Transcallosal approach for intraventricular gliomas: neuropsychological outcome and functionality of the corpus callosum.

The transcallosal approach is commonly used for surgery of lateral and third ventricle lesions. Cognitive deficits due to the transcallosal approach still remain controversial. Even if enormous efforts have been made in order to understand specific functions of the corpus callosum, still little is known. The present study was aimed to evaluate the neuropsychological results and the functionality of the corpus callosum in transferring visual, auditory and tactile information between the two hemispheres in a group of patients who were treated using the transcallosal approach. The study evaluated the neuropsychological status of five selected patients presenting low-grade lesions of lateral ventricles that had not previously undergone surgical treatments and that did not receive radiotherapy and chemotherapy. All patients were administered an extensive neuropsychological testing postoperatively and the interhemispheric transfer of visual, auditory and tactile information was also evaluated. Two patients were tested preoperatively. Incisions of 2.4 cm maximum of the corpus callosum length were operated. The postoperative cognitive profile was normal. In some patients, a postoperative subnormal performance in memory functions was found but it cannot be attributable to the surgical approach given that it was altered even pre-surgically. Small incisions of the corpus callosum preserved the integrity of this anatomical structure in transferring lateralized information between the two hemispheres. The transcallosal approach is a safe surgical route to lateral ventricles lesions and the neuropsychological evaluation of these cases could give new insights in the comprehension of corpus callosum functions.

Single-approach vertebral osteosynthesis in the treatment of spinal osteolysis by spondylodiscitis.

OBJECTIVEBoth spontaneous and iatrogenic spondylodiscitis are becoming ever more frequent, yet there are no definite treatment guidelines. For many years the treatment protocol was conservative medical management or surgical debridement with patients immobilized or bedridden for weeks and often resulting in spinal deformity. The eventual development of spinal deformity can be difficult to treat. Over the last few years, the authors have preferred a single-approach instrumented arthrodesis when spondylolysis that evolves in deformity from somatic wedging occurs.METHODSThe authors retrospectively reviewed the clinical, radiological, and surgical records of 11 patients treated over the past 3 years for spondylodiscitis with osteosynthesis.RESULTSOverall, the authors treated 11 patients: 3 cases with tuberculous spondylodiscitis (1 dorsal, 2 lumbar); 6 cases with Staphylococcus aureus spondylodiscitis (1 cervical, 2 dorsal, 2 lumbar, 1 dorsolumbar); 1 spondylodiscitis with postsurgical lumbar deformity; and in 1 dorsolumbar case the germ was not identified. Surgical approaches were chosen according to spinal level: In 8 dorsolumbar cases a posterior osteosynthesis was achieved. In 1 cervical case an anterior approach was performed with autologous bone graft from iliac crest. In 2 thoracolumbar cases a posterolateral costotransversectomy was needed. In 1 lumbosacral case iliac somatic grafting was used. Ten patients received adequate antibiotic treatment with clinical remission, and 1 case is in initial follow-up. No complications due to instrumentation were recorded. Spinal deformity was prevented in 10 cases, whereas preexisting spinal deformity was partially corrected in 1 case. In all cases, arthrodesis achieved vertebral stability.CONCLUSIONSThis study has the limitations of a retrospective review with a limited number of patients. Instrumentation does not appear to hamper healing from infection. Moreover, spinal stabilization, which is assisted by the infectious process even in the absence of bone graft, allows early mobilization. Instrumented osteosynthesis should be preferred for spondylodiscitis with osteolysis and spinal instability because it allows early mobilization and rehabilitation whenever necessary. It prevents spinal deformity and does not hamper healing of infections.

Mini-Craniotomy under Local Anesthesia to Treat Acute Subdural Hematoma in Deteriorating Elderly Patients.

Background and Study Aims Surgical treatment for acute subdural hematomas (ASDHs) in elderly patients is still considered unsatisfactory. Series focusing on the use of conventional craniotomy or decompressive craniectomy in such patients report discouraging results. Glasgow Coma Scale (GCS) score at admission seems to be crucial in the decision-making process. Deteriorating patients with a GCS score between 9 and 11 are those who would benefit most from the surgical treatment. Unfortunately, elderly patients often present other comorbidities that greatly increase the risk of severe complications after major neurosurgical procedures under general anesthesia. The aim of the present study was to evaluate the feasibility of performing a mini-craniotomy under local anesthesia to treat ASDHs in a select group of elderly patients who were somnolent but still breathing autonomously at admission (GCS 9-11). Material and Methods Twenty-eight elderly patients (age > 75 years) with ASDH and a GCS score at surgery ranging from 9 to 11 were surgically treated under local anesthesia by a single burr-hole mini-craniotomy (transverse diameter 3-5 cm) and hematoma evacuation. At the end of the procedure, an endoscopic inspection of the surgical cavity was performed to look for residual clots that were not visible under direct vision. Results The median operation time was 65 minutes. Hematoma evacuation was complete in 22 cases, complete consciousness recovery was observed in all patients but one, and reoperation was required for two patients. Conclusion Historically, elderly patients with ASDH treated with a traditional craniotomy performed under general anesthesia have not had a good prognosis. Our preliminary experience with this less invasive surgical and anesthesiological approach suggests that somnolent but autonomously breathing elderly patients could benefit from this approach, achieving an adequate hematoma evacuation and bypassing the complications related to intubation and artificial respiratory assistance.

