Preliminary Experience with 3-Dimensional-Exoscopic Untethering of a Type II Diastematomyelia: Technical Note and Review of the Literature.

OBJECTIVE: To describe the use of a high-definition 3-dimensional (3D) exoscope (VITOM 3D exoscope; KARL STORZ GmbH) for the neurosurgical treatment of a rare pediatric disease, type II diastematomyelia with associated tethered cord. METHODS: A 13-year-old girl who presented with diastematomyelia type II with a tethered cord was surgically treated with the aid of a high-definition 3D exoscope, with a third operator moving and pivoting its arm. Intraoperative monitoring and mapping were arranged. The surgery required a bilateral access to address both the split cord malformation and the tethering of the filum terminale. The filum terminale was identified and cut, and the connective fibrovascular tissue separating the 2 medullary halves was unraveled. These steps were performed with no changes of intraoperative monitoring. Pertinent literature was addressed carefully. RESULTS: The surgery was successful, and the patient was discharged home on the eleventh postoperative day without any complications. The 3-month postoperative magnetic resonance imaging scan demonstrated regular surgical outcomes; no dynamic motor disturbances were reported. To our knowledge, this is the first spinal congenital malformation treated with the use of a 3D exoscope. CONCLUSIONS: The use of 3D exoscope is advancing in spinal surgery, as it provides magnification, stereopsis, lighting, and definition comparable with the operating microscope; the addition of a third operator simplified the operations of moving around the arm, releasing these burdens for the surgeons. Our preliminary experience proved that the use of a 3D exoscope is feasible and safe for the surgical management of a type II diastematomyelia with tethered cord.

Ultrahigh-Definition-3-Dimensional Exoscope-Assisted Clipping of a Right Middle Cerebral Artery Unruptured Aneurysm with Indocyanine Green Video Angiography: Operative Video.

Ultrahigh-definition 3-dimensional exoscopes represent an excellent technologic innovation in contemporary neurosurgery. They combine the advantages of operating microscopes and endoscopes, offering excellent magnification and lighting, maintaining a relatively small footprint and optimal ergonomic features.1-5 One of the most interesting employments of exoscopes in neurosurgery is represented by intracranial vascular surgery. Reports in this field are still limited, but recent experience has shown that ultrahigh definition 3-dimensional exoscopes for aneurysm surgery are noninferior to operating microscopes for surgery duration, complication rate, and patient outcomes.6 In addition, many intraoperative techniques such as the indocyanine green videoangiography (ICG-VA) have been successfully implemented to exoscope-based surgery.7 We present herein the case of a 66-year-old woman that came to our attention for the incidental finding of 3 unruptured brain aneurysms. After neurosurgical consultation, the one located at the right middle cerebral artery bifurcation was considered eligible for surgery.8,9 As shown in Video 1, ICG-VA was employed after permanent clipping to allow immediate quality assurance of occlusion and distal vessel integrity. Postoperative course was uneventful, and follow-up examinations demonstrated the complete occlusion of the aneurysm. This report highlights the feasibility of exoscopic-based ICG-VA in vascular neurosurgery, given its ease of use, ergonomics, and excellent quality of vision provided to both surgeons and operating staff.

Endoscopic Endonasal Transethmoidal-Transsphenoidal Approach to a Cavernous Sinus Chondrosarcoma.

Objective We illustrate a cavernous sinus chondrosarcoma treated with an endoscopic endonasal transethmoidal-transsphenoidal approach. Design Case report of a 15-year-old girl with diplopia and esotropia due to complete abducens palsy. Preoperative images showed a right cavernous sinus lesion with multiple enhanced septa and intralesional calcified spots ( Fig. 1 ). Considering tumor location and the lateral dislocation of the carotid artery, an endoscopic endonasal approach was performed to relieve symptoms and to optimize the target geometry for adjuvant conformal radiotherapy. Setting The study was conducted at University of Insubria, Department of Neurosurgery, Varese, Italy. Participants Skull base team was participated in the study. Main Outcome Measures A transethmoidal-transsphenoidal approach was performed by using a four-hand technique. We used a route lateral to medial turbinate to access ethmoid and the sphenoid sinus. During the sphenoid phase, we exposed the medial wall of the cavernous sinus ( Fig. 2 ) and the lesion was then removed using curette. Skull base reconstruction was performed with fibrin glue and nasoseptal flap. Results No complications occurred after surgery, and the patient experienced a complete recovery of symptoms. A postoperative magnetic resonance imaging showed a small residual tumor inside the cavernous sinus ( Fig. 1 ). After percutaneous proton-bean therapy, patient experienced only temporary low-grade toxicity with local control within 2 years after treatment completion. Conclusion Endoscopic endonasal extended approach is a safe and well-tolerated procedure that is indicated in selected cases (intracavernous tumors, soft tumors not infiltrating the vessels and/or the nerves). A tailored approach according to tumor extension is crucial for the best access to the compartments involved. The link to the video can be found at: https://youtu.be/TsqXjqpuOws .

