar canal stenosis involves an open surgical decompression with laminectomy and foraminotomy, even if spinal surgery is moving towards minimal invasiveness procedures. Minimally-invasive surgery initially and recently spinal endoscopic techniques are becoming the standard procedures for lumbar disk prolapsed in consideration of the less surgical invasiveness with a considerable reducing in the amount of normal anatomy violation, in less risk of iatrogenic postoperative instability, minimal scar tissue formation and negligible blood loss when compared to the standard open approach. These techniques also reduce the postoperative pain with consequent less need of using pain medications as well as reduced hospital stay. METHODS: From August 2016 to July 2017, we prospectively collected data on 20 patients operated on for a lumbar canal stenosis using a pure interlaminar endoscopic route. This series includes 2 unilateral and 3 bilateral L5-S1 stenosis; ten L4-L5 stenosis (8 bilateral and 2 unilateral); four L3-L4 bilateral stenosis and one bilateral L2-L3 stenosis. Among these, six were two adjacent multiple levels stenosis: L4-L5-S1 two cases; L3-L4-L5 three cases and L2-L3-L4 one case. We reviewed the demographic data as well as the pre and postoperative Visual Analogue Score and Oswestry Disability Index at 3, 6 and 12 months. We also collected the surgical complications and the result of a six-month questionnaire on patients' satisfaction. RESULTS: The median operative time was 125 minutes (range between 45 and 300 minutes). Twenty-two (90%) of the patients were satisfied with the treatment received in terms of clinical results at one year follow-up. Two patients (10%) had been converted to an open procedure. CONCLUSIONS: The use of the endoscopic technique for the treatment of lumbar canal stenosis seems to be correlated with good results and can be a valid alternative to the classic, more invasive, open technique.

Full-Endoscopic Removal of Lumbar Juxtafacet Cysts: A Prospective Multicentric Study.

BACKGROUND: Lumbar juxtafacet cysts are benign lesions that grow at the level of facet joints or within neighboring structures. Recently, there is an ongoing trend toward less invasive procedures for treating degenerative spine diseases. Here we report a multicenter study of full-endoscopic surgery for juxtafacet cyst removal. METHODS: We prospectively collected patients with a diagnosis of lumbar juxtafacet cyst surgically treated in 3 institutions between January 2017 and August 2019. Patients of any sex and age were eligible if they had a single level unilateral lumbar juxtafacet cyst, invalidating radicular pain lasting >6 weeks, adequate imaging, and failed percutaneous or conservative treatment. Age at diagnosis; sex; preoperative, postoperative, and 6-month leg pain; surgical and medical complications; spine instability (preoperatively and at 6 and 12 months); and follow-up time were collected. RESULTS: Thirty-five patients were enrolled. Median operative time was 78 minutes, and mean leg pain went from a preoperative value of 6.8 (standard deviation [SD] = 1.2) to a postoperative value of 3.4 (SD = 1.1, P < 0.001) to 2.1 (SD = 1.7, P < 0.001) at 6 months. At a median follow-up of 15 months, approximately 89% of patients were pain-free or improved. We had 2 recurrences of radicular pain, treated conservatively. Only 2 surgical complications (6%) occurred: 2 small dural tears, both resolved without further intervention. CONCLUSIONS: Full-endoscopic surgery is feasible and safe for juxtafacet cyst removal. Our results are consistent with findings from recent full-endoscopic and series, with outcomes overlapping those reported for open or tubular techniques.

Is Full Endoscopic Lumbar Discectomy Less Invasive Than Conventional Surgery? A Randomized MRI Study.

