[Surgical Approaches to Petroclival Meningiomas Part 1: Microsurgical Anatomy]. / Abordajes quirúrgicos de meningiomas petroclivales parte 1: anatomía microquirúrgica.

Background: Most petroclival meningiomas are benign tumors, but their neurosurgical treatment is one of the greatest challenges in this field. Acquiring a deep practical knowledge of brain anatomy is the first step on the path to successfully meeting this challenge. To this end, the present paper is divided into two parts. The first regards the microsurgical anatomy and surgical approaches used in the management of petroclival meningiomas. The second correlates the brain anatomies of the 30 cases of petroclival meningiomas which the senior author (GRI) has operated on. Methods: Eight cadaver heads were dissected using surgical microscopes at the University of Arkansas microsurgery laboratory. The heads were stabilized in a Mayfield device to simulate surgical conditions and colored silicon was injected to highlight the differences between arteries and veins. The approaches performed were: cranio-orbital zygomatic, posterior and anterior petrosectomy, and retrosigmoid. Results: Three main surgical approaches were chosen to treat petroclival meningiomas: the pterional approach and its variants, the petrous approach and its variants, and the retrosigmoid approach. To rationalize the choice of approach, the clivus was separated into superior, middle, and inferior thirds. Conclusion: Several surgical approaches are useful in accessing the petroclival region. Acquiring a practical knowledge of this anatomy in a microsurgical laboratory is fundamental for any surgeon who intends to operate on petroclival meningiomas.

Cerebral Hemodynamics and Intracranial Compliance Impairment in Critically Ill COVID-19 Patients: A Pilot Study.

Introduction: One of the possible mechanisms by which the new coronavirus (SARS-Cov2) could induce brain damage is the impairment of cerebrovascular hemodynamics (CVH) and intracranial compliance (ICC) due to the elevation of intracranial pressure (ICP). The main objective of this study was to assess the presence of CVH and ICC alterations in patients with COVID-19 and evaluate their association with short-term clinical outcomes. Methods: Fifty consecutive critically ill COVID-19 patients were studied with transcranial Doppler (TCD) and non-invasive monitoring of ICC. Subjects were included upon ICU admission; CVH was evaluated using mean flow velocities in the middle cerebral arteries (mCBFV), pulsatility index (PI), and estimated cerebral perfusion pressure (eCPP), while ICC was assessed by using the P2/P1 ratio of the non-invasive ICP curve. A CVH/ICC score was computed using all these variables. The primary composite outcome was unsuccessful in weaning from respiratory support or death on day 7 (defined as UO). Results: At the first assessment (n = 50), only the P2/P1 ratio (median 1.20 [IQRs 1.00-1.28] vs. 1.00 [0.88-1.16]; p = 0.03) and eICP (14 [11-25] vs. 11 [7-15] mmHg; p = 0.01) were significantly higher among patients with an unfavorable outcome (UO) than others. Patients with UO had a significantly higher CVH/ICC score (9 [8-12] vs. 6 [5-7]; p < 0.001) than those with a favorable outcome; the area under the receiver operating curve (AUROC) for CVH/ICC score to predict UO was 0.86 (95% CIs 0.75-0.97); a score > 8.5 had 63 (46-77)% sensitivity and 87 (62-97)% specificity to predict UO. For those patients undergoing a second assessment (n = 29), after a median of 11 (5-31) days, all measured variables were similar between the two time-points. No differences in the measured variables between ICU non-survivors (n = 30) and survivors were observed. Conclusions: ICC impairment and CVH disturbances are often present in COVID-19 severe illness and could accurately predict an early poor outcome.

Obesity and its implications on cerebral circulation and intracranial compliance in severe COVID-19.

Objective: Multiple factors have been identified as causes of intracranial compliance impairment (ICCI) among patients with obesity. On the other hand, obesity has been linked with worst outcomes in COVID-19. Thus, the hypothesis of severe acute respiratory syndrome (SARS) conducing to cerebral hemodynamic disorders (CHD) able to worsen ICCI and play an additional role on prognosis determination for COVID-19 among obese patients becomes suitable. Methods: 50 cases of SARS by COVID-19 were evaluated, for the presence of ICCI and cerebrovascular circulatory disturbances in correspondence with whether unfavorable outcomes (death or impossibility for mechanical ventilation weaning [MVW]) within 7 days after evaluation. The objective was to observe whether obese patients (BMI ≥ 30) disclosed worse outcomes and tests results compared with lean subjects with same clinical background. Results: 23 (46%) patients among 50 had obesity. ICCI was verified in 18 (78%) obese, whereas in 13 (48%) of 27 non-obese (p = 0,029). CHD were not significantly different between groups, despite being high prevalent in both. 69% unfavorable outcomes were observed among obese and 44% for lean subjects (p = 0,075). Conclusion: In the present study, intracranial compliance impairment was significantly more observed among obese subjects and may have contributed for SARS COVID-19 worsen prognosis.

