Preventing Ventricular Catheter Displacement and Infection with the "Catheter-Locking Device-Assisted" Technique: A Retrospective Study of 231 Patients.

BACKGROUND: Inserting cerebrospinal fluid diversion devices such as external ventricular drains (EVDs) and ventriculoperitoneal shunts (VPSs) is a critical procedure. Unfortunately, complications such as catheter misplacement, dislocation, or infection can occur. Various surgical strategies aim to reduce these risks. One recent innovation is the "catheter-locking device-assisted" technique for EVD surgery. In this study, we examined its application in a larger group of cases encompassing both EVDs and VPSs over a 30-month period, with a focus on these complications. METHODS: All adult patients who underwent a shunt procedure for noninfectious hydrocephalus at our institution from January 2021 to June 2023 were reviewed. We compared complications between those treated with the "standard" technique (subgroup A) and those managed with the "catheter-locking device-assisted" approach (subgroup B). RESULTS: In the EVD surgical group (initial procedures, n = 161), 6 patients (3.7%) required reoperation owing to the catheter misplacement caused by inadvertent migration of the ventricular catheter within the operating room ("early" migration), while 11 patients (6.8%) experienced unintentional postoperative dislodgement ("delayed" migration). Seven patients (4.3%) developed an EVD-related infection after an average duration of 7.4 days. None of these complications were observed in subgroup B patients (P < 0.05). Among VPS patients (n = 137), 4 (2.9%), all in subgroup A, required reoperation due to intraoperative migration of the catheter (P = 0.121); no other complications were identified. CONCLUSIONS: The "catheter-locking device-assisted" technique may significantly decrease the occurrence of the most common EVD complications and can also prove beneficial in VPS surgery. However, further investigation is necessary.

Association between spontaneous intracranial epidural hematoma and craniofacial infections: A systematic literature review.

Background: Spontaneous and nontraumatic epidural hematoma (SEDH) is a rare entity. Etiology is various, including vascular malformations of the dura mater, hemorrhagic tumors, and coagulation defects. The association between SEDH and craniofacial infections is rather unusual. Methods: We performed a systematic review of the available literature using the PubMed, Cochrane Library, and Scopus research databases. Literature research was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We exclusively included studies reporting demographic and clinical data, published until October 31, 2022. We also report one case from our experience. Results: A total of 18 scientific publications, corresponding to 19 patients, met the inclusion criteria for the qualitative and quantitative analysis. Patients were mostly adolescents, with a clear male predominance. SEDHs frequently occurred in the frontal area, usually near the site of the infection. Surgical evacuation was the treatment of choice with good postoperative outcomes. Endoscopy of the involved paranasal sinus should be achieved as soon as possible to remove the cause of the SEDH. Conclusion: SEDH may occur as a rare and life-threatening complication of craniofacial infections; therefore, prompt recognition and treatment are mandatory.

"Catheter-Locking Device-Assisted" External Ventricular Drain Placement: A New Surgical Technique Preventing Intracranial Drain Displacement-Technical Note with Preliminary Single-Center Results.

Background External ventricular drain (EVD) placement is frequently performed in neurosurgical patients to divert cerebrospinal fluid (CSF) and monitor intracranial pressure. The traditional practice is the tunneled EVD technique performed in the operating room. EVD insertion through a bolt in intensive care units has also been reported. We describe here the usage of a novel technique, the " catheter-locking device -assisted" EVD placement, reporting our preliminary, observational single-center results. Methods From January to October 2021, 15 patients underwent a "catheter-locking device-assisted" EVD placement at our institute. For each of these patients, the following data were evaluated: (1) demographics, (2) etiology, (3) clinical presentation, (4) EVD complications, and (5) final clinical outcomes. Results Median age of our population was 64 years, with a female/male ratio of 2:1. Average Glasgow Coma Scale score on admission was 8. Each patient maintained the drainage for an average time of 14 days. None of the patients suffered from postoperative intracerebral hemorrhage, CSF leakage, catheter migration, or discontinuation of the drainage system; none developed signs of infection. Nine patients required a permanent CSF diversion system. Outcome was good in 14 patients. One patient died for the underlying disease. Conclusions The "catheter-locking device-assisted" EVD placement appears to be a safe and accurate alternative to both the standard tunneled and the bolt-assisted EVD insertion techniques. The use of this procedure may significantly reduce the incidence of the commonest EVD complications, though further investigation is required.

