Prediction of diabetes insipidus occurrence after endoscopic endonasal removal of sellar lesions using MRI-based radiomics and machine learning.

BACKGROUND: Pituitary adenomas and craniopharyngiomas are the most common lesions of the sellar region. These tumors are responsible for invasion or compression of crucial neurovascular structures. The involvement of the pituitary stalk warrants high rates of both pre- and post- operative diabetes insipidus. The aim of our study was to assess the accuracy of machine learning analysis from preoperative MRI of pituitary adenomas and craniopharyngiomas for the prediction of DI occurrence. METHODS: All patients underwent MRI exams either on a 1.5- or 3-T MR scanner from two Institutions, including coronal T2-weighted (T2-w) and contrast-enhanced T1-weighted (CE T1-w) Turbo Spin Echo sequences. Feature selection was carried out as a multi-step process, with a threshold of 0.75 to identify robust features. Further feature selection steps included filtering based on feature variance (threshold >0.01) and pairwise correlation (threshold <0.80). A Bayesian Network model was trained with 10-fold cross validation employing SMOTE to balance classes exclusively within the training folds. RESULTS: Thirty patients were included in this study. In total 2394 features were extracted and 1791 (75%) resulted stable after ICC analysis. The number of variant features was 1351 and of non-colinear features was 125. Finally, 10 features were selected by oneR ranking. The Bayesian Network model showed an accuracy of 63% with a precision of 77% for DI prediction (0.68 area under the precision-recall curve). CONCLUSIONS: We assessed the accuracy of machine learning analysis of texture-derived parameters from preoperative MRI of pituitary adenomas and craniopharyngiomas for the prediction of DI occurrence.

The dramatic increase in sudden cardiac deaths and the alarming low survival: A global call to action to improve outcome with the engagement of tertiary education system.

The number of out-of-hospital cardiac arrests, cause of disability and death, has dramatically increased worldwide, but despite the progress, the incidence of survival does not appear to have increased significantly. Bystander cardiopulmonary resuscitation (CPR) remains the principal factor in saving out-of-hospital cardiac arrest victims. Analyzing the immense efforts produced by states and professional organizations to train people in CPR skills for immediate intervention in the occurrence of a cardiac arrest, the primary global strategy is centered on CPR education and training for schoolchildren. But the rate of CPR training remains low, with wide differences among communities. The concept of CPR training for schoolchildren to increase bystander CPR rates needs to be implemented. We suggest a global call to action for the tertiary education system for CPR learning and training, including all undergraduate students regardless of the degree course, as a possible method to improve the traditional CPR training today centered on the secondary education system. Extending CPR training courses to the university educational system could significantly increase the number of people educated in life-saving maneuvers. The final objective is to improve the survival rate of patients with out-of-hospital primary cardiac arrest, which has dramatically increased worldwide.

Persistent severe visual field impairment is associated with obesity and tumour invasiveness, but not with pituitary dysfunction, in patients with craniopharyngioma.

PURPOSE: Craniopharyngiomas (CP) are benign tumours of the sellar region. Hypopituitarism, visual deficits, hypothalamic damage with consequent obesity and related increased cardiovascular risk, are complications due to the tumour itself or secondary to treatment strategy. We retrospectively correlated visual field status with clinical, neuroradiological, histopathological features and management strategy, in a single-centre cohort of patients with CP. METHODS: Thirty-four patients (16 M; median age 27.2 ± 21.8 yrs) with CP were included. We evaluated visual field status, assessed by means of standard automated perimetry and expressed as mean deviation (MD), at last follow-up visit (median 14 ± 11.7 yrs). MD has been correlated with clinical, radiological, histological data and treatment modalities. RESULTS: In univariate analysis worst eye MD was significantly associated with panhypopituitarism (p 0.010). In multivariable linear regression, panhypopituitarism (p 0.008), CP recurrence (p 0.020) and DI (p 0.004) were found to be the main independent predictors of a worse visual field outcome. When stratifying patients according to the degree of visual field impairment (MD < -12 dB Vs MD > -12 dB), the main independent predictors of worse visual field outcome were older age at diagnosis (p 0.010), CP histological subtype (p 0.004), invasiveness (p 0.04), CP recurrence (p 0.035), DI (p 0.002) and weight at last follow-up (p 0.012). CONCLUSION: In CP patients the long-term ophthalmological impairment is frequent, especially at older age, and strictly related to tumour invasiveness and recurrence, and associated to pituitary disfunction and obesity.

