Surgical management of acute subdural hematoma: a comparison between decompressive craniectomy and craniotomy on patients treated from 2010 to the present in a single center.

BACKGROUND: Acute subdural hematoma represents an important cause of disability and mortality. Its surgical treatment takes advantage of two surgical procedures: craniotomy and decompressive craniectomy, nevertheless the effectiveness of one procedure rather than the other is still debated. This study was conducted to identify which of the surgical procedures could provide better neurological outcome after traumatic acute subdural hematoma; as a secondary endpoint, the study tries to settle preoperative prognostic factors useful to identify the most appropriate surgical technique for every specific patient and kind of trauma. METHODS: A retrospective analysis was performed on patients who underwent craniotomy or decompressive craniectomy between January 2010 and July 2017 at the Department of Neurosurgery of Umberto I Hospital in Rome. Ninety-four patients were selected and reviewing clinical records, preoperative and postoperative's data were collected (e.g., GCS, mechanism of trauma, CT findings, mortality rate, neurological outcome at discharge, mRS at 12 months). Data were analyzed using χ2 test and the F test. The multivariate analysis was performed using a stepwise logistic regression. The analysis was carried out using SPSS software and a P value ≤0.05 was considered significant. RESULTS: In 94 patients, 46.8% underwent decompressive craniectomy and 53.2% underwent craniotomy. The mortality rate was (53.2%); it was shown to be related to a GCS<8 (P=0.033) and to age >60 years old (P=0.0001). Decompressive craniectomy was performed most frequently for high energy trauma (P=0.006); the mean GCS at admission was 7.91 for decompressive craniectomy and 9.64 for craniotomy (P=0.05). Patients who underwent decompressive craniectomy and survived surgery showed a better neurological outcome compared to those who underwent craniotomy (P=0.009). The evaluation of mRS after 12 months did not show a statistically significant difference between the two groups. CONCLUSIONS: In case of high energy trauma and GCS≤8 different neurosurgeons decided to perform most frequently decompressive craniectomy rather than craniotomy. Furthermore, even if not related to survival rate, decompressive craniectomy showed a better neurological outcome especially in patients with GCS≤8 at admission. In conclusion, even if prospective studies are required, these results depict the current attitude about the choice between craniotomy and decompressive craniectomy.

Ruptured Brain Arteriovenous Malformations: Surgical Timing and Outcomes-A Retrospective Study of 25 Cases.

Background One important problem in treatment of ruptured brain arteriovenous malformations (bAVMs) is surgical timing. The aim of the study was to understand which parameters affect surgical timing and outcomes the most. Materials and Methods Between January 2010 and December 2018, 25 patients underwent surgery for a ruptured bAVM at our institute. Intracerebral hemorrhage (ICH) score was used to evaluate hemorrhage severity, while Spetzler-Martin scale for AVM architecture. We divided patients in two groups: "early surgery" and "delayed surgery." The modified Rankin Scale (mRS) evaluated the outcomes. Results Eleven patients were in the "early surgery" group: age 38 ± 18 years, Glasgow Coma Scale (GCS) 7.64 ± 2.86, ICH score 2.82 ± 0.71, hematoma volume 45.55 ± 23.21 mL. Infratentorial origin of hemorrhage was found in 27.3% cases; AVM grades were I to II in 82%, III in 9%, and IV in 9% cases. Outcome at 3 months was favorable in 36.4% cases and in 54.5% after 1 year. Fourteen patients were in the "delayed surgery" group: age 41 ± 16 years, GCS 13.21 ± 2.39, ICH score 1.14 ± 0.81, hematoma volume 29.89 ± 21.33 mL. Infratentorial origin of hemorrhage was found in 14.2% cases; AVM grades were I to II in 50% and III in 50%. Outcome at 3 months was favorable in 78.6% cases and in 92.8% after 1 year. Conclusions The early outcome is influenced more by the ICH score, while the delayed outcome by Spetzler-Martin grading. These results suggest that it is better to perform surgery after a rest period, away from the hemorrhage when possible. Moreover, this study suggests how in young patient with a high ICH score and a low AVM grade, early surgery seems to be a valid and feasible therapeutic strategy.

Outcome Features Analysis in Intramedullary Tumors of the Cervicomedullary Junction: A Surgical Series.