Extradural hemorrhagic spinal cavernous angioma in a paucisymptomatic child: A rare case with review of the current literature.

Background: Cavernous angiomas, also referred to as cavernous hemangiomas or cavernomas (CMs), are vascular malformative benign neoplasms that may develop in any part of the central nervous system. Spinal CMs are uncommon (overall incidence rate of 0.04-0.05%). Pure epidural CMs account for 1-2% of all spinal CMs and 4% of all spinal epidural tumors. Diagnosis is extremely rare in the pediatric age. To the best of our knowledge, only 10 cases have been described so far. The treatment of choice is microsurgical resection. Case Description: We describe here the rare case of a cervicothoracic hemorrhagic spinal epidural cavernoma in a paucisymptomatic, 8-year-old female Bangladeshi child. C7-T2 laminectomy with excision of a scarcely defined, capsulated dark red lesion was performed with good recovery. Conclusion: Spinal epidural cavernomas are rare. Childhood presentation is even rarer. The reason could be found in a greater "compliance" and to a rarer occurrence of acute bleeding in children, thus resulting in a delayed diagnosis. Surgical excision is the gold standard of treatment.

Microsurgical Anatomy of the Hypoglossal Nerve in the Lateral Approaches to the Craniovertebral Junction: A Study on Fresh Non-Formalin-Fixed Human Specimens.

The aim of this anatomical study is to describe the anatomy of the hypoglossal nerve (HN) from its origin to the extracranial portion as it appears by performing a combined posterolateral and anterolateral approach to the craniovertebral junction (CVJ). Twelve fresh, non-formalin-fixed adult cadaveric heads (24 sides) were analyzed for the simulation of the combined lateral approach to the CVJ. The HN is divided into three main parts: cisternal, intracanalicular, and extracranial The anatomical relationships between the HN and other nerves, muscles, arteries and veins were carefully recorded, and some measurements were made between the HN and related structures. Thus, various landmarks were determined for the easy identification of the HN. Understanding the detailed anatomy of the HN and its relationships with the surrounding structures is crucial to prevent some complications during CVJ surgery.

A new device for bone cranial flap fixation: Technical note and surgical remarks. A multicentric experience.

BACKGROUND: Fixation of bone flaps after craniotomy is a routine part of every neurosurgical procedure. The ideal fixation device should be safe, reliable, biologically inert, easy to use, and inexpensive and should not produce artifacts on neuroimaging. The authors describe a new device that meets these criteria. METHODS: This is an observational, multicentric, and case series study of 56 patients who underwent a craniotomy and were subject to cranial bone flap fixation with the NT cranial small fixation system. A case-control group in whom titanium miniplates and screws were implanted was collected. All patients underwent CT scans of the head with 3D reconstruction at day 1 and day 90 postoperatively to evaluate bone flap position and fusion. RESULTS: A total of 140 NT cranial small were implanted in 56 patients (mean age 44.2, range 22-63 years). The new device has shown stronger fixation qualities with optimal bone flap fusion and good cosmetic features. No surgical or relevant postsurgical follow-up complications have been associated with the device. CONCLUSION: Although this is a preliminary report in a relatively small number of patients, NT cranial small provides a safe, reliable, and easily applied postoperative cranial bone flap fixation system.

Intracranial capillary hemangiomas: literature review in pediatric and adult population.