Neurosurgery on the web: an analysis of the web-visibility of the European Neurosurgical Societies.

Nowadays, internet provides a great opportunity that allows the research community to constantly increase their scientific collaboration, together with information distribution. Aim of this study is to investigate the European National Neurosurgical Societies (ENNS) web-visibility that represents the necessary basis for diffusion of neurosurgical knowledge to both patients and neurosurgeons. We evaluated the web-visibility of each Neurosurgical Society affiliated to the European Associations of Neurosurgical Societies (EANS) using 3 different parameters: 1) the availability of the full list of all Neurosurgical Centers (NCs) of the country in each ENNS website; 2) the availability of a specific English-written section on the ENNS web-site; and 3) the availability of at least one section titled "news and events" and/or "educational" and/or "patient info" on the ENNS website. The web-visibility was categorized in significant (at least 2 out of 3 items fulfilled), not significant (1 out of 3 only) and insufficient (all not fulfilled). We also evaluated the web-visibility of single NCs, and the availability on the web of society's sections dealing with specific neurosurgical topics for each ENNS. Through the EANS Website we identified 38 ENNS. The rate of ENNS with significant web-visibility was 39%, while 24% of ENNS showed to have a not-significant web-visibility, while 37% had an insufficient visibility. The most unattended criterion was the availability of an English-written section of the website. Among ENNS with a significant web-visibility, this specific criterion was fulfilled in only 53% of cases. This percentage goes down to the 22% for ENNS with a non-significant web-visibility. The full list of NCs was available in 87% of cases for significant profiles and in zero cases for not-significant ones. Finally, the web-visibility rate of single NCs among different ENNS was 80%. Specific sections focusing on specific neurosurgical topics were available in 5 out of 38 ENNS websites (13%). This study highlighted the importance of increasing the ENNS web-visibility to spread the neurosurgical knowledge for patients, neurosurgeons and trainees. This could lead to an easier ENNS interaction, increasing the international collaboration between neurosurgical centers in the clinical, research and educational settings.

Giant sacral schwannoma excised under intraoperative neuromonitoring in an elderly patient: case report.

Schwannomas are mainly benign tumors arising from the Schwann cells of the peripheral nerve sheath. These tumors can often be associated with non-specific symptoms, such as abdominal heaviness. In this article, we present a detailed description of the surgical management of a giant sacral schwannoma in an elderly patient, for which intraoperative neuromonitoring made it possible to distinguish easily the nerves of the sacral plexus from which the tumor originated and to remove it without complications. Treatment of these rare and symptomatic giant tumors is still a challenge for surgeons; to treat adequately these tumors; a multidisciplinary approach is required to ensure an optimal therapeutic approach to reduce the risk of recurrence and, on the other hand, is not associated with unnecessary iatrogenic neurological damage.

Natura non facit saltus: a phase 2 proposal to manage brain tumors cases from the Neuro-oncology section of the Italian Society of Neurosurgery (SINch®).

The Coronavirus (COVID-19) pandemic has fast spread throughout the world in more than 200 countries, resulting in the need for a de-prioritization of elective medical care to face the demands of the global health crisis. Although the acute and catastrophic phase of the pandemic seems to have been left behind, it is also clear that the virus will not disappear soon, and we must live with it for a period of unpredictable length, the COVID-19 era. In this setting, a common coordinated approach to treat patients harboring brain tumors is urgently required to guarantee the best updated oncological care and to reduce the risk of viral infection during hospitalization. The study group on Neuro-oncology of Italian Society of Neurosurgery, SINCh gathered pieces of evidence and data and would like to suggest a practice protocol of care for neurosurgical oncologic procedures in the COVID-19 era. The present document aimed at summarizing current evidence and expert opinions to help neurosurgeons in taking decisions on their patients harboring different brain tumors.