BACKGROUND: In the present randomized prospective study, we compared the surgical invasiveness using a quantitative volumetric analysis of postoperative paravertebral muscle signal intensity changes between transforaminal full endoscopic lumbar discectomy (FELD) and open discectomy (OD). METHODS: We prospectively collected the data from 50 patients with a single-level lumbar foraminal herniation, invalidating radicular pain, and adequate imaging studies available (postoperative magnetic resonance imaging [MRI] <24 hours). These patients had been randomly assigned to FELD (n = 25) or OD (n = 25). Data were collected on age, sex, leg and back pain, complications, and follow-up time. Muscle segmentations were performed manually using 3DSlicer software on postoperative isovolumetric T1-weighted contrast-enhanced and T2-weighted short tau inversion recovery MRI scans. Both sequences were processed using multiplanar reconstruction in orthogonal planes. The clinical and demographic characteristics and volumetric data were then compared between the 2 groups. RESULTS: We found a higher mean volume of paravertebral muscle signal alterations among the OD-treated patients in both T2-weighted short tau inversion recovery MRI (P ≤ 0.001) and T1-weighted contrast-enhanced MRI (P ≤ 0.001) scans than among the FELD-treated patients. No differences were found between the median preoperative and postoperative leg pain between the 2 groups (P = 1.000). The median scores for postoperative back pain were significantly lower for the FELD group (P ≤ 0.001), as was the median interval from surgery to autonomous mobilization (P = 0.001). CONCLUSIONS: We found a significant difference in signal intensity of the paravertebral muscles between the FELD and OD groups, reflective of the minor surgical invasiveness of endoscopic discectomy. FELD resulted in less trauma to the paraspinal muscles, possibly also reducing inflammatory cytokine release and, therefore, is a valuable tool for spinal surgeons.

Transforaminal percutaneous endoscopic lumbar discectomy: outcome and complications in 270 cases.

BACKGROUND: The endoscopic approach was introduced in the clinical practice in 1980 with the aim to remove the prolapsed disk and free the compressed nerve using the least disruptive surgical technique, assuring in the same time, the resolution of the symptoms and a faster return back to normal life activity. Over the years, thanks to an extraordinary technical improvement either in terms of quality of images or development of many different tailored instrumentations there has been a huge spreading of the endoscope use across the different surgical fields. For this reason, the transforaminal percutaneous endoscopic lumbar discectomy can be considered, at the moment, the least invasive procedure for the removal of lumbar disc prolapsed. The aim of this study was to analyze the clinical outcome and complications rate on a large cumulative series operated on in two years period. METHODS: We presented a retrospective series involving 270 cases of lumbar disk herniation managed surgically only by a percutaneous transforaminal endoscopic technique in two units and by two surgeons. All patients had a minimum follow-up of 6 months. Primary study end points were evaluation of outcomes using the visual analogue scale and Oswestri Disability Index preoperatively and at 3, 6 and 12 months as well as the complications and the recurrence rates. RESULTS: Our results, with a positive outcome around 93%, confirmed the effectiveness of transforaminal percutaneous endoscopic discectomy in the treatment of lumbar disc herniation when compare to open microdiscectomy. Also, the complications (5.5%) and the recurrence rate (4.1%) could be considered within the standard results. CONCLUSIONS: The transforaminal percutaneous endoscopic lumbar discectomy is a safe and effective procedure to treat lumbar disc prolapsed. Surgical experience and correct patients' selection are crucial factors affecting the outcome.

Ruptured Tentorial Arteriovenous Fistula: Endoscopic-Assisted Microsurgical Disconnection Using Indocyanine Green Videoangiography Guidance.

Tentorial dural arteriovenous fistulas are rare causes of intracranial hemorrhage and nervous tissue venous congestion. Due to their extensive arterial supply and difficult transvenous endovascular navigation, they are frequently managed microsurgically. Precise identification of the venous drainage, its retractorless exposition, and real-time verification of arteriovenous disconnection are the mainstays of surgery. We describe the case of 61-year-old man presenting with a cerebellar hematoma causing obstructive hydrocephalus, resolved by emergent endoscopic third ventriculocisternostomy, with no need of external ventricular drain.1 Brain angiograms showed a straight sinus dural arteriovenous fistula. The fistulous point could not be reached endovascularly due to the small caliber and tortuosity of the arterial feeders and difficult transvenous navigation, and then the endovascular treatment was limited to closure of both occipital arteries. At surgery, indocyanine green videoangiography with semiquantitative assessment of flow dynamics identified the draining vein originating from the dura of the left wall of the straight sinus (Video 1). After the draining vein was clipped at its origin from the straight sinus and the endoscopic view confirmed that the clip's tips straddled the vein, control indocyanine green videoangiography showed no more early injection of the draining vein and restoration of the normal venous drainage. Postoperative angiograms confirmed the elimination of the fistula. The patient was discharged to a rehabilitation facility 5 days postoperatively and regained functional independence, with a modified Rankin Scale score of zero by the third month after surgery. Relevant teaching points are exposed at the end of the case narration.

