Haemostatic technique in malignant gliomas.

INTRODUCTION: Haemostasis in brain surgery is mandatory to avoid postoperative re-bleeding and a poor outcome. Postoperative intra-cavity haemorrhage is a frequent complication, especially in surgery of malignant gliomas because of the fragility of pathological vessels. MATERIAL AND METHODS: In this technical note, we describe our 'compression' technique used to achieve haemostasis in adult patients who underwent surgery for supratentorial malignant gliomas (GBM) at our Institute from January 2019 to January 2022. Peri-operative work-up included clinical status, laboratory data and contrast brain CT, performed at 24 hours after surgery, or earlier for patients with neurological worsening. RESULTS: A total of 82 patients was included in this study, 46 males (57%) and 36 females (43%). A post-operative intra-cavity haemorrhage was documented by postoperative CT-scan in 3/82 patients (3.65%), and the mean surgical time was 3.66 hours. No late bleeding was observed 48 hours after surgery. CONCLUSIONS: We have documented the good results of our technique to achieve haemostasis in patients operated for malignant glioma (GBM). The technique described in this study seems to be safe and useful to avoid post-operative bleeding in the surgery of cerebral GBM.

Fronto-orbito-zygomatic (FOZ) approach for infratemporal fossa lesions extending to middle cranial fossa: our experience and review of literature.

AIM OF THE STUDY: Tumours of the infratemporal fossa (ITF) are rare and include primary tumours, contiguity lesions and metastases. Surgical resection is the gold standard. The fronto-orbito-zygomatic (FOZ) approach is commonly used in order to obtain safe access to the lateral skull base and ITF to resect intra- and extra-cranial tumours. We here describe our series of ITF lesions extending to the middle cranial fossa and/or orbit, treated by single- or two piece FOZ. MATERIAL AND METHODS: All cases of single- or two-piece FOZ approach for an infratemporal fossa lesion extending to the middle cranial fossa operated at our Institution from January 2014 to January 2018 were retrospectively reviewed. The follow-up was for a minimum of four months and a maximum of 60 months. The inclusion criteria were lesions involving the ITF with an extension to the middle cranial fossa and/or orbit. Baseline characteristics of patients, tumour localisation, tumour extension, diffusion route, histology, extent of tumour resection, postoperative treatment, and post-operative complications were evaluated. RESULTS: Nine patients underwent a surgical procedure with a FOZ approach, two of them with a single-piece approach and the remainder with a two-piece one. All patients had an ITF localisation. Gross total removal (GTR) was achieved in 7/9 patients. Only one patient, with non-total removal (NTR), underwent radiotherapy. CONCLUSIONS: For the treatment of ITF fossa tumours extending to the orbit and or middle cranial fossa, we believe that both FOZ techniques are effective and allow a good medial extension toward the cavernous sinus and parasellar region. But a two-piece craniotomy may ensure a more medial extension and a wider angle of work compared to a one-piece craniotomy.

Timing of cranial reconstruction after cranioplasty infections: are we ready for a re-thinking? A comparative analysis of delayed versus immediate cranioplasty after debridement in a series of 48 patients.

The optimal management of cranioplasty infections remains a matter of debate. Most authors have suggested that the infected bone/implant removal is mandatory, combined with prolonged antibiotic therapy before reconstruction. However, failures can occur, even with 12-18-month intervals between the surgeries. Longer wait times before cranial reconstruction increase the risks of socioeconomic burdens and further complications, as observed in decompressed patients hosting shunts. In our department, we treated 48 cranioplasty infections over a period of 8 years, divided into two groups. For Group A (n = 26), the treatment consisted of cranioplasty removal and debridement, followed by a delayed reconstruction. Group B (n = 22) received 2 weeks of broad-spectrum antibiotics, followed by an "aggressive" field debridement and immediate cranioplasty. All patients received a minimum of 8 weeks of post-operative antibiotic therapy and were scheduled for clinic-radiological follow-ups for at least 36 months. Significant differences were observed between Groups A and B with respect to the number of failures (respectively 7 versus 1), the global operative time (significantly longer for Group B), germ identification (respectively 7 versus 13), and the overall length of hospital stay (on average, 61.04 days in Group A versus 47.41 days in Group B). Three shunted patients in Group A developed sinking flap syndrome. Shunt resetting allowed symptom control until cranioplasty in one subject, whereas two did not improve, even after reconstruction. In selected patients, an aggressive field debridement, followed by the immediate replacement of an infected cranioplasty, may represent a safe and valuable option.