An Unusual But Possible Complication After Endoscopic Third Ventriculostomy.

BACKGROUND: We present an unusual but possible complication after ETV for the treatment of acute hydrocephalus due to malfunction of a previously implanted V-P shunt. CASE DESCRIPTION: A 12-year-old male patient was urgently operated upon by means of an endoscopic third-ventriculostomy and the positioning of a temporary external ventricular catheter because of the malfunction of a previously implanted V-P shunt; immediately after the operation, the tip of the external catheter caused an obstruction of the ostomy, which was resolved with the withdrawn of catheter for circa 1 cm, left closed and ultimately removed after 4 days. The patient did not present any further symptom and remained shunt-free at the last 2-year follow-up visit. CONCLUSIONS: One should consider such occurrence in cases of early ETV failure when a ventricular catheter is left in situ, even though temporarily.

Italian consensus and recommendations on diagnosis and treatment of low-grade gliomas. An intersociety (SINch/AINO/SIN) document.

In 2018, the SINch (Italian Society of Neurosurgery) Neuro-Oncology Section, AINO (Italian Association of Neuro-Oncology) and SIN (Italian Association of Neurology) Neuro-Oncology Section formed a collaborative Task Force to look at the diagnosis and treatment of low-grade gliomas (LGGs). The Task Force included neurologists, neurosurgeons, neuro-oncologists, pathologists, radiologists, radiation oncologists, medical oncologists, a neuropsychologist and a methodologist. For operational purposes, the Task Force was divided into five Working Groups: diagnosis, surgical treatment, adjuvant treatments, supportive therapies, and follow-up. The resulting guidance document is based on the available evidence and provides recommendations on diagnosis and treatment of LGG patients, considering all aspects of patient care along their disease trajectory.

Gelatin-thrombin hemostatic matrix in neurosurgical procedures: hemostatic effectiveness and economic value of clinical and surgical procedure-related benefits.

BACKGROUND: Gelatin-thrombin hemostatic matrix (FloSeal®) use is associated with shorter surgical times and less blood loss, parameters that are highly valued in neurosurgical procedures. We aimed to assess the effectiveness of gelatin-thrombin in neurosurgical procedures and estimate its economic value. METHODS: In a 6-month retrospective evaluation at 2 hospitals, intraoperative and postoperative information were collected from patients undergoing neurosurgical procedures where bleeding was controlled with gelatin-thrombin matrix or according to local bleeding control guidelines (control group). Study endpoints were: length of surgery, estimated blood loss, hospitalization duration, blood units utilized, intensive care unit days, postoperative complications, and time to recovery. Statistical methods compared endpoints between the gelatin-thrombin and control groups and resource utilization costs were estimated. RESULTS: Seventy-eight patients (38 gelatin-thrombin; 40 control) were included. Gelatin-thrombin was associated with a shorter surgery duration than control (166±40 versus 185±55 minutes, P=0.0839); a lower estimated blood loss (185±80 versus 250±95 mL; P=0.0017); a shorter hospital stay (10±3 versus 13±3 days; P<0.001); fewer intensive care unit days (10 days/3 patients and 20 days/4 patients); and shorter time to recovery (3±2.2 versus 4±2.8 weeks; P=0.0861). Fewer gelatin-thrombin patients experienced postoperative complications (3 minor) than the control group (5 minor; 3 major). No gelatin-thrombin patient required blood transfusion; 5 units were administered in the control group. The cost of gelatin-thrombin (€ 268.40/unit) was offset by the shorter surgery duration (difference of 19 minutes at € 858/hour) and the economic value of improved the other endpoint outcomes (i.e., shorter hospital stay, lesser blood loss/lack of need for transfusion, fewer intensive care unit days, and complications). CONCLUSIONS: The use of gelatin-thrombin hemostatic matrix in patients undergoing neurosurgical procedures was associated with better intra- and postoperative parameters than conventional hemostasis methods, with these parameters having substantial economic benefits.