A Novel Hybrid Endoscopic Approach for Anterior Cervical Discectomy and Fusion and a Meta-Analysis of the Literature.

BACKGROUND: We describe our experience in the endoscopic treatment of cervical spondylosis. We present a "hybrid" technique that is similar to an open anterior cervical discectomy with fusion but is performed endoscopically. We also analyzed data from studies on endoscopic cervical discectomies published in the past 2 decades. METHODS: We prospectively collected and analyzed data on all patients who underwent endoscopic cervical discectomy and fusion from January 2017 to January 2019. Data included age, sex, location, diagnosis, arm pain, degree of myelopathy and disability, and adverse events. Also, several databases were explored from January 1998 to December 2018, and 11 studies describing data about the anterior endoscopic treatment of cervical spondylosis, with and without fusion, were retrieved. We pooled these studies into a meta-analysis. RESULTS: Arm pain decreased from a preoperative mean visual analogue scale value of 7 to a postoperative value of 2.1, and Nurick grade improved from a mean value of 3.1 to 1.8 at 12 months. 36-Item Short Form Survey scores increased from a mean preoperative value of 67 to 83.2, whereas the mean Oswestry Disability Index score decreased from 65.7 to a final mean value of 23.1 at 12 months. Median hospitalization time was 36 hours. Our meta-analysis found a satisfactory outcome in 88% of patients at last follow-up, an overall recurrence rate of 3%, and a revision rate of 5%. CONCLUSIONS: We described the feasibility and safety of anterior hybrid endoscopic cervical discectomy, overcoming some of the limitations of the previously described percutaneous discectomies and shifting the standard open technique into an endoscopic procedure.

Purely Endoscopic Resection of Cavernoma of the Septum Pellucidum.

The intraventricular location of a cavernoma is a rare entity and accounts for approximately 2.5% of all cavernomas of the central nervous system. They are commonly found in the lateral ventricle followed by the third and fourth ventricles. The location in the septum pellucidum is rare, and only four cases have been reported in the international literature. An open craniotomy was performed in all these cases. To the best of our knowledge, this is the first case of a cavernoma of the septum pellucidum successfully resected using a purely endoscopic transventricular approach.

Microsurgical Disconnection of Ruptured Intracranial Pial Arteriovenous Fistula Guided by Indocyanine Green Videoangiography.

Intracranial arteriovenous fistulas, rare causes of spontaneous intracerebral bleeding, are direct communications between an arterial feeder and an arterialized vein that drains a normal brain. Arteriovenous disconnection is the only effective treatment for this type of vascular malformation, which is often reached microsurgically due to the difficult endovascular access. Intraoperative indocyanine green videoangiography (ICG-VA) is a valuable help in identifying the arterialized draining vein and its direct communication with the arterial feeder and in confirming real-time interruption of the fistula. We describe the case of a 46-year-old man presenting with sudden onset of headache and left arm motor and sensory deficits associated with a frontoparietal hematoma evacuated 1 week earlier in another institution. Digital subtraction angiography showed a direct communication between an anterior parietal branch of the right middle cerebral artery and a parietal vein. Given the difficulty to reach the point of the fistula endovascularly because of the small caliber and tortuosity of the arterial feeder, as well as the short and relatively rapid flow through the arteriovenous communication, we decided to proceed with microsurgical treatment. Under intraoperative neurophysiologic monitoring the fistula was located with the aid of ICG-VA and interrupted (Video 1). Both control ICG-VA and postoperative angiogram confirmed resolution of the fistula. At a 3-month follow-up the patient had a complete neurologic recovery.

Skin Glue for Wounds Closure in Brain Surgery: Our Updated Experience.