The Role of the Transorbital Superior Eyelid Approach in the Management of Selected Spheno-orbital Meningiomas: In-Depth Analysis of Indications, Technique, and Outcomes from the Study of a Cohort of 35 Patients.

Objective Primary goal in spheno-orbital meningioma (SOM) surgery still remains complete resection. Nevertheless, given their highly infiltrative nature, a growing body of literature suggests to shift toward function-sparing surgeries. We here present our experience in the management of SOMs through the endoscopic superior eyelid approach (SEA). Methods Surgical database from our multidisciplinary work group was retrospectively reviewed to identify patients treated for SOMs in the last 10 years by our senior authors, analyzing and correlating clinical, radiological, and outcome variables among the different approaches used. Results There were 35 patients (mean age of 57.3 ± 12.86 years), with a mean follow-up of 31.5 months (range: 6-84 months). The most common preoperative complaint was proptosis (62.9%) followed by diplopia and visual deficit. Greater and lesser sphenoid wings were the areas mainly involved by the pathology (91.4% and 88.6%, respectively), whereas orbital invasion was evidenced in one-third of cases. Patients were operated on through craniotomic (48.6%), endoscopic superior eyelid (37.1%), and combined cranioendoscopic (14.3%) approaches. Simpson grades 0 to II were accomplished in 46.2% of SEA and 76.5% of craniotomies. All patients with a preoperative visual deficit improved in the postoperative period, independently from the approach used. On patients who underwent endoscopic SEA, there was improved their short-/long-term postoperative Karnofsky Performance Status. Conclusions Endoscopic SEA is a safe and effective alternative to transcranial approaches in very selected cases of SOMs, where the planned primary objective was to obtain a maximally safe resection, aimed at symptom relief, rather than a gross total resection at any cost.

Endoscopic Endonasal Pituitary Hemi-Rotation Approach to the Upper Clivus: Anatomical Study and Clinical Report.

AIM: To report on the endoscopic endonasal pituitary hemi-rotation approach (EPHRA) in a preclinical setting and in a preliminary clinical experience. MATERIAL AND METHODS: EPHRA was performed in five fresh-frozen head and neck specimens (a total of 10 sides) and in a selected case of a right-sided dorsum sellae chordoma. RESULTS: The approach described allowed exposure of the lateral part of the upper clivus in all the specimens and in the case reported. To evaluate the maximum possible degree of hypophyseal hemi-rotation, the hemi-rotation angle (HRA) of the approach was measured and reported for all sides of the specimens. In 9 out of 10 cadaver head sides, and in the clinical case, it was possible to avoid sectioning of the inferior hypophyseal artery. No complications occurred during or after the procedure. CONCLUSION: EPHRA represents an addition to the techniques already described and finds indications in case of non-massive neoformations of the lateral upper clivus. Clinical applications and limitations still need to be clarified in further clinical studies.

The "DOLPHINS" Project: A Low-Cost Real-Time Multivariate Process Control From Large Sensor Arrays Providing Sparse Binary Data.