Minimally Invasive Supraorbital Key-hole Approach for the Treatment of Anterior Cranial Fossa Meningiomas.

The most important target of minimally invasive surgery is to obtain the best therapeutic effect with the least iatrogenic injury. In this background, a pivotal role in contemporary neurosurgery is played by the supraorbital key-hole approach proposed by Perneczky for anterior cranial base surgery. In this article, it is presented as a possible valid alternative to the traditional craniotomies in anterior cranial fossa meningiomas removal. From January 2008 to January 2012 at our department 56 patients underwent anterior cranial base meningiomas removal. Thirty-three patients were submitted to traditional approaches while 23 to supraorbital key-hole technique. A clinical and neuroradiological pre- and postoperative evaluation were performed, with attention to eventual complications, length of surgical procedure, and hospitalization. Compared to traditional approaches the supraorbital key-hole approach was associated neither to a greater range of postoperative complications nor to a longer surgical procedure and hospitalization while permitting the same lesion control. With this technique, minimization of brain exposition and manipulation with reduction of unwanted iatrogenic injuries, neurovascular structures preservation, and a better aesthetic result are possible. The supraorbital key-hole approach according to Perneckzy could represent a valid alternative to traditional approaches in anterior cranial base meningiomas surgery.

Endoscopic Transnasal Odontoidectomy With Anterior C1 Arch Preservation and Anterior Vertebral Column Reconstruction in Patients With Irreducible Bulbomedullary Compression by Complex Craniovertebral Junction Abnormalities: Operative Nuance.

BACKGROUND: During the past decades, the transoral transpharyngeal approach has been advocated as the standard route for the removal of odontoid causing an irreducible symptomatic neural compression. However, it may be potentially associated with a significant built-in morbidity because of the splitting of the soft palate for an adequate working angle, tracheostomy, and incision of the oral mucosa, causing exposure to a higher risk of infection by oral flora. OBJECTIVE: To describe our experience with the minimally invasive pure endoscopic transnasal odontoidectomy in patients with bulbomedullary compression affected by complex anterior craniovertebral junction abnormalities. METHODS: Five patients underwent a pure endoscopic neuronavigation-assisted transnasal odontoidectomy with anterior C1 arch preservation. Moreover, the anterior cervical spine column was reconstructed by filling the gap between the C1 arch and the residual C2 body with autologous/artificial bone. Neither tracheostomy nor enteral tube feeding were needed in any case. RESULTS: A postoperative neurological improvement was observed in all patients. Postoperative imaging confirmed a satisfactory spinal cord decompression with cervical anterior column arthrodesis, and without evidence of instability at follow-up, so far. CONCLUSION: The endoscopic transnasal approach seems to represent an efficient and safe alternative to the transoral route for the resection of odontoid process causing irreducible bulbomedullary compression. It provides a straightforward and minimally invasive natural surgical corridor to the anterior craniocervical junction, allowing a better working angle with preservation of spine biomechanics, while minimizing potential comorbidities.

Piezosurgery as a further technical adjunct in minimally invasive supraorbital keyhole approach and lateral orbitotomy.

OBJECTIVE: One of the problems in neurosurgery is how to perform rapid and effective craniotomies that minimize the risk of injury to underlying eloquent structures. The traditional high-powered pneumatic tools and saws are efficient in terms of speed and penetration, but they can provoke bone necrosis and sometimes damage neurovascular structures. As an alternative, we evaluated the piezoelectric bone scalpel (piezosurgery), a device that potentially allows thinner and more precise bone cutting without lesioning neighboring delicate structures, even in the case of accidental contact. MATERIAL AND METHODS: From January 2009 to December 2011, 20 patients (8 men and 12 women), 19 to 72 years of age (mean: 49.3 years) were treated using piezosurgery. Surgery was performed for the removal of anterior cranial fossa meningiomas, orbital tumors, and sinonasal lesions with intracranial extension. RESULTS: The time required to perform craniotomy using piezosurgery is a few minutes longer than with traditional drills. No damage was observed using the piezoelectric device. Follow-up clinical and neuroradiologic evaluation showed a faster and better ossification of the bone flap with good esthetic results. CONCLUSIONS: Piezosurgery is a new promising technique for selective bone cutting with soft tissue preservation. This instrument seems suitable to perform precise thin osteotomies while limiting damage to the bone itself and to the underlying delicate structures even in the case of unintentional contact. These advantages make the piezoelectric bone scalpel a particularly attractive instrument in neurosurgery.