OBJECT: The aim of this study is to investigate the impact of surgery for different cervicomedullary lesions on symptomatic pattern expression and postoperative outcome. We focused on specific outcome features of the early and late postoperative assessments. The former relies on surgery-related transient and permanent morbidity and feasibility of radicality in eloquent areas, whereas the latter on long-term course in lower grade tumors and benign tumorlike lesions (cavernomas, etc.). MATERIAL AND METHODS: We retrospectively analyzed 28 cases of intramedullary tumors of the cervicomedullary junction surgically treated at our institution between 1990 and 2018. All cases were stratified for gender, histology, macroscopic appearance, location, surgical approach, and presence of a plane of dissection (POD). Mean follow-up was 5.6 years and it was performed via periodic magnetic resonance imaging (MRI) and functional assessments (Karnofsky Performance Scale [KPS] and modified McCormick [MC] grading system). RESULTS: In all, 78.5% were low-grade tumors (or benign lesions) and 21.5% were high-grade tumors. Sixty-one percent underwent median suboccipital approach, 18% a posterolateral approach, and 21% a posterior cervical approach. Gross total resection was achieved in 54% of cases, near-total resection (>90%) in 14%, and subtotal resection (50-90%) in 32% of cases. Early postoperative morbidity was 25%, but late functional evaluation in 79% of the patients showed KPS > 70 and MC grade I; only 21% of cases showed KPS < 70 and MC grades II and III at late follow-up. Mean overall survival was 7 years in low-grade tumors or cavernomas and 11.7 months in high-grade tumors. Progression-free survival at the end of follow-up was 71% (evaluated mainly on low-grade tumors). CONCLUSIONS: The surgical goal should be to achieve maximal cytoreduction and minimal postoperative neurologic damage. Functional outcome is influenced by the presence of a POD, radicality, histology, preoperative status, and employment of advanced neuroimaging planning and intraoperative monitoring.

Microsurgical Treatment of Anterior Communicating Artery Aneurysms: A 20-year Single-institution Experience.

BACKGROUND: Anterior communicating artery (AComA) aneurysms are the most frequent intracranial aneurysms. They have a high risk of rupture, morbidity, and mortality following rupture. Surgical treatment is complex because of their deep location, proximity to the perforators, and their different projections and relations with the parent vessels. This retrospective study reports our experience in the surgical management of AComA aneurysms, describing how the microsurgical strategy is influenced by their projection and size, the orientation of the AComA complex, and the location and caliber of the parent vessels. METHODS: We reviewed all the patients treated surgically at our institution from September 1995 to March 2015 for ruptured and unruptured AComA aneurysms. Operative reports, neuroimages, and intraoperative videos were analyzed, and the surgical technique was examined. Illustrative cases are also included. RESULTS: A complete documentation was available for 223 (75.3%) of the 296 treated patients. Medium-size (55.1%) and superiorly projecting (31.8%) aneurysms were the most represented; 158 patients (70.9%) had different A1 diameters. A left- or right-sided pterional approach was performed in 85 patients (38.1%) and 138 patients (61.9%), respectively. A complete occlusion was documented in 185 patients (83%). CONCLUSIONS: Posterior and superior projections are the most complex to deal with because of the difficult dissection of the perforators and the contralateral A2, respectively. Approaching from the side of the dominant A1 ensures a prompt proximal control. Searching preoperatively for an eventual rotation of the AComA complex and for the location of the A2s can be very helpful for intraoperative orientation.

Proposal of Standardization of Closure Techniques After Endoscopic Pituitary and Skull Base Surgery Based on Postoperative Cerebrospinal Fluid Leak Risk Classification.