The efficacy of postoperative bracing after spine surgery for lumbar degenerative diseases: a systematic review.

PURPOSE: Postoperative bracing treatment is widely used after surgery for lumbar degenerative diseases. However, the guidelines are lacking in this regard, and its use is mainly driven by individual surgeon preferences. The objective of the current review was to evaluate the available evidence on the use of postoperative bracing after surgery for degenerative disease of the lumbar spine. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed while conducting a systematic search of the PubMed/Medline, Scopus, and Cochrane databases from January 1990 to January 2019. High-quality studies were included that evaluated disability, pain, quality of life, the rate of fusion, complications, and rate of reoperations in patients who had surgery for lumbar degenerative disease, with and without postoperative bracing. The overall strength of evidence across the studies was assessed using the Grading of Recommendations Assessment, Development, and Evaluation framework. RESULTS: Of the 391 citations screened, four randomized controlled trials met the inclusion criteria and were included in the review. Based on low- to moderate-quality evidence, postoperative bracing in patients with lumbar degenerative disease does not result in improved disability, pain, and quality of life compared to no bracing patients. Low-quality evidence suggests that there was no significant difference between the two groups in terms of the rate of fusion, complications, and the need for reoperation. CONCLUSIONS: To date, there is not a medical evidence to support the use of bracing after surgery for lumbar degenerative disease. These slides can be retrieved under Electronic Supplementary Material.

Characteristics of treatment and outcome in elderly patients with brain glioblastoma: a retrospective analysis of case series.

Treatment modalities affecting quality of life and survival in elderly brain glioblastoma patients are not well defined. A single-institution data were analyzed during a 3-year period to disclose prognostic difference in management related to age. Karnofsky Performance Scale (KPS), overall survival (OS), and adjuvant therapy were evaluated. The case group comprised of elderly patients (>75 years), while the control group included those of younger age (<65 years). The investigated variables were correlated between the groups. Twenty elderly patients and a corresponding number of younger ones were analyzed. Preoperative KPS >70 indicated longer overall survival. Statistically significant correlation was recorded in both the control (p=0.036) and case (p=0.0053) groups. Lower postoperative KPS was significantly correlated with shorter OS in elderly patients (p=0.023). The correlation between the extent of tumor resection and OS was statistically significant in younger patients only (p=0.04). Overall survival was significantly shorter in elderly patients regardless of the extent of tumor resection (p=0.0057). Adjuvant therapy was significantly associated with longer OS in both the case (p=0.032) and control (p=0.013) groups. Elderly population is a more endangered group of surgical brain glioblastoma patients having lower quality of life and shorter overall survival. The management protocol should be personalized for each individual case in this age group of patients to reduce postoperative complications and grant a satisfactory quality of life.

Risk factors for post-traumatic hydrocephalus following decompressive craniectomy.

BACKGROUND: Post-traumatic hydrocephalus (PTH) is one of the main complications of decompressive craniectomy (DC) after traumatic brain injury (TBI). Then, the recognition of risk factors and subsequent prompt diagnosis and treatment of PTH can improve the outcome of these patients. The purpose of this study was to identify factors associated with the development of PTH requiring surgical treatment in patients undergoing DC for TBI. METHODS: In this study, we collected the data of 190 patients (149 males and 41 females), who underwent DC for TBI in our Center. Then we analyzed the type of surgical treatment for all patients affected by PTH and the risk factors associated with the development of PTH. RESULTS: Post-traumatic hydrocephalus (PTH) developed in 37 patients out of 130 alive 30 days after DC (28.4%). The development of PTH required ventriculoperitoneal shunt (VPS) in 34 patients out of 37 (91.9%), while, in the remaining 3 patients, cerebrospinal fluid hydrodynamic (CSF) disturbances resolved after urgent cranioplasty and temporary external lumbar drain. Multivariate analysis showed that the presence of interhemispheric hygroma (p < 0.001) and delayed cranioplasty (3 months after DC) (p < 0.001) was significantly associated with the need for a VPS or other surgical procedure for PTH. Finally, among the 130 patients alive after 30 days from DC, PTH was associated with unfavorable outcome as measured by the 6-month Glasgow Outcome Scale score (p < 0.0001). CONCLUSIONS: Our results showed that delayed cranial reconstruction was associated with an increasing rate of PTH after DC. The presence of an interhemispheric hygroma was an independent predictive radiological sign of PTH in decompressed patients for severe TBI.