Reoperation for recurrent glioblastomas: What to expect?

BACKGROUND: The current standard treatment for glioblastoma (GBM) is maximal safe surgical resection followed by radiation and chemotherapy. Unfortunately, the disease will invariably recur even with the best treatment. Although the literature suggests some advantages in reoperating patients harboring GBM, controversy remains. Here, we asked whether reoperation is an efficacious treatment strategy for GBM, and under which circumstances, it confers a better prognosis. METHODS: We retrospectively reviewed 286 consecutive cases of newly diagnosed GBM in a single university hospital from 2008 to 2015. We evaluated clinical and epidemiological parameters possibly influencing overall survival (OS) by multivariate Cox regression analysis. OS was calculated using the Kaplan-Meier method in patients submitted to one or two surgical procedures. Finally, the survival curves were fitted with the Weibull model, and survival rates at 6, 12, and 24 months were estimated. RESULTS: The reoperated group survived significantly longer (n = 63, OS = 20.0 ± 2.3 vs. 11.4 ± 1.0 months, P < 0.0001). Second, the multivariate analysis revealed an association between survival and number of surgeries, initial Karnofsky Performance Status, and age (all P < 0.001). Survival estimates according to the Weibull regression model revealed higher survival probabilities for reoperation compared with one operation at 6 months (83.74 ± 3.42 vs. 63.56 ± 3.59, respectively), 12 months (64.00 ± 4.85 vs. 37.53 ± 3.52), and 24 months (32.53 ± 4.78 vs. 12.02 ± 2.36). CONCLUSION: Our data support the indication of reoperation for GBM, especially for younger patients with good functional status. Under these circumstances, survival can be doubled at 12 and 24 months.

Petroclival Meningiomas: Factors Determining the Choice of Approach.

Objectives To review a surgical series of petroclival meningiomas and the factors considered in the choice of approach. Design Retrospective review. Setting The study was conducted in a university hospital in southern Brazil. Participants Twenty-two patients with petroclival meningioma originating from the upper two-thirds of the clivus medial to the fifth cranial nerve. Main Outcome Measures Gross-total resection, mortality, major morbidity, new cranial nerve deficits and tumor progression or recurrence. Results Retrosigmoid approach was used in tumors <3 cm and in those at or below the internal auditory meatus. Posterior petrosectomy was performed for tumors extending into the middle fossa. Gross-total resection was performed in 11 patients (50%). The mean follow-up time was 32 months (6-75 months). There were four cases of tumor progression or recurrence, which were treated with radiosurgery. Conclusions Resection of petroclival meningiomas remains challenging. In most cases, the retrosigmoid approach was sufficient, without affecting the degree of tumor resection. Petrosal approaches were reserved for patients with tumor extension into the middle fossa.

Petroclival meningiomas: Remaining controversies in light of minimally invasive approaches.

Surgical resection of petroclival meningiomas remains challenging due to their deep location and relationship to vital neurovascular structures. Although the natural history of these tumors involves a slow course, the incidence of cranial nerve deficits and the extent of tumor resection vary widely in the literature. Some reviews on this topic have been conducted, but data remain fragmentary and based on retrospective case series, which hinders attempts at meta-analysis. Within this context, research into the use of minimally invasive approaches, including in neuroendoscopy, continues to emerge. The objective of this narrative review is to analyze the available literature on the surgical treatment of petroclival meningiomas, with a focus on attempts at endoscopy-assisted resection.

Spontaneous acute subdural hematoma and intracerebral hemorrhage in a patient with thrombotic microangiopathy during pregnancy.

Preeclampsia, HELLP syndrome (hemolysis, elevated liver enzymes, and low-platelet count), and acute fatty liver of pregnancy are the main causes of thrombotic microangiopathy and evere liver dysfunction during pregnancy and represent different manifestations of the same pathological continuum. The case of a 35-week pregnant woman who was admitted to an intensive care unit immediately after a Cesarean section due to fetal death and the presence of nausea, vomiting, and jaundice is reported. Postpartum preeclampsia and acute fatty liver of pregnancy were diagnosed. The patient developed an acute subdural hematoma and an intracerebral hemorrhage, which were subjected to neurosurgical treatment. The patient died from refractory hemolytic anemia and spontaneous bleeding of multiple organs. Preeclampsia HELLP syndrome, and acute fatty liver of pregnancy might overlap and be associated with potentially fatal complications, including intracranial hemorrhage, as in the present case. Early detection and diagnosis are crucial to ensure management and treatment success.