Postoperative cerebrospinal fluid (CSF) leak still represents the main limitation of endonasal endoscopic surgery. The aim of the study is to classify the risk of postoperative leak and to propose a decision-making protocol to be applied in the preoperative phase based on radiological data and on intraoperative findings to obtain the best closure.One hundred fifty-two patients were treated in our institution; these patients were divided into 2 groups because from January 2013 the closure technique was standardized adopting a preoperative decision-making protocol. The Postoperative CSF leak Risk Classification (PCRC) was estimated taking into account the size of the lesion, the extent of the osteodural defect, and the presence of intraoperative CSF leak (iCSF-L). The closure techniques were classified into 3 types according to PCRC estimation (A, B, and C).The incidence of the use of a nasoseptal flap is significantly increased in the second group 80.3% versus 19.8% of the first group and the difference was statistically significant P < 0.0001. The incidence of postoperative CSF leak (pCSF-L) in the first group was 9.3%. The incidence of postoperative pCSF-L in the second group was 1.5%. An analysis of the pCSF-L rate in the 2 groups showed a statistically significant difference P = 0.04.The type of closure programmed was effective in almost all patients, allowing to avoid the possibility of a CSF leak. Our protocol showed a significant total reduction in the incidence of CSF leak, but especially in that subgroup of patients where a leak is usually unexpected.

Chiari Malformations.

BACKGROUND: Chiari malformations (CM) represent a group of anomalies characterized by descent of the cerebellar tonsils or vermis into the cervical spinal canal. These malformations can be associated with abnormalities such as hydrocephalus, spina bifida, hydromyelia, syringomyelia, curvature of the spine (kyphosis and scoliosis) and tethered cord syndrome. Hereditary syndromes and other disorders that affect growth and bone formation-such as craniosynostosis, Ehlers-Danlos syndromes and Klippel-Feil syndrome-can also be associated with CM. METHODS: The literature concerning treatment is large, and an extensive range of therapeutic protocols have been described. The literature is inclined in favour of surgery; however, there is controversy over when to perform surgery and which procedure is most appropriate. Lately, the indications for stabilization have been under discussion. RESULTS AND CONCLUSION: In this paper we review the literature and discuss the historical background, anatomical forms, pathophysiology, clinical presentation, relationships with other diseases and diagnostic procedures for these abnormalities.

UAIS: Unruptured Aneurysms Italian Study.

BACKGROUND: Unruptured intracranial aneurysms (UIAs) are increasingly identified and are an important health-care burden; in the past they were commonly treated by surgical clipping, but nowadays endovascular coil embolization is increasingly employed as an alternative. METHODS: The Unruptured Aneurysms Italian Study (UAIS) is a multicentric cooperative prospective study aimed to delineate the "State of the Art" of UIAs treatment in Italy. 51 Italian Neurosurgical and Neuroradiological Units, representatives of all 20 Italian regions are involved in the Study. RESULTS: UAIS started on June 2003 and ended on July 2007. 1138 patients were collected by that date, but 181 were ruled-out due to severe violation of the protocol; 957 had complete data and could be statistically evaluated. CONCLUSIONS: UAIS demonstrates that the treatment of UAs, as performed in Italy as a Nation, is effective in improving long-term outcome vs. natural history, particularly in aneurysms larger than 7 mm.

Multidisciplinary management of spontaneous spinal infections: is there a correlation between timing, type of treatment and outcome?

BACKGROUND: Spontaneous spinal infections (SSIs) represent a rare and serious pathological entity. We tried to study a correlation between type of treatment, timing of treatment and clinical outcome through a multivariate analysis of an observational cohort study with the aim to define what is the optimal clinico-therapeutic management. METHODS: We performed a retrospective observational cohort study on all consecutive patients observed in our Institute in a period of 13 years; from 2001 to 2014 we enrolled 50 consecutive patients with symptomatic spontaneous spinal infections (no previous surgery or recent infection in other site), confirmed with diagnostic imaging. The inclusion parameters were: diagnostic imaging, signs and symptoms positive for SSI, no history of recent infection or surgery. Of each parameter analyzed, we calculated mean and standard deviation and when necessary correlation (ρ), covariance (σ) and relation coefficient between type of treatment, timing of treatment and clinical outcome. RESULTS: Our results suggest that an increase of one day from the onset of symptoms and the start of therapy leads to an increase in the Oswestry Disability Index Scale both at 6 months than at 1 year, with a statistical relevance, so our experience shows a statistically significant correlation and a positive co-variance between timing and outcome at 6 months and 1 year. CONCLUSIONS: SSI are rare, very difficult to diagnose and represent a significant clinical problem. If not properly managed, they may lead to significant impact in the quality of life. The most relevant problem is not the treatment, conservative or surgical, but early diagnosis, so a careful physical, laboratory and imaging examination is fundamental, with an important help provided by isolation of the pathogen and histology. In our experience early diagnosis has a fundamental role. In the light of this, current treatment protocols may require a prompt and multidisciplinary management including infectivologists, neuroradiologists and spine surgeons.