Capillary hemangiomas (CHs) of the central nervous system represent a rare diagnosed pathology. CHs are benign vascular tumors whose most common manifestations are dermal and mucous and mainly occur during childhood or adolescence, while the involvement of the central nervous system can occur in a wider age range. We conducted a PubMed research on literature published until March 2020. We only enrolled cases with histological documented presence of intracranial CH. For every case collected, we analyzed age, sex, localization, neuroimaging studies performed, the presence of extracranial CHs, symptoms, neurological deficits, extent of surgical resection (biopsy, partial or gross total), adjunct treatment received (radiotherapy, chemotherapy, Trans-Arterial Embolization TAE), and outcome. Up to March 2020, the literature review identified 52 cases to which we added the case of our personal experience. The mean age was 26 with slightly female prevalence (28 F, 25 M). The most common presenting symptom was headache (21 cases, 40%). The surgical treatment consisted of biopsy in 7 cases (13%), partial resection in 10 cases (19%), gross total resection in 31 cases (58.5%), biopsy followed by total resection in 2 cases (3%), and partial resection followed by total resection in 1 case (1.5%), and the diagnosis was obtained from an autopsy sample in 1 case (1.5%). For symptomatic lesions, surgery is a valid option to obtain histological characterization, neurological improvement, and where possible a total resection. Stereotactic radiotherapy can be used if the lesion is not surgically approachable or as an adjuvant treatment in case of partial resection, having shown good results in terms of long-term disease control.

A rare case of retroclival epidural hematoma: case report and review of the literature.

Retroclival epidural hematomas (REDHs) are rare and almost exclusively found in the pediatric age group. Frequently, the etiology is related to accidental trauma, though other mechanisms have been observed, including coagulopathy, non-accidental trauma, and pituitary apoplexy. A 76-year-old man was admitted to our emergency department after a loss of consciousness. He presented with a Glasgow Coma Scale of 13(E3V4M6). He complained of headache accompanied by nausea and vomiting. A computer tomography (CT) revealed a hemorrhage along the clivus and dens. Magnetic resonance imaging (MRI) demonstrated the retroclival hematoma in epidural space. At discharge headache resolved without medical or operative intervention. REDHs are likely underdiagnosed in adults and magnetic resonance imaging is superior for identifying these lesions. Atlanto-occipital dislocation should be considered in all cases of REDH. Most cases exhibit a benign clinical course with conservative management, surgical management is dictated based on the presence of hydrocephalus, brainstem compression, and occipitocervical instability.

Trigeminal Neuralgia Secondary to Intracranial Neoplastic Lesions: a Case Series and Comprehensive Review.

It is known that intracranial tumors may trigger trigeminal neuralgia (TN) in some patients although the exact prevalence and occurrence is not completely defined yet. In the present study, we present a case series of patients with brain tumor and a clinical diagnosis of TN as the first and main manifestation of the disease. A retrospective analysis was performed involving patients diagnosed with brain tumor whose exclusive clinical feature our department focused on was TN. In addition, a review of all published cases was performed. From January 2017 to November 2018, 718 patients with brain tumor were admitted to our department, 17 of which suffered of TN, of which 8 patients presented with at least another neurologic symptom and 9 patients presented with TN alone, with typical symptoms of stubbing electric pain in 6 cases. In our series, we found that 2.3% of patients admitted for brain tumors had TN. In 0.8% of cases, TN was the main clinical symptom. The prevalence of tumor lesion in patients with facial neuropathic pain is not defined, but it is a well-known recognized initial symptom; however, early cerebral magnetic resonance imaging (MRI) is not yet strongly recommended in patients with newly diagnosed trigeminal neuralgia. The purpose of this article is, especially in unusual cases, to show that the application of such MR techniques and preoperative evaluation may contribute to diagnosis, indication, and surgery planning.

Development of a delayed acute epidural hematoma following contralateral epidural hematoma evacuation: case report and review of literature.