Clinical and psychological outcome after surgery for lumbar spinal stenosis: A prospective observational study with analysis of prognostic factors.

BACKGROUND: The identification of psychological risk factors is important for the selection of patients before spinal surgery. Moreover, the effect of surgical decompression in lumbar spinal stenosis (LSS) on psychological outcome is not previously well analyzed. AIM OF PAPER: to investigate clinical and psychological outcome after surgery for LSS and the effect of depressive symptoms and anxiety on the clinical outcome. MATERIALS AND METHODS: A total of 25 patients with symptomatic LSS underwent decompressive surgery with or without spinal stabilization were prospectively enrolled in this observational surgery. The Symptom Checklist-90-Revised (SCL-90-R) was used to assess global psychological distress with a summary score termed Global Severity Index (GSI) and single psychological disorders including depression (DEP) and anxiety (ANX). The clinical outcome of surgery was evaluated with the Oswestry Disability Index (ODI) and visual analogue scale (VAS) pain assessment. RESULTS: Compared with baseline, there was a statistically significant improvement in VAS, ODI and GSI after surgery (p<0.05) in all patients. Univariate analysis revealed that patients with high GSI and anxiety and depression scores had significantly higher ODI and VAS scores in the follow-up with a bad outcome. CONCLUSIONS: Surgery for spinal stenosis was effective to treat pain and disability. In this prospective study baseline global psychological distress, depression and anxiety were associated with poorer clinical outcome.

Supraorbital subfrontal trans-laminar endoscope-assisted approach for tumors of the posterior third ventricle.

BACKGROUND: Different surgical approaches have been developed for dealing with third ventricle lesions, all aimed at obtaining a safe removal minimizing brain manipulation. The supraorbital subfrontal trans-lamina terminalis route, commonly employed only for the anterior third ventricle, could represent, in selected cases with endoscopic assistance, an alternative approach to posterior third ventricular lesions. METHODS: Seven patients underwent a supraorbital subfrontal trans-laminar endoscope-assisted approach to posterior third ventricle tumors (two craniopharyngiomas, one papillary tumor of the pineal region, one pineocytoma, two neurocytomas, one glioblastoma). Moreover, a conventional third ventriculostomy was performed via the same trans-laminar approach in four cases. RESULTS: Complete tumor removal was accomplished in four cases, subtotal removal in two cases, and a simple biopsy in one case. Adjuvant radiotherapy and/or chemotherapy was administered, if required, on the basis of the histologic diagnosis. No major complications occurred after surgery except for an intratumoral hemorrhage in a patient undergoing a biopsy for a glioblastoma, which simply delayed the beginning of adjuvant radiochemotherapy. No ventriculoperitoneal shunt placement was needed in these patients at the most recent clinical and radiologic session (average 39.57 months, range 13-85 months). Two illustrative cases are presented. CONCLUSIONS: The supraorbital subfrontal trans-laminar endoscope-assisted approach may provide, in selected cases, an efficient and safe route for dealing with posterior third ventricular tumors.

Treatment of unstable thoracolumbar junction fractures: short-segment pedicle fixation with inclusion of the fracture level versus long-segment instrumentation.