Fibrous Pituitary Macroadenomas: Predictive Role of Preoperative Radiologic Investigations for Proper Surgical Planning in a Cohort of 66 Patients.

OBJECTIVE: The endoscopic technique is in many cases the technique of choice for the removal of pituitary adenomas. Extended endoscopic approaches make it possible to remove lesions with suprasellar and parasellar extension and fibrous consistency. We identify some characteristics that might point to the adoption of an expanded approach in the preoperative phase. METHODS: We considered 66 consecutive cases treated for pituitary macroadenomas. All patients underwent preoperative magnetic resonance imaging and computed tomography, as well as postoperative magnetic resonance imaging. From the analysis of surgical reports and preoperative radiologic investigations, we extracted data related to size, extension, morphologic characteristics, consistency, and type of approach used (sellar or expanded). The degree of removal was judged to be total, near total, subtotal, or partial. RESULTS: The data showed that in some cases it is possible to assume in advance that there is a need for an expanded endoscopic approach. The features that led to an extended approach for extracapsular dissection of the lesion were the size of the tumor; an hourglass/dumbbell shape; lateral extension to the suprasellar carotid artery; Knosp degree 3 or 4; contrast enhancement heterogeneity; intratumoral hemorrhage, erosion, or discontinuity of the sellar floor; and increased sellar depth, which predicts increased thickness. CONCLUSIONS: The ability to predict the consistency of pituitary adenomas allows the surgeon to design a surgical procedure tailored to the patient. This approach has advantages concerning the extent of resection and allows a radical strategy with a single surgical procedure to be pursued.

Delayed surgery in neurologically intact patients affected by thoraco-lumbar junction burst fractures: to reduce pain and improve quality of life.

BACKGROUND: This is a retrospective study on 18 patients affected by thoraco-lumbar junction burst fractures (TLJBF) A3 or A4 at computed tomography (CT) scan who referred to our hospital. To assess the surgical results in terms of pain and quality of life in a series of neurologically intact patients affected by TLJBF who underwent surgery after 3-4 months from the injury. In literature there is controversy if pain could be an indication for surgery in TLJBF and series of patients conservatively managed with success have been reported. METHODS: A retrospective study on 18 patients is reported. Patients included in this series were neurologically intact and affected by a TLJBF A3 or A4 at CT scan, the height of the burst vertebral body was >50%, spinal canal invasion was <30% and kyphosis deformity <30 degrees. Pain and quality of life were evaluated using graphic rating scale (GRS) and EuroQol (EQ-5D) scores on admission, at the clinical follow-up and in post-surgical period. RESULTS: Comparing pre- and post-operative EQ-5D, the scores had a statistically significant decrease after the operation (P<0.001) [pre-surgery EQ-5D was 2.60 (SD =0.67), post-surgery EQ-5D was 1.37 (SD =0.41)]. Also analyzing the EQ5D-VAS scores, the t-test revealed that surgery (P<0.01) improved the quality of life with statistically significance (EQ5D-VAS pre =43.89, SD =12.43 and EQ5D-VAS post =73.33, SD =10.84). Analyzing pre- and post-surgical GRS scores, the pain decreased significantly with the maximum mean difference among the 2nd and 3rd month before surgery and at 12 months after surgery (respectively D =5.444, P<0.001 and D =5.167, P<0.001). CONCLUSIONS: Conservatively managed patients affected by TLJBF require a strict clinical follow-up since pain sometimes is present in the following months and it affects the quality of life. Surgery should be considered for these cases.

Emerging Strategies and Future Perspective in Neuro-Oncology Using Transcranial Focused Ultrasonography Technology.