Surgery of malignant motor-eloquent gliomas guided by sodium-fluorescein and navigated transcranial magnetic stimulation: a novel technique to increase the maximal safe resection.

BACKGROUND: Maximal safe resection is the goal of modern surgical treatment of high-grade gliomas (HGGs) located close to the motor cortex (M1) and/or the corticospinal tract (CST). Preoperative planning based on navigated transcranial magnetic stimulation (nTMS) and fluorescence-guided resection (FGR) using sodium-fluorescein have been separately described to increase the extent of resection (EOR) while preserving the motor pathway. We assessed the efficacy of the combination of these techniques for surgery of motor-eloquent HGGs. METHODS: We enrolled patients with motor-eloquent HGGs operated at the Departments of Neurosurgery of the University of Messina, Italy, and of the Charitè Universitatsmedizin Berlin, Germany, between 2016 and 2019. All patients underwent nTMS mapping of M1, and nTMS-based DTI tractography of CST. Tumor resection was guided by intraoperative neurophysiological mapping (IONM) supported by sodium-fluorescein fluorescence and by intraoperative visualization of the nTMS-based information through neuronavigation. EOR and new permanent motor deficits were compared with a historical control group of patients operated exclusively with IONM guidance. RESULTS: Seventy-nine patients were enrolled, while 55 patients were included as controls. The gross total resection (GTR) rate was significantly higher in patients operated using nTMS + FGR compared with controls (64.5% vs. 47.2%, P=0.04). As well, postoperative new permanent motor deficits were reduced in the study group vs. controls (11.4% vs. 20%). CONCLUSIONS: In this series, the combination of sodium-fluorescein FGR with nTMS-based planning improved surgical treatment of motor-eloquent HGGs. It represents a valuable support to IONM-guided resection, increasing the GTR rate while reducing the occurrence of permanent motor deficits.

A Survey on Pituitary Surgery in Italy.

BACKGROUND: Pituitary tumors are a heterogeneous group of lesions that are usually benign. Therefore, a proper understanding of the anatomy, physiology, and pathology is mandatory to achieve favorable outcomes. Accordingly, diagnostic tests and treatment guidelines should be determined and implemented. Thus, we decided to perform a multicenter study among Italian neurosurgical centers performing pituitary surgery to provide an actual depiction from the neurosurgical standpoint. METHODS: On behalf of the SINch (Società Italiana di Neurochirurgia), a survey was undertaken with the participants to explore the activities in the field of pituitary surgery within 41 public institutions. RESULTS: Of the 41 centers, 37 participated in the present study. The total number of neurosurgical procedures performed in 2016 was 1479. Most of the procedures were performed using the transsphenoidal approach (1320 transsphenoidal [1204 endoscopic, 53 microscopic, 53 endoscope-assisted microscopic] vs. 159 transcranial). A multidisciplinary tumor board is convened regularly in 32 of 37 centers, and a research laboratory is present in 18 centers. CONCLUSIONS: Diagnosing pituitary/hypothalamus disorders and treating them is the result of teamwork, composed of several diverse experts. Regarding neurosurgery, our findings have confirmed the central role of the transsphenoidal approach, with preference toward the endoscopic technique. Better outcomes can be expected at centers with a multidisciplinary team and a full, or part of a, residency program, with a greater surgical caseload.

Pituitary atypical teratoid rhabdoid tumor in a patient with prolactinoma: A unique description.