The formation of a post-traumatic delayed epidural hematoma (DEDH) is a rare but well-described complication in the literature. It is defined as an extradural bleeding not evident at the first computed tomography (CT) scan performed after trauma, but evidenced by further radiological evaluations. The most supported hypothesis about the mechanism responsible for the formation of a DEDH concerns above all the loss of a tamponade effect given by the reduction of intracranial pressure with medical or surgical treatment. A 30-year-old man was admitted to the emergency department with an epidural hematoma (EDH) associated with a linear calvarial bitemporal coronal fracture. A few hours after the surgical procedure for hematoma evacuation, the patient developed a DEDH contralateral to the site of surgical procedure. The literature review identified other 27 analogue cases. The presence of a calvarial fracture contralateral to the site of a craniotomy and the intraoperative brain swelling during EDH removal are suspicious for the development of DEDH. A CT scan has to be urgently performed in this situation. The timing of postoperative radiological examinations after EDH removal has to consider possible complications and has to be balanced on the basis of patient's clinical condition and neuroradiological data, such as skull fractures or intraoperative anomalies. The development of a DEDH after the surgical removal of an EDH is a rare event, characterized by a high mortality rate. DEDH develops preferentially on the contralateral side and with a concomitant skull fracture.

Vertebroplasty and delayed subdural cauda equina hematoma: Review of literature and case report.

Vertebroplasy is considered an alternative and effective treatment of painful oncologic spine disease. Major complications are very rare, but with high morbidity and occur in less than 1% of patients who undergo vertebroplasty. Spinal subdural hematoma (SDH) is an extremely rare complication, usual developing within 12 h to 24 h after the procedure. We report the case of a tardive SDH in an oncologic patient who underwent VP for Myxoid Liposarcoma metastasis. Trying to explain the pathogenesis, we support the hypothesis that both venous congestion of the vertebral venous plexus of the vertebral body and venous congestion due to a traumatic injury can provoke SDH. To our best knowledge, only 4 cases of spinal subdural hematoma following a transpedicular vertebroplasty have been previously described in International literature and only one of them occurred two weeks after that surgical procedures. Percutaneous verteboplasty is a well-known treatment of pain oncologic spine disease, used to provide pain relief and improvement of quality life and is considered a simple surgical procedure, involving a low risk of complications, but related to high morbidity, such as SDH. Therefore it has to be performed by experienced and skilled surgeons, that should also recognize possible risk factors, making SDH more risky.

Sudden benzodiazepine-induced resolution of post-operative pediatric cerebellar mutism syndrome: a clinical-SPECT study.

Post-operative pediatric cerebellar mutism syndrome (PPCMS) is a clinical syndrome arising from cerebellar injury and characterized by absence of speech and other possible symptoms and signs. Rare reports described some benefit after administration of dopamine agonist therapy, but no treatment has proven efficacy. In this paper, we report on the dramatic, sudden resolution of PPCMS induced by midazolam administration in a boy who underwent posterior fossa surgery for choroid plexus papilloma of the fourth ventricle. In addition to clinical improvement, post-midazolam single-photon emission computed tomography also demonstrated amelioration of brain perfusion.

The only case of mycotic aneurysm of the PICA: Clinical-radiological remarks and review of literature.

We present the first and only case, reported in literature, of a 67-years-old man with a mycotic aneurysm (MA) of the left posterior inferior cerebellar artery (PICA), caused by group B Streptococcus, that we surgically treated, performing neck aneurysm clipping, preserving patency of parent vessel. Moreover the peculiarity of this case is represented by the fact that the MA is originated from a tooth abscess, treated about two years before. To date, there have been only 10 cases of association between MA with either tooth pathologies or dental surgical procedures and our case is the only one originating from PICA. Therefore an extensive literature analysis was performed. Hence if we observe a patient with a fusiform aneurysm in posterior intracranial circulation and clinical history of fever and/or persistent neck swelling after dental pathologies, it is mandatory to consider the possibility of a MA, for a correct differential diagnosis. If the diagnosis is confirmed, it is necessary to research the origin of infection and to set the specific antibiotics therapy.