BACKGROUND: The surgical management of thoracolumbar burst fractures frequently involves posterior pedicle screw fixation. However, the application of short- or long-segment instrumentation is still controversial. The aim of this study was to compare the outcome of the short-segment fixation with inclusion of the fracture level (SSFIFL) versus the traditional long-segment fixation (LSF) for the treatment of unstable thoracolumbar junction fractures. METHODS: From December 2009 to February 2014, 60 patients with unstable thoracolumbar junction fractures (T11-L2) were divided into two groups according to the number of instrumented levels. Group 1 included 30 patients treated by SSFIFL (six-screw construct including the fracture level). Group 2 included 30 patients treated by LSF (eight-screw construct excluding the fracture level). Local kyphosis angle (LKA), anterior body height (ABH), posterior body height (PBH), ABH/PBH ratio of fractured vertebra, and Asia Scale Impairment Scale were evaluated. RESULTS: The two groups were similar in regard to age, sex, trauma etiology, fracture level, fracture type, neurologic status, pre-operative LKA, ABH, PBH, and ABH/PBH ratio and follow-up (p > 0.05). Reduction of post-traumatic kyphosis (assessed with LKA) and restoration of fracture-induced wedge shape of the vertebral body (assessed with ABH, PBH, and ABH/PBH ratio) at post-operative period were not significantly different between group 1 and group 2 (p = 0.234; p = 0.754). There was no significant difference between the two groups in term of correction loss at the last follow-up too (LKA was 15.97° ± 5.62° for SSFIFL and 17.76° ± 11.22° for LSF [p = 0.427]). Neurological outcome was similar in both groups. CONCLUSIONS: Inclusion of fracture level in a short-segment fixation for a thoracolumbar junction fractures results in a kyphosis correction and in a maintenance of the sagittal alignment similar to a long-segment instrumentation. Finally, this technique allowed us to save two or more segments of vertebral motion.

Radiologic and Blood Markers Predicting Long-Term Neurologic Outcome Following Decompressive Craniectomy for Malignant Ischemic Stroke: A Preliminary Single-Center Study.

BACKGROUND: Malignant ischemic stroke (MIS) is defined by progressive cerebral edema leading to increased intracranial pressure (ICP), compression of neural structures, and, eventually, death. Decompressive craniectomy (DC) has been advocated as a lifesaving procedure in the management of patients with MIS. This study aims to identify pre- and postoperative predictive variables of neurologic outcomes in patients undergoing DC for MIS. METHODS: We conducted a retrospective study of patients undergoing DC in a single center from April 2016 to April 2020. Preoperative workup included baseline clinical status, laboratory data, and brain computed tomography (CT). The primary outcome was the 6-month modified Rankin score (mRS). The secondary outcome was the 30-day mortality. RESULTS: During data capture, a total of 58 patients fulfilled the criteria for MIS, of which 22 underwent DC for medically refractory increased ICP and were included in the present analysis. The overall median age was 58.5 years. An immediate (24 hour) postoperative extended Glasgow Outcome Scale (GOSE) score ≥5 was associated with a good 6-month mRS (1-3; p = 0.004). Similarly, low postoperative neutrophils (p = 0.002), low lymphocytes (p = 0.004), decreased neutrophil-to-lymphocyte ratio (NLR; p = 0.02), and decreased platelet-to-lymphocytes ratio (PLR; p = 0.03) were associated with good neurologic outcomes. Preoperative variables independently associated with worsened 6-month mRS were the following: increased age (odds ratio [OR]: 1.10; 95% confidence interval [CI]: 1.01-1.20; p = 0.02), increased National Institutes of Health Stroke Scale (NIHSS) score (OR: 7.8; 95% CI: 2.5-12.5; p = 0.035), Glasgow Coma Scale (GCS) score less than 8 at the time of neurosurgical referral (OR: 21.63; 95% CI: 1.42-328; p = 0.02), and increased partial thromboplastin time (PTT) before surgery (OR: 2.11; 95% CI: 1.11-4; p = 0.02). Decreased postoperative lymphocytes confirmed a protective role against worsened functional outcomes (OR: 0.01; 95% CI: 0.01-0.4; p = 0.02). Decreased postoperative lymphocyte count was associated with a protective role against increased mRS (OR: 0.01; 95% CI: 0.01-0.4; p = 0.02). The occurrence of hydrocephalus at the postoperative CT scan was associated with 30-day mortality (p = 0.005), while the persistence of postoperative compression of the ambient and crural cistern showed a trend towards higher mortality (p = 0.07). CONCLUSIONS: This study reports that patients undergoing DC for MIS showing decreased postoperative blood inflammatory markers achieved better 6-month neurologic outcomes than patients with increased inflammatory markers. Similarly, poor NIHSS score, poor GCS score, increased age, and larger PTT values at the time of surgery were independent predictors of poor outcomes. Moreover, the persistence of postoperative compression of basal cisterns and the occurrence of hydrocephalus are associated with 30-day mortality.