Atypical teratoid rhabdoid tumor (ATRT) is an aggressive tumor of the CNS and characteristically occurs in the pediatric age. In adulthood, ATRT is rare and it is mainly localized in the cerebral hemispheres. Only 16 cases of ATRT have been described in the sellar region up to now. Interestingly, all sellar ATRTs occurred in adult female patients. Herein we report a novel case of sellar ATRT in a patient with previous history of lactotroph adenoma. Similar to other sellar ATRTs, this case occurred in a female adult patient. At histological examination, it was characterized by a small number of rhabdoid cells. In addition, it did not have homozygous deletion of SMARCB1 gene, but it rather showed a frameshift mutation at exon 4 of SMARCB1 which had not been previously found in ATRT. Clinico-pathological and molecular findings observed in this case confirm previous evidence that sellar ATRT seems to be a distinct entity. Association with previous prolactin-secreting pituitary adenoma is discussed.

The efficacy of 90cm-long peritoneal shunt catheters in newborns and infants.

BACKGROUND: Ventriculoperitoneal (VP) shunt is one of the options for the treatment of hydrocephalus. The aim of this study is to describe the efficacy and safety of a 90cm-long peritoneal catheter in newborns and infants treated for hydrocephalus. We analyzed the incidence of distal-related complications and the need of successive surgeries for malfunction or for lengthening of the peritoneal catheter. METHODS: We reviewed medical records of neonates and infants treated with a VP shunt using a 90cm-long peritoneal catheter. Function and integrity of shunts were assessed through abdominal echographic studies, skull, neck, chest and abdomen X-rays. We compared shunt revision rates due to distal complications and insufficient length of the peritoneal catheter in the study group with an historical control group composed by newborns and infants treated with a standard VP shunt at our Institution during the last twenty years. RESULTS: Three neonates and 3 infants were treated with the insertion of the 90cm-long distal catheter into the peritoneal cavity for its total length. The mean follow-up was 7.6 years. As compared to controls, in the study group the revision rate for distal complications was not significantly increased (P=0.33), whereas revision surgeries due to insufficient peritoneal catheter length were significantly reduced (P=0.04). CONCLUSIONS: This study demonstrates for the first time that the use of 90cm-long peritoneal catheters in neonates and infants is a safe and effective procedure. It does not increase the incidence of abdominal complications, avoiding the need of revision for insufficient length of the peritoneal catheter.

Aggressive Pituitary Adenomas: The Dark Side of the Moon.

BACKGROUND: Although pituitary adenomas are considered benign lesions, a small group may show clinically aggressive behavior, sometimes independently from the classic markers of aggressiveness, including the Ki67 labeling index or p53 expression. METHODS: We selected 7 patients harboring a pituitary tumor with clinical features of aggressiveness. Patients underwent a full preoperative and postoperative endocrinologic and neuroradiologic workup. Two were nonfunctioning, 2 prolactin-secreting, 2 adrenocorticotrophic hormone-secreting, and 1 a growth hormone-secreting adenoma. RESULTS: The 7 patients underwent a total of 17 surgical procedures. At the first surgical procedure, gross total removal was achieved in none of the patients, whereas subtotal removal (>90% of tumor removed) was achieved in 4/7 cases and partial removal (<90% of tumor removed) in 3/7 cases. At first operation, 4/7 patients showed a Ki67 index ≤3% and 2/7 >3%; this information was not available for 1 patient. Postoperatively, all patients underwent radiation therapy. Three patients received chemotherapy with temozolomide. Three patients underwent peptide receptor radionuclide therapy. To date, 1 patient has died of tumor progression, and 2 patients are in a poor general condition. The remaining 4 patients are in a fair/good condition, without any major complaints. The mean follow-up is 43.42 months. CONCLUSIONS: Aggressive pituitary adenomas represent a specific and still underestimated entity, often diagnosed late. Clinical and neuroradiologic rapid progression is often the only marker of aggressiveness. Surgical debulking remains the first therapeutic option. Multidisciplinary management is mandatory to offer these patients targeted therapeutic options.