The "DOLPHINS" project started in 2018 under a collaboration between three partners: CNH Industrial Iveco (CHNi), RADA (an informatics company), and the Chemistry Department of the University of Turin. The project's main aim was to establish a predictive maintenance method in real-time at a pilot plant (CNHi Iveco, Brescia, Italy). This project currently allows maintenance technicians to intervene on machinery preventively, avoiding breakdowns or stops in the production process. For this purpose, several predictive maintenance models were tested starting from databases on programmable logic controllers (PLCs) already available, thus taking advantage of Machine Learning techniques without investing additional resources in purchasing or installing new sensors. The instrumentation and PLCs related to the truck sides' paneling phase were considered at the beginning of the project. The instrumentation under evaluation was equipped with sensors already connected to PLCs (only on/off switches, i.e., neither analog sensors nor continuous measurements are available, and the data are in sparse binary format) so that the data provided by PLCs were acquired in a binary way before being processed by multivariate data analysis (MDA) models. Several MDA approaches were tested (e.g., PCA, PLS-DA, SVM, XGBoost, and SIMCA) and validated in the plant (in terms of repeated double cross-validation strategies). The optimal approach currently used involves combining PCA and SIMCA models, whose performances are continuously monitored, and the various models are updated and tested weekly. Tuning the time range predictions enabled the shop floor and the maintenance operators to achieve sensitivity and specificity values higher than 90%, but the performance results are constantly improved since new data are collected daily. Furthermore, the information on where to carry out intervention is provided to the maintenance technicians between 30 min and 3 h before the breakdown.

CERN-MEDICIS: A Review Since Commissioning in 2017.

The CERN-MEDICIS (MEDical Isotopes Collected from ISolde) facility has delivered its first radioactive ion beam at CERN (Switzerland) in December 2017 to support the research and development in nuclear medicine using non-conventional radionuclides. Since then, fourteen institutes, including CERN, have joined the collaboration to drive the scientific program of this unique installation and evaluate the needs of the community to improve the research in imaging, diagnostics, radiation therapy and personalized medicine. The facility has been built as an extension of the ISOLDE (Isotope Separator On Line DEvice) facility at CERN. Handling of open radioisotope sources is made possible thanks to its Radiological Controlled Area and laboratory. Targets are being irradiated by the 1.4 GeV proton beam delivered by the CERN Proton Synchrotron Booster (PSB) on a station placed between the High Resolution Separator (HRS) ISOLDE target station and its beam dump. Irradiated target materials are also received from external institutes to undergo mass separation at CERN-MEDICIS. All targets are handled via a remote handling system and exploited on a dedicated isotope separator beamline. To allow for the release and collection of a specific radionuclide of medical interest, each target is heated to temperatures of up to 2,300°C. The created ions are extracted and accelerated to an energy up to 60 kV, and the beam steered through an off-line sector field magnet mass separator. This is followed by the extraction of the radionuclide of interest through mass separation and its subsequent implantation into a collection foil. In addition, the MELISSA (MEDICIS Laser Ion Source Setup At CERN) laser laboratory, in service since April 2019, helps to increase the separation efficiency and the selectivity. After collection, the implanted radionuclides are dispatched to the biomedical research centers, participating in the CERN-MEDICIS collaboration, for Research & Development in imaging or treatment. Since its commissioning, the CERN-MEDICIS facility has provided its partner institutes with non-conventional medical radionuclides such as Tb-149, Tb-152, Tb-155, Sm-153, Tm-165, Tm-167, Er-169, Yb-175, and Ac-225 with a high specific activity. This article provides a review of the achievements and milestones of CERN-MEDICIS since it has produced its first radioactive isotope in December 2017, with a special focus on its most recent operation in 2020.

Endoscopic Endonasal Odontoidectomy Preserving Atlantoaxial Stability: a Pediatric Case.

Objectives We illustrate endoscopic endonasal odontoidectomy for the Chiari-I malformation respecting craniovertebral junction (CVJ) stability. Design Case report of a 12-year-old girl affected by the Chiari-I malformation. Magnetic resonance imaging (MRI) showed tonsillar herniation, basilar invagination, and dental retroversion, causing angulation and compression of the bulbomedullary junction. Patient underwent endoscopic third ventriculostomy (ETV) with reduction of ventricular size and resolution of gait disturbances, but she complained the Valsalva-induced headaches, hiccup, and dysesthesias in the lower limbs. Endoscopic endonasal odontoidectomy was chosen to decompress the cervicomedullary junction. Setting The research was conducted at University Hospital "Ospedale di Circolo," Department of Neurosurgery at Varese in Italy. Participants Patients were from neurosurgical and ENT (ear, nose, and throat) skull base team. Main Outcome Measures A bilateral paraseptal approach was performed, using a four-hand technique. After resection of posterior edge of the nasal septum, the choana is entered and a rhinopharynx muscle-mucosal flap is dissected subperiosteal and transposed in oral cavity. The CVJ is exposed and, using neuronavigation and neuromonitoring, odontoidectomy is fulfilled until dura is reached, preserving the anterior arch of C1. Reconstruction is obtained suturing the flap previously harvested. Results Postoperative course was unremarkable and the patient experienced improvement of symptoms. Postoperative MRI documented the appearance of tight cerebrospinal fluid (CSF) film anterior to bulbomedullary junction and in retrotonsillar spaces, opening of the bulbomedullary angle, and slight tonsils reduction. No CVJ instability was occurred with any need of posterior fixation. Conclusion Endoscopic endonasal odontoidectomy is a feasible approach for CVJ malformation. In this case, bulbar decompression was achieved preserving CVJ stability and avoiding posterior fixation. The link to the video can be found at: https://youtu.be/VIobocHfCuc .