Bone Flap Resorption After Cranioplasty: Risk Factors and Proposal of the Flap Integrity Score.

BACKGROUND: Bone flap resorption is a known complication of postdecompressive autologous cranioplasty. Although several potential etiopathogenetic factors have been investigated, their role is still under discussion. To further complicate things, resorption is not an all-or-nothing event, patients frequently presenting with different degrees of flap remodeling. Focus of this paper was to describe the elaboration of a score quantifying bone resorption according to a set of clinical and radiological criteria, hopefully allowing prompt identification of patients needing resurgery before the development of adverse events. METHODS: In a 10-year period, 281 autologous cranioplasties were performed at our institution following decompressive craniectomy. Pertinent clinical and radiological information was registered. A set of 3 clinical and 3 radiological parameters was established to score the degree of resorption, identified under the acronym FIS (Flap Integrity Score). Three groups of patients emerged, respectively showing no (208), partial (32), and advanced (41) resorption. RESULTS: An overall 14.6% incidence of advanced bone resorption was found in our series. Younger age, bone multifragmentation, higher postcranioplasty Glasgow Outcome Scale scores, <2 cm distance of medial craniectomy border from the midline, and cause leading to decompressive craniectomy were associated to a statistically significant higher risk of developing a relevant bone flap resorption. The first three variables were confirmed as risk factors in multivariate analysis. Flap Integrity Score well discriminated the 3 different groups. CONCLUSIONS: Autologous bone repositioning is still a valuable, low-cost, cosmetically and functionally satisfactory procedure. Nonetheless, although resorption affects a minor percentage of patients, its early identification and treatment can improve long-term results.

The Prognostic Role of Volumetric MRI Evaluation in the Surgical Treatment of Glioblastoma.

Background: Glioblastoma is the most common primary brain neoplasm in adults, with a poor prognosis despite a constant effort to improve patient survival. Some neuroradiological volumetric parameters seem to play a predictive role in overall survival (OS) and progression-free survival (PFS). The aim of this study was to analyze the impact of the volumetric areas of contrast-enhancing tumors and perineoplastic edema on the survival of patients treated for glioblastoma. Methods: A series of 87 patients who underwent surgery was retrospectively analyzed; OS and PFS were considered the end points of the study. For each patient, a multidisciplinary revision was conducted in collaboration with the Neuroradiology and Neuro-Oncology Board. Manual and semiautomatic measurements were adopted to perform the radiological evaluation, and the following quantitative parameters were retrospectively analyzed: contrast enhancement preoperative tumor volume (CE-PTV), contrast enhancement postoperative tumor volume (CE-RTV), edema/infiltration preoperative volume (T2/FLAIR-PV), edema/infiltration postoperative volume (T2/FLAIR-RV), necrosis volume inside the tumor (NV), and total tumor volume including necrosis (TV). Results: The median OS value was 9 months, and the median PFS value was 4 months; the mean values were 12.3 and 6.9 months, respectively. Multivariate analysis showed that the OS-related factors were adjuvant chemoradiotherapy (p < 0.0001), CE-PTV < 15 cm3 (p = 0.03), surgical resection > 95% (p = 0.004), and the presence of a "pseudocapsulated" radiological morphology (p = 0.04). Conclusions: Maximal safe resection is one of the most relevant predictive factors for patient survival. Semiautomatic preoperative MRI evaluation could play a key role in prognostically categorizing these tumors.

Analysis of prognostic factors and the role of epilepsy in neurosurgical patients with brain metastases.