MiRNA expression profiling in human gliomas: upregulated miR-363 increases cell survival and proliferation.

The role of microRNAs (miRNAs) in glioma biology is increasingly recognized. To investigate the regulatory mechanisms governing the malignant signature of gliomas with different grades of malignancy, we analyzed miRNA expression profiles in human grade I-IV tumor samples and primary glioma cell cultures. Multiplex real-time PCR was used to profile miRNA expression in a set of World Health Organization (WHO) grade I (pilocytic astrocytoma), II (diffuse fibrillary astrocytoma), and IV (glioblastoma multiforme) astrocytic tumors and primary glioma cell cultures. Primary glioma cell cultures were used to evaluate the effect of transfection of specific miRNAs and miRNA inhibitors. miRNA microarray showed that a set of miRNAs was consistently upregulated in all glioma samples. miR-363 was upregulated in all tumor specimens and cell lines, and its expression correlated with tumor grading. The transfection of glioma cells with the specific inhibitor of miR-363 increased the expression level of tumor suppressor growth-associated protein 43 (GAP-43). Transfection of miR-363 induced cell survival, while inhibition of miR-363 significantly reduced glioma cell viability. Furthermore, miRNA-363 inhibition induced the downregulation of AKT, cyclin-D1, matrix metalloproteinase (MMP)-2, MMP-9, and Bcl-2 and upregulation of caspase 3. Together, these data suggest that the upregulation of miR-363 may play a role in malignant glioma signature.

Microvascular Decompression for Trigeminal Neuralgia: Technical Refinement for Complication Avoidance.

BACKGROUND: Microvascular decompression (MVD) represents the most effective and safe surgical option for the treatment of trigeminal neuralgia since it was first popularized by Jannetta 50 years ago. Despite several advances, complications such as cerebellar and vascular injury, hearing loss, muscular atrophy, cerebrospinal fluid (CSF) leak, postoperative cutaneous pain, and sensory disturbances still occur and may negatively affect the outcome. We propose some technical nuances of the surgical procedure that were used in our recent series. METHODS: We used a novel hockey stick-shaped retromastoid skin incision, preserving the major nerves of the occipital and temporal areas. Microsurgical steps were performed without the use of retractors. CSF leakage was prevented with a watertight dural closure and multilayer osteodural reconstruction. RESULTS: The refined surgical steps were perfected in the last consecutive 15 cases of our series. In these cases we did not record any cutaneous pain, sensory disturbances, or CSF leakage. The average diameter of the craniectomy was 18 mm. No patient reported major complications related to the intradural microsurgical maneuvers. In all cases the neurovascular conflict was found and solved with a good outcome in terms of pain disappearance. CONCLUSIONS: Our minimally invasive approach was demonstrated to guarantee an optimal exposure of the cerebellopontine angle and minimize the rate of complications related to skin incision and muscular dissection, microsurgical steps, and closure.

Post-Treatment Edema after Meningioma Radiosurgery is a Predictable Complication.

Symptomatic post-treatment edema (PTE) causing seizures, focal deficits, and intracranial hypertension is a rather common complication of meningioma radiosurgery. Factors associated to the occurrence of PTE still needs to be clarified. We retrospectively analyzed our patients' data to identify factors associated with the development of symptomatic PTE. Supposed risk factors were systematically analyzed. Between July 2007 and March 2014, 245 meningiomas in 229 patients were treated by a single fraction or multisession radiosurgery (2-5 fractions) or hypofractionated stereotactic radiotherapy (6-15 fractions) using the CyberKnife system (Accuray Inc., Sunnyvale, CA) at the University Hospital of Messina, Italy. Local tumor control was achieved in 200 of 212 patients with World Health Organization (WHO) Grade I meningiomas (94%) at a mean follow-up of 62 months. Symptomatic PTE on MRI was diagnosed in 19 patients (8.3%) causing seizure (n=17, 89%), aggravating headache (n=12, 63%), or focal deficits (n=13, 68%). Four variables were found to be associated with the likelihood of edema development, including tumor volume > 4.5 mL, non-basal tumor location, tight brain/tumor interface, and atypical histology. Nonetheless, when multivariate logistic regression analysis was performed, only tumor volume and brain-tumor interface turned out to be independent predictors of PTE development. Our results suggest that the factor associated with the risk of developing PTE is associated to characteristics of meningioma rather than to the treatment modality used. Accordingly, an appropriate patient selection is the way to achieve safe treatment and long-term disease control.