Cauda equina syndrome secondary to portal vein thrombosis: case report of favorable outcome with conservative treatment.

Epidural varicosis is a rare though well-known cause of cauda equina syndrome (CES). Although inferior vena cava (IVC) obstruction is the most common finding in such cases, portal vein hypertension can lead to epidural venous plexus engorgement by means of lumbar portocaval shunt activation.A 40-year-old woman presented with right-sided sciatica, which progressed to right foot drop and a 3-day history of vesical tenesmus and fecal retention. She was initially diagnosed with L4-5 lumbar disc protrusion. However, contrast-enhanced lumbar MRI scan showed the presence of epidural varices in the L3-S1 tract. Given the absence of vascular anomalies amenable to resection, etiological conservative treatment was addressed. Therefore, a complete diagnostic workup was performed and revealed deep vein thrombosis (DVT), pulmonary embolism, and portal vein thrombosis. Oral anticoagulant therapy was initiated and prompt resolution of CES was observed. To the authors' knowledge, this is the first report of CES secondary to epidural varicosis in the setting of acute portal vein thrombosis and extrahepatic portal vein obstruction (EHPVO). In cases of epidural varicosis, conservative etiological treatment is the most appropriate choice as CES may be the epiphenomenon of underlying systemic pathophysiological processes.

Emergency endovascular treatment of cavernous internal carotid artery acute bleeding with flow diverter stent: a single-center experience.

BACKGROUND AND OBJECTIVE: To describe our single-center experience in the treatment of cavernous internal carotid artery (ICA) acute bleeding with flow diverter stent (FDS), as a single endovascular procedure or combined with an endoscopic endonasal approach. METHODS: We analyze a case series of 5 patients with cavernous ICA acute bleeding, i.e., 3 iatrogenic, 1 post-traumatic, and 1 erosive neoplastic. After an immediate nasal packing to temporarily bleeding control, patients underwent digital subtraction angiography (DSA) to identify the site of the ICA injury. A concomitant balloon occlusion test (BOT) was performed, to exclude post-occlusive ischemic neurological damage. An FDS was placed with parallel intravenous infusion of abciximab in 3 cases and tirofiban in 2 cases. In two patients, an innovative "sandwich technique" combining the endovascular reconstruction with an extracranial intrasphenoidal cavernous ICA resurfacing with autologous flaps or grafts by endoscopic endonasal approach was performed. RESULTS: No patient had periprocedural ischemic-hemorrhagic complications. All patients had a regular clinical evolution, without general complications or new onset of focal neurological deficits. No further bleeding occurred in 3 patients, while 2 cases experienced a mild rebleeding in a period ranging from 5 to 15 days after the endovascular procedure. In these two cases, we proceeded with an endoscopic endonasal procedure to resurface the exposed ICA wall in the sphenoid sinus. CONCLUSIONS: Although the treatment of choice for cavernous ICA acute bleeding remains the occlusion of the injured vessel, in cases of poor hemodynamic compensation at the BTO, the endovascular FDS emergency placement can be effective. A combined endoscopic endonasal technique to support the extracranial side of the vessel using autologous flaps or grafts can be performed to prevent the risk of rebleeding.

Skull-base surgery during the COVID-19 pandemic: the Italian Skull Base Society recommendations.

Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), is highly contagious with devastating impacts for healthcare systems worldwide. Medical staff are at high risk of viral contamination and it is imperative to know what personal protective equipment (PPE) is appropriate for each situation. Furthermore, elective clinics and operations have been reduced in order to mobilize manpower to the acute specialties combating the outbreak; appropriate differentiation between patients who require immediate care and those who can receive telephone consultation or whose treatment might viably be postponed is therefore crucial. Italy was 1 of the earliest and hardest-hit European countries and therefore the Italian Skull Base Society board has promulgated specific recommendations based on consensus best practices and the literature, where available. Only urgent surgical operations are recommended and all patients should be tested at least twice (on days 4 and 2 prior to surgery). For positive patients, procedures should be postponed until after swab test negativization. If the procedure is vital to the survival of the patient, filtering facepiece 3 (FFP3) and/or powered air purifying respirator (PAPR) devices, goggles, full-face visor, double gloves, water-resistant gowns, and protective caps are mandatory. For negative patients, use of at least an FFP2 mask is recommended. In all cases the use of drills, which promote the aerosolization of potentially infected mucous particles, should be avoided. Given the potential neurotropism of SARS-CoV-2, dura handling should be minimized. It is only through widely-agreed protocols and teamwork that we will be able to deal with the evolving and complex implications of this new pandemic.

Multicenter external validation of the Zurich Pituitary Score.

PURPOSE: Recently, the Zurich Pituitary Score (ZPS) has been proposed as a new quantitative preoperative classification scheme for predicting gross total resection (GTR), extent of resection (EOR), and residual tumor volume (RV) in endoscopic pituitary surgery. We evaluated the external validity of the ZPS. METHODS: In three reference centers for pituitary surgery, the ZPS was applied and correlated to GTR, EOR, and RV. Furthermore, its inter-rater agreement was assessed. RESULTS: A total of 485 patients (53% male; age, 53.8 ± 15.7) were included. ZPS grades I, II, III, and IV were observed in 110 (23%), 270 (56%), 64 (13%), and 41 (8%) patients, respectively. GTR was achieved in 358 (74%) cases, with mean EOR of 87.6% ± 20.3% and RV of 1.42 ± 2.80 cm3. With increasing ZPS grade, strongly significant decreasing trends for GTR (I, 92%; II, 77%; III, 67%; IV, 15%; p < 0.001) and EOR (I, 93.8%; II, 89.9%; III, 88.1%; IV, 75.4%; p < 0.001) were found. Similarly, RV increased steadily ([cm3] I, 0.16; II, 0.61; III, 2.01; IV, 3.84; p < 0.001). We observed intraclass correlation coefficients of 0.837 (95% CI, 0.804-0.865) for intercarotid distance and 0.964 (95% CI, 0.956-0.970) for adenoma diameter, and Cohen's kappa of 0.972 (95% CI, 0.952-0.992) for the ZPS grades. CONCLUSIONS: Application of the ZPS in three external cohorts was successful. The ZPS generalized well in terms of GTR, EOR, and RV; demonstrated excellent inter-rater agreement; and can safely and effectively be applied as a quantitative classification of adenomas with relevance to surgical outcome.

The Helmet-Visor Pericranial Flap as a Viable Option for Anterior Cranial Base Reconstruction in Complex Oncologic Cases.

OBJECTIVE: To describe a novel bilaterally pedicled pericranial flap for anterior cranial base reconstruction after removal of complex frontobasal cancers extending to the frontal region, thus precluding the use of standard reconstructive techniques. METHODS: In selected oncologic cranial base surgeries, the use of the standard galea frontalis pericranial flap for reconstructive purposes may be precluded by tumor infiltration. In such cases, dura mater reconstruction and exclusion of frontal sinuses from the intracranial space can be performed using a large superficial temporal artery bilaterally pedicled pericranial flap obtained from both temporoparietal regions. Surgical technique, indication, contraindication, complications, and degree of resection are recorded to evaluate the efficacy of this surgical method. RESULTS: A 48-year-old man affected by a recurrence of frontobasal squamous cell carcinoma was surgically treated by combined transcranial and endoscopic endonasal resection. A large pericranial flap pedicled bilaterally on the parietal branches of the superficial temporal artery was obtained, transposed anteriorly, carefully watertight sutured to the dural defect, and used to exclude cranialized frontal sinuses as well. The reconstruction was successful, and the patient was discharged home on the tenth postoperative day without any complications and/or development of cerebrospinal fluid leak. Contrast-enhanced magnetic resonance imaging 3 months after surgery was clear from disease with consolidated surgical outcomes. CONCLUSIONS: This novel pericranial flap seems to be easily obtained and effective for anterior cranial base reconstruction when the use of a traditional galea frontalis flap is precluded for oncologic reasons and there are concerns for the possible development of contaminations and cerebrospinal fluid leaks.