BACKGROUND: Traditional wound closure techniques include skin sutures and metal clips. Cyanoacrylate has good neovascularization, epithelialization, and antimicrobial activity properties and a fast application procedure. This study presents our long-term experience. METHODS: We retrospectively selected 362 patients who underwent brain surgery from January 2007 to March 2017. Exclusion criteria were applied for repeat surgeries, emergency/posttraumatic procedures, wound infections, wounds longer than 16 cm, skull base cases, and postoperative patients who stayed in the intensive care unit more than 1 day. We collected data from 250 cases of supratentorial procedures and 112 cases of infratentorial procedures. The median wound length was 11 cm (range, 4-15 cm); the median age was 51 years. We followed-up all patients for 1, 3, and 12 months focusing on wound complications, cosmetic results, based on the Hollander Wound Evaluation Scale (HWES), and patient satisfaction using a visual analog scale. RESULTS: Cosmetic results were very good (HWES score of 5-6) in 99.5% of cases at 12 months. Patient satisfaction reached almost 100% at 12 months. We experienced 2 cases of wound dehiscence and 2 others with poor cosmetic results. The main complaint was a feeling of discomfort, during the first 2 weeks after surgery, because of the dried glue along the wound's edges. CONCLUSIONS: With additional research, we can confirm that cyanoacrylate glue may be a valid and useful alternative to traditional techniques for wound closure in brain surgery, carrying several advantages. However, a randomized controlled trial with a large number of patients is warranted to confirm our findings.

Type II Fractures in Older Adults: Can They Be Treated Conservatively?: A Single-Center Experience and Review of the Literature.

BACKGROUND: Odontoid fractures are the most common acute cervical spinal fractures in the geriatric population. Their rate is increasing along with the rising age of the elderly population. Whereas conservative management with external immobilization is reported as the treatment of choice for type I and III odontoid fractures, there are no clear indications concerning the best treatment for type II fractures. In younger patients surgical management is considered the best choice, but in older adults the rate of good outcomes worsens and operative risk because of comorbidities increases. METHODS: We report our retrospective single-center experience with conservative treatment of type II odontoid fractures in an elderly population, focusing on both radiologic and functional outcomes to compare our results with the recent literature. RESULTS: Among the 21 selected subjects with a minimum follow-up of 18 months, 19 (90.5%) showed a satisfactory clinical outcome, with an adequate bony healing in 10 cases and nonsymptomatic pseudarthrosis in 9 patients. All these patients were satisfied with the conservative results and could stop use of the collar. Two patients (9.5%) did not show any improvement and had to keep the collar indefinitely. CONCLUSIONS: Our study was limited because it was a retrospective review, with a limited number of patients. Nevertheless, the clinical and radiologic outcomes of our patients differ from the results of other studies, suggesting that conservative management of these fractures in this population does not necessarily lead to a bad clinical outcome or delayed surgery.

Hemodynamic Stress, Inflammation, and Intracranial Aneurysm Development and Rupture: A Systematic Review.

BACKGROUND: There seems to be a pathogenetic link between hemodynamics and inflammatory arterial wall alteration leading to the development and rupture of intracranial aneurysms (IAs). Noninvasive assessment of the inflammatory status of the aneurysm wall may guide the management of unruptured IAs by identifying reliable markers for increased rupture risk. METHODS: We conducted a qualitative systematic review following the ENTREQ (Enhancing Transparency in Reporting the Synthesis of Qualitative Research) framework. A search was made in MEDLINE/PubMed, Embase, and CINAHL from database inception to October 2017 using the terms "intracranial aneurysm" and "cerebral aneurysm" linked with the following key words: inflammation, hemodynamic(s), remodeling, macrophages, neutrophils, lymphocytes, complement system, vascular smooth muscle cells, mast cells, cytokines, and inflammatory biomarkers. RESULTS: One hundred and twenty-three articles were included in the review. CONCLUSIONS: In this systematic review, we explore the relationship between hemodynamic stress, inflammation, vascular remodeling, and the formation and rupture of IAs to develop novel strategies to predict the individual risk of aneurysmal rupture.

Complex developmental abnormality of the atlas mimicking a Jefferson fracture: Diagnostic tips and tricks.

Congenital atlas abnormalities are rare - often asymptomatic - findings, not requiring any specific treatment. They are frequently discovered, by chance, in trauma patients, in the course of the radiological work flow at the Emergency Department. In these cases they may represent a diagnostic challenge, since physicians are expected to differentiate them from complex C1 fractures (isolated Jefferson's fractures or associated with Anderson and d'Alonzo's fractures) requiring surgical treatment. Although difficult to identify, a correct diagnosis is mandatory in order to optimize the patient's treatment. In this article we report a case of congenital atlas abnormality, and discuss the tips and tricks to make a correct differential diagnosis through the most appropriate clinical and radiological work flow.