Hematoma subdural agudo espontâneo e hemorragia intracerebral em paciente com microangiopatia trombótica gestacional / Spontaneous acute subdural hematoma and intracerebral hemorrhage in a patient with thrombotic microangiopathy during pregnancy

Pré-eclâmpsia, síndrome HELLP (hemólise, elevação de enzimas hepáticas e plaquetopenia) e fígado gorduroso agudo da gestação são as principais causas de microangiopatia trombótica e disfunção hepática grave durante a gestação, representando um spectrum do mesmo processo patológico. Relatou-se aqui o caso de uma gestante com 35 semanas internada em unidade de terapia intensiva no pós-operatório imediato de cesariana por morte fetal, com náuseas, vômitos e icterícia. Diagnosticaram-se pré-eclâmpsia pós-parto e fígado gorduroso agudo da gestação. Houve evolução tardia com hematoma subdural agudo e hemorragia intracerebral, sendo realizado tratamento neurocirúrgico. A paciente foi a óbito por anemia hemolítica refratária, com sangramento espontâneo em múltiplos órgãos. Pré-eclâmpsia, síndrome HELLP e fígado gorduroso agudo da gestação são processos patológicos que podem se sobrepor e se associar a complicações potencialmente fatais, como a hemorragia intracraniana aqui descrita. Sua detecção e diagnóstico precoces são fundamentais para a instituição de manejo adequado e sucesso do tratamento.

Preeclampsia, HELLP syndrome (hemolysis, elevated liver enzymes, and low-platelet count), and acute fatty liver of pregnancy are the main causes of thrombotic microangiopathy and evere liver dysfunction during pregnancy and represent different manifestations of the same pathological continuum. The case of a 35-week pregnant woman who was admitted to an intensive care unit immediately after a Cesarean section due to fetal death and the presence of nausea, vomiting, and jaundice is reported. Postpartum preeclampsia and acute fatty liver of pregnancy were diagnosed. The patient developed an acute subdural hematoma and an intracerebral hemorrhage, which were subjected to neurosurgical treatment. The patient died from refractory hemolytic anemia and spontaneous bleeding of multiple organs. Preeclampsia HELLP syndrome, and acute fatty liver of pregnancy might overlap and be associated with potentially fatal complications, including intracranial hemorrhage, as in the present case. Early detection and diagnosis are crucial to ensure management and treatment success.

Benign fasciculations responsive to gabapentin.

Fasciculations are symptoms present in a broad spectrum of conditions, ranging from normal manifestations to motor neuron diseases. They also represent the main picture of benign fasciculation syndrome. We report a case of such syndrome: a 48-years-old woman complaining about fasciculations for three decades who remained with the symptoms even after the compensation of a disclosed hyperthyroidism. The introduction of gabapentin rendered control of her fasciculations. The available data in the literature about the therapeutic approaches for fasciculations are revised, as long as the rare reports of evolution from patients with "benign" fasciculations to cases of amyotrophic lateral sclerosis, underlining the importance of following the patients with fasciculations.

Benign fasciculations responsive to gabapentin

Fasciculations are symptoms present in a broad spectrum of conditions, ranging from normal manifestations to motor neuron diseases. They also represent the main picture of benign fasciculation syndrome. We report a case of such syndrome: a 48-years-old woman complaining about fasciculations for three decades who remained with the symptoms even after the compensation of a disclosed hyperthyroidism. The introduction of gabapentin rendered control of her fasciculations. The available data in the literature about the therapeutic approaches for fasciculations are revised, as long as the rare reports of evolution from patients with "benign" fasciculations to cases of amyotrophic lateral sclerosis, underlining the importance of following the patients with fasciculations.

Fasciculações são sintomas presentes em um amplo espectro de condições, desde manifestações normais até doenças do neurônio motor. Elas representam também o principal aspecto da síndrome de fasciculações benignas. Relatamos um caso desta síndrome: uma paciente de 48 anos com queixas de fasciculações por três décadas que, mesmo após a compensação de um quadro de hipertireoidismo, permaneceu com os sintomas. A introdução de gabapentina levou a controle das fasciculações. Os dados disponíveis na literatura sobre as abordagens terapêuticas para fasciculações são revisados, assim como os raros relatos de evolução de pacientes com fasciculações "benignas" para casos de esclerose lateral amiotrófica, salientando a importância do seguimento dos pacientes com fasciculações.