Background: Brain metastases (BMs) represent the most frequent brain tumors in adults. The identification of key prognostic factors is essential for choosing the therapeutic strategy tailored to each patient. Epilepsy can precede several months of other clinical presentations of BMs. This work aimed to study the impact of epilepsy and other prognostic factors on BMs patients' survival. Methods: This retrospective study included 51 patients diagnosed with BMs and who underwent neurosurgery between 2010 and 2021. The impact of BM features and patient's clinical characteristics on the overall survival (OS) was analyzed through uni- and multivariate analysis. Results: The average OS was 25.98 months and differed according to the histology of the primary tumor. The primary tumor localization and the presence of extracranial metastases had a statistically significant impact on the OS, and patients with single BM showed a superior OS to those with multifocal lesions. The localization of BMs in the temporal lobe correlated with the highest OS. The OS was significantly higher in patients who presented seizures in their clinical onset and in those who had better post-surgical Karnofsky performance status, no post-surgical complications, and who underwent post-surgical treatment. Conclusion: Our study has highlighted prognostically favorable patient and tumor factors. Among those, a clinical onset with epileptic seizures can help identify brain metastasis hitherto silent. This could lead to immediate diagnostic-therapeutic interventions with more aggressive therapies after appropriate multidisciplinary evaluation.

Ruptured proximal pontine artery aneurysm and association with cerebellopontine angle cistern arterial venous malformation fed by the same artery: A surgical challenge.

Background: The coexistence of hyper-inflow aneurysms and cerebellopontine angle cistern (CPAc) arterial venous malformations (AVMs) have been rarely reported and most commonly associated with high risk of bleeding. Case Descriptions: We present two cases of CPAc AVMs admitted for acute subarachnoid hemorrhage from rupture of a parent right pontine artery aneurysm. Admission history, neurology at presentation, pre/post-operative imaging, approach selection, and results are thoroughly reviewed and presented. The acute origin angle of the vessel from the basilar artery made both malformations unsuitable for endovascular treatment. The surgical strategy was differently tailored in the two patients, respectively, using a Le Fort I/transclival and a Kawase approach. The aneurysm was clipped in the first case, and the AVM was excised in the second one, as required by the anatomical context. Aneurysm exclusion and AVM size reduction were obtained in the first case, while complete AVM removal and later aneurysm disappearance were obtained in the second one. A high-flow cerebrospinal fluid leak in the first case was successfully treated by an endoscopic approach. Both patients experienced a satisfactory neurological outcome in the follow-up. Conclusion: Pontine artery aneurysms, especially when associated with CPAc AVMs, represent a surgical challenge, due to their rarity and anatomical peculiarity, which typically requires complex operative approaches. Multimodal preoperative imaging, appropriate timing, and accurate target selection, together with versatile strategies, are the keys to a successful treatment.

Post-traumatic decompressive craniectomy: Prognostic factors and long-term follow-up.

Background: Decompressive craniectomy (DC) is still controversial in neurosurgery. According to the most recent trials, DC seems to increase survival in case of refractory intracranial pressure. On the other hand, the risk of postsurgical poor outcomes remain high. The present study aimed to evaluate a series of preoperative factors potentially impacting on long-term follow-up of traumatic brain injury (TBI) patients treated with DC. Methods: We analyzed the first follow-up year of a series of 75 TBI patients treated with DC at our department in five years (2015-2019). Demographic, clinical, and radiological parameters were retrospectively collected from clinical records. Blood examinations were analyzed to calculate the preoperative neutrophil-to-lymphocyte ratio (NLR). Disability rating scale (DRS) was used to classify patients' outcomes (good outcome [G.O.] if DRS ≤11 and poor outcome [P.O.] if DRS ≥12) at 6 and 12 months. Results: At six months follow-up, 25 out of 75 patients had DRS ≤11, while at 12 months, 30 out of 75 patients were included in the G.O. group . Admission Glasgow Coma Scale (GCS) >8 was significantly associated with six months G.O. Increased NLR values and the interval between DC and cranioplasty >3 months were significantly correlated to a P.O. at 6- and 12-month follow-up. Conclusion: Since DC still represents a controversial therapeutic strategy, selecting parameters to help stratify TBI patients' potential outcomes is paramount. GCS at admission, the interval between DC and cranioplasty, and preoperative NLR values seem to correlate with the long-term outcome.