BACKGROUND: Despite the progress achieved in recent years, the prognosis of patients with primary brain tumors remains poor. Research efforts have therefore focused on identifying more effective and minimally invasive treatment methods. Magnetic resonance-guided transcranial focused ultrasonography (MRgFUS) is a consolidated minimally invasive therapeutic technique, which has recently acquired a role also in the treatment of some nononcologic intracranial diseases. METHODS: We reviewed the latest studies to take stock of the potential of MRgFUS. RESULTS: The objective of the research in the last decade was to apply FUS also to the treatment of intracranial neoplastic diseases, using both the thermal effects (thermal ablation) and, above all, the ability to permeabilize the blood-brain barrier and modify the tumor microenvironment. This strategy may allow the use of drugs that are poorly active on the central nervous system or active selectively at high doses, minimize the side effects, and substantially modify the prognosis of patients affected by these diseases. CONCLUSIONS: In the future, targeted drug delivery, immunotherapy, and gene therapy will probably become main players in the treatment of brain neoplasms, with the aid of MRgFUS. In this way, it will be possible to directly intervene on tumor cells and preserve healthy tissue.

Giant Cell Ependymoma of Cervicomedullary Junction: A Case Report of a Long-Term Survivor and Literature Review.

BACKGROUND: Ependymoma accounts for 3%-9% of all neuroepithelial tumors. Giant cell ependymoma (GCE) is a rare and distinct variant, with only 22 cases described in the literature. The 2007 World Health Organization classification first acknowledged this rare subtype. The cytologic features of GCE include the presence of pleomorphic giant cells with several cellular atypias, which at intraoperative frozen diagnosis may appear to be high-grade glial lesions. Despite its apparently malignant histology, GCE seems to be a neoplasm with a relatively good prognosis. Extended tumor removal is the gold standard without adjuvant treatment. CASE DESCRIPTION: We describe the first case, to our knowledge, of GCE situated at the cervicomedullary junction in a 62-year-old patient. Surgery was performed with combined intraoperative monitoring of motor evoked potentials and somatosensory evoked potentials. Intraoperative frozen diagnosis revealed a high-grade glial neoplasm; however, gross total resection was achieved. The definitive diagnosis was GCE. At follow-up evaluation 11 years after surgery, the patient did not present with any tumor recurrence. CONCLUSIONS: As the intraoperative diagnosis can be misleading, whenever a cleavage plane is recognized, it is essential to perform a gross total resection with the aid of intraoperative neurophysiologic monitoring, to improve prognosis and neurologic outcome. Data reported in the literature show that prognosis is mainly influenced by grade of resection.

Isolated Pediatric Intramedullary Schwannoma: Case Report and Review of Literature.

BACKGROUND: Intramedullary (IM) schwannomas are rare entities representing 0.3%-1% of intramedullary tumors and 1.1% of spinal schwannomas. Beside many theories proposed, their rare occurrence might be related to the absence of Schwann cells in the spinal cord. Pediatric IM schwannomas are uncommon, and in the absence of neurofibromatosis they are extremely rare. To date, few cases have been reported in the literature. CASE DESCRIPTION: We describe the case of an 8-year-old female affected by a progressive paraparesis. Neuroradiologic investigations showed an oval-shaped mass at the level of T10-T11. The patient underwent surgery, performed under neurophysiologic monitoring. The patient was operated on with complete removal of the lesion. The postoperative course was uneventful. CONCLUSIONS: The clinical, neuroradiologic, and intraoperative findings are presented, along with a review of the literature. Despite the number of lesions potentially compressing the spinal cord, IM schwannoma is rare but should be taken into account in the differential diagnosis.

Total en-bloc spondylectomy through a posterior approach: technique and surgical outcome in thoracic metastases.

BACKGROUND: In 1981, Roy-Camille et al. have firstly reported the total en-bloc spondylectomy (TES) through a posterior approach for cases of malignant spine tumors in order to reduce the local recurrence and to increase the patient's survival. By then, this surgery has been increasingly gaining recognition. However, it requires a high level of technical ability and knowledge of spinal anatomy, physiology, and biomechanics. METHOD: Herein, we report the patient's selection and technique to execute the TES for cases of thoracic metastasis. CONCLUSION: This surgery is technically demanding so the patient's selection requires a careful pre-operative evaluation. However, it can be suggested for patients affected by intracompartmental lesions with a good prognosis since the tumor's progression is "limited" by local barriers as demonstrated by histological studies.

Quality of Life After Craniovertebral Junction Meningioma Resection: Shaping the Real Neurologic and Functional Expectancies About These Surgeries in a Contemporary Large Multicenter Experience.