Telo-velar approach to fourth-ventricle tumours: how I do it.

BACKGROUND: The "telo-velar" approach is an alternative to cerebellar splitting to gain access to the fourth ventricle through the so-called cerebello-medullary fissure (CMF). METHOD: In this approach, the CMF is exposed and access to the ventricle is obtained by incising the tela chorioidea and inferior medullary velum. This approach enables the exploration of the entire ventricle cavity from the obex to the aqueduct. CONCLUSIONS: The exposure of the fourth ventricle is satisfactory and the floor of the fourth ventricle can be visualised early and protected. The extent of resection and outcome are satisfactory in most patients, including those with large tumours or lesions attached to the lateral or superolateral recesses of the ventricle. The deep rostral tumour attachment is the main limitation of the telo-velar approach. KEY POINTS: • Early exposure of the interface lesion-floor of the fourth ventricle favours a safer tumour dissection. • We feel that resection of tonsils is not necessary in the surgical setting. • The posterior arch of C1 should be removed only if the tonsils are below the level of the foramen magnum. • The improved access to the lateral recess of the ventricle makes the telo-velar approach particularly effective in lesions attached to cerebellar peduncles. • The wide dissection of the cerebello-medullary fissure and gentle tonsils retraction may prevent from the occurrence of cerebellar mutism or other major cerebellar dysfunctions. • Even the bilateral opening of the CMF does not result in cerebellar mutism if wide and cautious dissection, avoiding retraction and vascular injuries, is obtained. • The exposure of the fourth ventricle was satisfactory also in patients harbouring lesions attached to the lateral or even the superolateral recesses of the ventricle. • A deep rostral tumour attachment seems to be, at least in our experience, the main specific limitation of the telo-velar approach. • The risk of hydrocephalus can be reduced by opening of the fissure bilaterally, exposing the aqueduct, and by cisterna magna-fourth ventricle communication augmentation. • The EVD is taken in place for 48-72 h to prevent possible abrupt increase of the intracranial pressure and to favour wound closure.

The pioneering contribution of italian surgeons to skull base surgery.

The origin of neurosurgery as a modern, successful, and separate branch of surgery could be dated back to the end of the 19th century. The most important development of surgery occurred in Europe, particularly in Italy, where there was a unique environment, allowing brilliant open-minded surgeons to perform, with success, neurosurgical operations. Neurosurgery began at the skull base. In everyday practice, we still pay tribute to early Italian neuroanatomists and pioneer neurosurgeons who represented a starting point in a new, obscure, and still challenging field of medicine and surgery during their times. In this paper, we report at a glance the contributions of Tito Vanzetti from Padua (1809-1888), for his operation on a destructive skull base cyst that had, indeed, an intracranial expansion; of Davide Giordano (1864-1954) from Venice, who described the first transnasal approach to the pituitary gland; and, most importantly, of Francesco Durante from Messina (1844-1934), who was the first surgeon in the history of neurosurgery to successfully remove a cranial base meningioma. They carried out the first detailed reported surgical excision of intracranial lesions at the skull base, diagnosed only through clinical signs; used many of the advances of the 19th century; and conceived and performed new operative strategies and approaches. Their operations were radical enough to allow the patient to survive the surgery and, in the case of Durante, for the first time, to obtain more than 12 years of good survival at a time when a tumor of this type would have been fatal.