Glioblastoma: A Retrospective Analysis of the Role of the Maximal Surgical Resection on Overall Survival and Progression Free Survival.

BACKGROUND: Glioblastoma (GBM) is the most common and aggressive primary brain tumor in adults; despite advances in the understanding of GBM pathogenesis, significant achievements in treating this disease are still lacking. The aim of this study was to evaluate the prognostic significance of the extent of surgical resection (EOR), beyond the neoplastic mass, on the overall survival (OS). METHODS: A retrospective review of a single-institution glioblastoma patient database (January 2012-September 2021) was undertaken. The series is composed of 64 patients who underwent surgery at the University Department of Neurosurgery of Ancona; the series was divided into four groups based on the amount of tumor mass excision with the fluid-attenuated inversion recovery (FLAIR) abnormalities (SUPr-supratotal resection, GTR-gross total resection, STR-subtotal resection, BIOPSY). The hypothesis was that the maximal resection of FLAIR abnormalities may improve the overall survival compared to the resection of the visible T1 contrast-enhanced neoplastic area only. RESULTS: In the univariate analysis, SUPr and GTR are correlated with the overall survival (p = 0.001); the percentage of total neoplastic removal threshold conditioning outcome was 90% (p = 0.027). These results were confirmed by the multivariate analysis. CONCLUSIONS: Maximal surgical resection, when feasible, involving areas of FLAIR abnormalities represents an advantageous approach for the OS in GBM patients.

Managing Ventriculoperitoneal Shunt Exposure in Adult Patients: Surgical Options and Implant Removal Prevention.

BACKGROUND: Ventriculoperitoneal (VP) shunt exposure is rare. Small series reporting on managing this complication mainly focus on the pediatric population, where wound breaks over cerebrospinal fluid (CSF) chambers are observed most frequently. However, case series on adult patients are missing. METHODS: Between June 2004 and December 2019, 18 patients underwent VP shunt revision due to implant exposure. Pertinent data were retrospectively collected from the hospital database. Their full clinical history, laboratory values, neuroradiological imaging, pretreatment CSF characteristics, photographic and video material, and surgery types were reviewed. RESULTS: The ventricular catheter was exposed in 8 patients (the frontal region in 6 and the occipital region in 2), the valve chamber at the retroauricular region in 6, the shunt tube in 7 (at the neck in 4, the supraclavicular region in 2, and the abdominal incision in 1). Multiple exposure sites were found in 2 cases. Two patients with CSF infections benefitted from system removal and temporary external ventricular drainage until infection control was achieved. The remaining 16 patients underwent on-ward revision (wound curettage, skin mobilisation, and resuture over the exposed part of the shunt), which was effective in 14 patients, but further revision was required in 2 patients. CONCLUSIONS: While rare, VP shunt exposure is a serious complication. In our experience, a prompt and accurate on-ward revision could save the implant in most patients without CSF infections.

Endoscopic transnasal odontoid resection to decompress the bulbo-medullary junction: a reliable anterior minimally invasive technique without posterior fusion.

PURPOSE: Anterior decompression of the craniovertebral junction is reserved to patients with irreducible ventral bulbo-medullary lesions and rapidly deteriorating neurological functions. Classically performed through the transoral approach, the exposure of this region can be now achieved by a minimally invasive endonasal endoscopic approach (EEA). METHODS: Four patients with irreducible, anterior bulbo-medullary compression due to rheumatoid pannus and basilar invagination were enrolled. The imaged-guided EEA was used to resect the odontoid process, trying to preserve the C1 anterior arch. RESULTS: Neurological improvement and adequate bulbo-medullary decompression were obtained in all patients. In two cases, anterior C1 ring was preserved. These patients did not required a posterior fusion. CONCLUSIONS: Compared with the standard transoral technique, the EEA provides the same good exposure but with potentially less complications. The preservation of the anterior C1 arch can contribute to avoid cranial settling and posterior fusion with its related risk of subaxial instability.