Mesenchymal stem cells in lumbar spine surgery: a single institution experience about red bone marrow and fat tissue derived MSCs.

BACKGROUND: Mesenchymal stem cells (MSCs) are undifferentiated, multipotent cells, which have the ability to self-renew and differentiate into many tissue types. MSCs have shown therapeutic applications in different medical fields and could represent a successful treatment of degenerative disc disease (DDD). Several studies have demonstrated, ex vivo or in animal models, the MSCs efficacy in spine surgery. The authors aim to demonstrate their efficacy in humans. METHODS: Twenty-two consecutive patients, who suffered of spine DDD, were submitted: in 11 cases the MSCs were harvested from red bone marrow, 11 from fat tissue. The red bone marrow withdrawal was performed from the vertebral bodies; processed by a fully-automated, mobile system. The fat tissue withdrawal was acted from the subcutaneous adipose tissue; processed through a microfluidic fractioning procedure. MSCs were implanted in the central part of the nucleus pulposus of the DDD or added to bone chips to accelerate posterolateral arthrodesis. RESULTS: All the 14 posterolateral fusions and MSCs implantations showed at three months a complete bone bridge, stable at follow-up. The one intersomatic implantation gained a complete interbody fusion after one month; while 80% black discs treated with MSCs presented a new T2-W hyperintensity at postoperative MRI. The mean Visual Analogue Scale Pain Score improved from 70±20 to 10±5 at 12 months, as the ODI score from 70±5% to 20±10%. CONCLUSIONS: There are several questions that need to be answered but MCSs look promising in lumbar spine surgery, both to block the aging of the disc both to accelerate the fusion processes in arthrodesis.

Cervical Posttraumatic Unilateral Locked Facets: Clinical, Radiologic, and Surgical Remarks on a Series of 33 Patients.

STUDY DESIGN: Radiographic and clinical analysis. OBJECTIVE: Review author's experience with anterior discectomy, interbody fusion, and anterior cervical plating in 33 patients with posttraumatic unilateral cervical locked facets. SUMMARY OF BACKGROUND DATA: Unilateral cervical locked facet syndrome is a relatively uncommon injury that often is misdiagnosed and therefore subject to a dangerous delay in surgery. Management of this trauma is controversial. MATERIALS AND METHODS: Thirty-three patients with radiologically proven diagnosis of postraumatic unilateral cervical locked facets were treated by skull traction and surgical operation from January 2005 to December 2009. All patients preoperatively were assessed for neurological examination and underwent x-rays, magnetic resonance imaging, and computed tomography evaluation of the cervical spine. RESULTS: The unilateral locked facet level was C4-C5 in 13 patients, C5-C6 in 10, C6-C7 in 8, and C3-C4 in 2 patients. After closed reduction attempt with Crutchfield system, the correct alignment was achieved in 30 patients, who underwent anterior discectomy with cage, interbody fusion, and anterior cervical plating. In 3 patients there was an overdistraction and therefore a closed reduction was not possible, so they were firstly operated by posterior approach with opened reduction of the facets, lateral mass screws, and posterolateral fusion. In 2 of these patients there was an anterior fragment of the disk in the canal, so was also performed an anterior approach with discectomy, cage, and plating. There were no surgery-related complications. Postoperative neurological status was unchanged in the 3 patients with tetraplegia and improved in 8 of the 10 patients with radiculopathy. Fusion was obtained in all patients, as showed in the clinical and radiologic follow-up. CONCLUSIONS: The authors conclude that an anterior approach provides a safe and effective alternative for the treatment of patients with posttraumatic unilateral cervical locked facet, when preoperatively the cervical alignment of the dislocation is achieved with a closed reduction.

Single institute experience on 108 consecutive cases of type II odontoid fractures: surgery versus conservative treatment.