Combined Multiportal Endoscopic Endonasal and Transcranial Approach for Recurrent Tuberculum Sellae Meningioma: Operative Video.

Surgery for anterior cranial base lesions is challenging because tumors often spread from their origin to sinuses, orbits, and middle cranial fossa, resulting in risky surgeries.1,2 To approach such complex diseases, recently combined multiportal approaches have been proposed.3,4 At the best of our knowledge, operative application of a combined endoscopic endonasal and transcranial surgery for complex anterior cranial base lesions has not been described. Therefore a surgical video of such an approach is presented. A 37-year-old woman affected by a huge recurrence of a tuberculum meningioma extended to right orbit presented to our department, complaining of right ocular bulb dislocation with multidirectional limitations in eye movements (Video 1). Given the complexity and localization of the lesion, a combined endoscopic endonasal-transcranial surgery was performed. Such a combined approach, although demanding in terms of the presence of both otolaryngologist and neurosurgeon during the surgery, also requires strong synergy among them and permits them to control anterior cranial base lesions from both specialists' perspectives, simultaneously. In this case, while an endonasal corridor permitted an accurate excision of ethmoidal and medial orbital wall part of the lesion, a bicoronal approach allowed the aggression of the anterior cranial base portion of the tumor, allowing good control of cranial base neurovascular structures, eventually obtaining a gross total resection, without perioperative complications. Furthermore, a combined multiportal approach allows cooperative strategies among the surgeons involved, leading to safer, quicker, and more effective resections with less brain retraction, given the wide angles of views to the lesion that a multiportal approach can offer.

Impact of the newly proposed ICRU/ICRP quantities on neutron calibration fields and extended range neutron rem-counters.

In July 2017, the International Commission on Radiation Units and Measurements (ICRU) and the International Commission on Radiological Protection (ICRP) proposed the introduction of new operational quantities for external radiation exposure, with the aim of improving coherence between protection quantities and operational quantities within the system of radiological protection. A change in operational quantities will impact both instrumentation and reference radiation fields used for their calibration. This paper evaluates the potential impact of the new quantity ambient dose, H*, meant to replace ambient dose equivalent, H*(10), on two neutron reference fields, the Am-Be source and the CERF high-energy workplace field, and on the response of two models of extended-range neutron rem counters (LINUS and LUPIN). The conclusions are that calibration procedures should in general not be affected and that changes should only be expected in calibration coefficients. Considering the acceptable measurement uncertainties for operational radiation protection, for the extended-range rem counters changes in their design would not be required for measurements outside particle accelerators shielding and for aircrew dosimetry. One can expect that this type of instrument can still be calibrated with Am-Be source neutrons and employed in neutron fields with energy distributions spanning several decades. For uses in radiation fields with very peculiar neutron energy distribution, a specific workplace field calibration may instead be required.

Endoscopic Endonasal Approaches for Treatment of Craniovertebral Junction Tumours.

Tumours involving the craniovertebral junction (CVJ) are challenging because of their local invasiveness and high recurrence rates, as well as their proximity to critical neurovascular structures and the difficulty of reconstructing the resulting skull base defect at this site. Several surgical techniques are currently available to access these lesions, including the far lateral, extreme lateral, direct lateral, transcervical, transoral and transnasal approaches. In this paper, application of the endoscopic endonasal approach (EEA) in the treatment of CVJ tumours is analysed. The indications, contraindications, preoperative workup, step-by-step surgical technique, skull base reconstruction options and postoperative management are described. The advantages and limitations of the EEA are also discussed. Finally, a systematic review of the literature is provided to elucidate the levels of evidence supporting the use of the EEA in this field. Employment of this approach to the CVJ has contributed to high success rates in achieving gross total resection of tumours and improvement in neurological symptoms. Intraoperative and postoperative complication rates are acceptable, with cerebrospinal fluid leakage being the major concern (with a 17-25% incidence). Moreover, in comparison with traditional approaches to the CVJ, the EEA provides lower rates of postoperative dysphagia and respiratory complications. Use of the EEA for treatment of CVJ tumours appears to be a rational alternative to the conventional transoral, transcranial and transcervical approaches in selected cases. Multidisciplinary teamwork including different specialists-such as medical and radiation oncologists, radiologists, otorhinolaryngologists and neurosurgeons-is strongly recommended for the purpose of offering the best treatment strategy for the patient.