OBJECTIVE: Craniovertebral junction (CVJ) meningiomas are one of the most surgically complex conditions in neuro-oncologic surgery. The aim of this work is to correlate our data with clinical outcome to outline factors leading to a worse functional prognosis. METHODS: We analyzed sex, age, clinical presentation, topography, surgical approach, Simpson grade resection, postoperative lower cranial nerve deficits, consistency, histology, site of origin, presence of a capsule, and radiologic and clinical follow-up at 1, 6, and 12 months of 61 patients affected by CVJ meningiomas, operated on in our institution from 1992 to 2014. RESULTS: 78.7% of patients were women (mean age, 52.85 years); the onset symptom was pain in 65.5% of cases. The mean preoperative Nurick grade of the sample was 3.78; the most frequent histologic type was endotheliomatous (42.8%). We treated 22 patients with a posterior median approach (5 with lateral and 17 with posterolateral axial topography); in 39 cases (30 anterolateral and 9 anterior) we performed a posterolateral approach. Gross total removal was achieved in 85.2% of cases. We recorded a final follow-up step overall neurologic improvement in the cohort (average preoperative Nurick grade, 3.81, and at 12 months, 2.13). Twenty-nine patients presented with lower cranial nerve deficit (permanent or transient) and no statistically significant association was found between surgical approach and temporary or permanent postoperative complications. CONCLUSIONS: We selected, in our experience, some predictors of worse outcome: preoperative sphincter impairment, absence of a capsule, cranial site of origin, a poor preoperative functional status, and firm consistency of the tumor.

Aneurysms of the Intracranial Segment of the Ophthalmic Artery Trunk: Case Report and Systematic Literature Review.

Aneurysms arising from the ophthalmic artery trunk (OAT) are very rare, particularly in the artery's intracranial course. The onset of a subarachnoid hemorrhage (SAH) from a ruptured OAT aneurysm in this segment is extremely rare. We present a case and discuss the anatomy, clinical significance, and therapeutic options for an aneurysm at this site. We also retrospectively analyzed the record of a patient with a ruptured aneurysm of the intracranial segment of the OAT and conducted a comprehensive and systematic review of the PubMed and Scopus databases for literature on this pathology. Only one case report of SAH from an aneurysm of the intracranial segment of the OAT was published in the literature. Only in our case was the intracranial OAT segment aneurysm discovered in the acute phase of SAH. Conventional angiography with three-dimensional acquisition may help detect aneurysms at this level. Detailed knowledge of the anatomy of the OAT is of paramount importance for both surgical and endovascular approaches. Surgical treatment is complex because of difficulties in accessing the orbital region and the risk of optic nerve and vascular injuries. Endovascular treatment, when feasible, could be a good alternative to reduce the risk of loss of vision related to surgical manipulation.

Surgery for vertebral involvement in multiple myeloma.

BACKGROUND: To evaluate the results of surgery for vertebral involvement in multiple myeloma (MM) following the introduction of the new chemotherapy in 2006. METHODS: Retrospective cohort study evaluating the patients with MM vertebral lesions from January 2006 to January 2014. Outcomes were based upon participation in ODI and EQ-5D. Statistical interpretation of the data was performed with SPSS version 19 software (SPSS Inc, Chicago, IL, USA). RESULTS: One hundred twenty patients affected by MM were potentially eligible for recruitment. About 1/3 patients needed an operation for vertebral involvement. The disability was mainly related to the number of vertebrae affected by MM. No difference in disability and quality of life was observed between operated and non-operated patients, according to age, levels, and follow-up. The operated patients with a Thoracic location reported lower disability and higher quality of life than non-operated patients. Non-operated patients with one or two vertebrae affected reported lower levels of quality of life. CONCLUSIONS: When a spinal column involvement occurs, the probability of undergoing surgery is about 40%. Operated patients show a moderate disability and the increased tendency is related to the number of vertebrae involved. The quality of life is middle in average and middle-high in patients operated for thoracic lesions. Nowadays the spinal surgeon must have a perspective view about MM vertebral lesions, evaluating the stability of the spine, the presence of deformity, the risk of vertebral fractures and the presence of drug resistant pain, that deteriorate the disability and the quality of life related to the underlying disease.