AIM: The incidence of cervical fractures in industrialized countries is about 11.000 cases per year. The objective of our study was to determine which of two treatments was more effective for the management of Type II odontoid fractures. MATERIAL AND METHODS: This study involved 108 cervical fractures treated at the "Department of Neurosurgery of Policlinico Umberto I" in Rome between 2002 and 2013. Sixty of the 108 axis fractures were treated conservatively with external immobilization, and the remaining 48 were treated surgically. RESULTS: Patients undergoing surgery had a higher rate of fusion (91.67% vs. 46.67%) and shorter bone healing times (17 weeks compared to 21 weeks) than the patients who received conservative treatment. CONCLUSION: All fractures of the odontoid process, without dislocation, should be treated with rigid external immobilization (preferably with a "Halo-vest"). All fractures of the odontoid process with dens dislocation > 5 mm should be considered as candidates for surgery. Type II odontoid fractures in patients over 50 years old should also be candidates for surgical treatment, while the outcome of such fractures, as regards conservative treatment, is better for patients under 50 years old.

Granular cell tumor of the neurohypophysis: a single-institution experience.

Granular cell tumor (GCT) is a rare neoplasm occurring in the sellar and suprasellar spaces. It is a primary tumor of the neurohypophysis, presumably arising from the pituicytes, a distinctive glial cell of the neurohypophysis. GCTs in most reported cases show biologically benign behavior with slow growth. Only 70 cases of hypophyseal GCTs have been reported in the literature. We report a case of GCT in the neurohypophysis of a 46-year-old woman and discuss the histological and clinical features of this neoplasm together with the treatment modalities, reviewing the pertinent literature.

Extent of tumor removal and molecular markers in cerebral glioblastoma: a combined prognostic factors study in a surgical series of 105 patients.

OBJECT: In this paper, the authors' goal was to evaluate the prognostic value of YKL-40 expression as a prognostic factor for glioblastomas and to compare its validity to the already known MGMT. METHODS: Between January 2002 and January 2007, 105 patients were treated for cerebral glioblastoma. The extent of removal was classified in 4 groups. YKL-40 expression was evaluated by a semiquantitative immunohistochemical staining scale (0, no staining; 1, mild expression; and 2, strong expression). MGMT promoter methylation status was analyzed with methylation-specific polymerase chain reaction. All patients received adjuvant radiotherapy and chemotherapy. Kaplan-Meier curves were used to analyze progression-free survival (PFS) and overall survival (OS), and to compare these parameters between the subgroups stratified by extent of surgical removal, MGMT methylation, and YKL-40 expression. The log-rank test was used to determine statistical significance. A multivariate regression analysis was applied to extent of removal, YKL-40 expression, and MGMT status to check their specific statistical power and to test the independence of the variables. RESULTS: There were 55 men and 50 women with a mean age of 58 years. Extent of surgical removal is reported. The MGMT promoter was methylated in 48 patients and nonmethylated in 57. Analysis of YKL-40 expression is reported. The median PFS was 10.7 months (14.9 months in the gross-total removal subgroup) (p < 0.0001), and the median OS was 12.5 months (17.4 months in the gross-total removal group) (p < 0.0001). In the univariate analysis, OS was significantly correlated to the extent of resection (p < 0.0001), MGMT status (p < 0.0001), and YKL-40 (p < 0.0001). Multivariate analysis showed that all 3 factors reached statistical significance with respect to patient survival. In particular, surgical removal contributed more than the 2 other factors to the survival prediction (ß = -0.6254). Interestingly, YKL-40 (ß = -0.3867) contributed more than MGMT (ß = -0.1705) to the predicted survival. CONCLUSIONS: The extent of removal is the most important factor influencing the OS of patients harboring glioblastomas. When biological aggressiveness is taken into account, YKL-40 expression was found to be an independent prognostic factor that predicts OS better than MGMT status.