Emergency placement of a Flow Diverter Stent for an Iatrogenic Internal Carotid Artery Injury During Endoscopic Pituitary Surgery.

BACKGROUND: Internal carotid artery (ICA) injury is 1 of the most feared complications in endoscopic pituitary surgery. Different endovascular techniques are available for the management of early and delayed ICA injuries. CASE REPORT: We report a case of emergency endovascular treatment with a flow diverter stent for an ICA injury that occurred during endoscopic transphenoidal surgery for pituitary macroadenoma in a 66-year-old man. Effective intraoperative hemostasis was achieved by direct packing of the sphenoid sinus. Digital subtraction angiography demonstrated extravasation of the contrast agent into the sphenoidal sinus from the anterior genu of the intracavernous portion of the right ICA. Balloon test occlusion resulted in a prominent delay in the venous phase in the right hemisphere during occlusion of the right ICA. Taking into account the hemodynamic stability and the absence of intracranial bleeding, we considered the ICA injury as if it were a pseudoaneurysm. Therefore, an emergency release of a flow diverter stent was performed, in association with antiplatelet therapy. No periprocedural complications occurred. The patient was discharged without neurologic deficits. The last follow-up studies at 6 months (digital subtraction angiography and magnetic resonance imaging) confirmed the regular placement of the stent and vessel reconstruction. CONCLUSIONS: Despite the presence of acute hemorrhage and the need for antiplatelet therapy, a flow diverter stent can be used as emergency treatment of ICA injury in selected circumstances.

CERN IRRADIATION FACILITIES.

CERN provides unique irradiation facilities for applications in dosimetry, metrology, intercomparison of radiation protection devices, benchmark of Monte Carlo codes and radiation damage studies to electronics.

Transorbital endoscopic approaches to the skull base: current concepts and future perspectives.

INTRODUCTION: Transorbital endoscopic surgery is one of the most recent fields of skull base surgery. This paper presents the emerging applications of transorbital endoscopic approaches to the skull base and their current results on the treatment of selected extradural and intradural lesions, based on a review of meta-analysis and recent clinical series. EVIDENCE ACQUISITION: A PubMed, Cochrane and Ovid search for articles published from 2000 to 2015 was performed using the search terms "endoscopic skull base surgery", "transorbital endoscopic approach", and "transorbital neuroendoscopic surgery". No anatomical or preclinical studies were included in the present review. Among the clinical case series available, only those describing transorbital approaches to the skull base have been considered, excluding from the analysis the studies addressing the orbit and orbital pathologies. EVIDENCE SYNTHESIS: Although performed in extremely selected cases, there is a growing body of evidence suggesting that this technique may be effective for the treatment of cerebrospinal fluid leaks, for the drainage of epidural abscess or hematoma, and for the removal of several skull base tumors such as spheno-orbital meningioma. For the treatment of intradural pathologies there is only anecdotal evidence suggesting effectiveness and safety. Factors that may contribute to the enhanced efficacy compared to traditional external approaches were the acceptable complication rates, the reduced hospitalization time and limited morbidity for the patients, avoiding the need for large external craniotomies and brain retraction. CONCLUSIONS: Minimally-invasive endoscopic skull base surgery has substantially evolved in the last decades through the collaboration of different teams around the world. The transorbital endoscopic approaches directed to the anterior and middle cranial base may represent safe and feasible techniques with great potential for new applications in the nearby future.

New radiation protection calibration facility at CERN.

The CERN radiation protection group has designed a new state-of-the-art calibration laboratory to replace the present facility, which is >20 y old. The new laboratory, presently under construction, will be equipped with neutron and gamma sources, as well as an X-ray generator and a beta irradiator. The present work describes the project to design the facility, including the facility placement criteria, the 'point-zero' measurements and the shielding study performed via FLUKA Monte Carlo simulations.