Neurological outcome in a series of 58 patients operated for traumatic thoracolumbar spinal cord injuries.

BACKGROUND: Traumatic thoracolumbar spinal fractures represent approximately 65% of all traumatic spinal fractures and are frequently associated to permanent disability with significant social and economic impact. These injuries create severe physical limitations depending on neurological status, level of fracture, severity of injury, patient age and comorbidities. Predicting neurological improvement in patients with traumatic spinal cord injuries (SCIs) is very difficult because it is related to different preoperative prognostic factors. We evaluated the neurological improvement related to the preoperative neurological conditions and the anatomic level of spinal cord injury. METHODS: From January 2004 to June 2010, we operated 207 patients for unstable thoracolumbar spinal fractures. We carried out a retrospective analysis of 69 patients with traumatic SCIs operated on by a posterior fixation performed within 24 hours from the trauma. The preoperative neurological conditions (ASIA grade), the type of the fracture, the anatomic level of spinal cord injury and the postoperative neurological improvement were evaluated for each patient. RESULTS: The ASIA grade at admission (P = 0,0005), the fracture type according to the AO spine classification (P = 0,0002), and the anatomic location of the injury (P = 0,0213) represented predictive factors of neurological improvement at univariate analysis. The preoperative neurological status (P = 0,0491) and the fracture type (P = 0,049) confirmed a positive predictive value also in the multivariate analysis. CONCLUSIONS: Our study confirms that the preoperative neurological status, the fracture type and the anatomic location of the fracture are predictive factors of the neurological outcome in patients with spinal cord injury.

Combined endoscopic transforaminal-transchoroidal approach for the treatment of third ventricle colloid cysts.

Colloid cysts are histologically benign lesions whose primary goal of treatment should be complete resection to avoid recurrence and sudden death. Open surgery is traditionally considered the standard approach, but, recently, the endoscopic technique has been recognized as a viable and safe alternative to microsurgery. The endoscopic approach to colloid cysts of the third ventricle is usually performed through the foramen of Monro. However, this route does not provide adequate visualization of the cyst attachment on the tela choroidea. The combined endoscopic transforaminal-transchoroidal approach (ETTA), providing exposure of the entire cyst and a better visualization of the tela choroidea, could increase the chances of achieving a complete cyst resection. Between April 2005 and February 2011, 19 patients with symptomatic colloid cyst of the third ventricle underwent an endoscopic transfrontal-transforaminal approach. Five of these patients, harboring a cyst firmly adherent to the tela choroidea or attached to the middle/posterior roof of the third ventricle, required a combined ETTA. Postoperative MRI documented a gross-total resection in all 5 cases. There were no major complications and only 1 patient experienced a transient worsening of the memory deficit. To date, no cyst recurrence has been observed. An ETTA is a minimally invasive procedure that can allow for a safe and complete resection of third ventricle colloid cysts, even in cases in which the lesions are firmly attached to the tela choroidea or located in the middle/posterior roof of the third ventricle.

A rare case of chordoma and craniopharyngioma treated by an endoscopic endonasal, transtubercular transclival approach.

Co-occurrence of different brain tumors is rarely observed, being more frequent in patients affected by genetic syndromes like phacomatoses. Different histological types of intracranial lesions may present at different times in the clinical history of the patient or, more rarely, they may occurr at the same moment. In these last cases, particularly for tumors located in adjacent areas of the brain, diagnostic difficulties may arise. Moreover, even when the correct diagnosis is established, treatment strategy becomes complex and a single staged approach could be ineffective in obtaining successful tumor removal. We report a case of simultaneous sellar-suprasellar craniopharyngioma and intradural clival chordoma, successfully treated by a single staged, extended, fully endoscopic endonasal approach, which required no following adjuvant therapy. We also discuss the potential etiopathogenesis of the two lesions, reviewing the literature.

Improving the endoscopic endonasal transclival approach: the importance of a precise layer by layer reconstruction.

BACKGROUND. The endoscopic endonasal transclival approach (EETCA) is a minimally-invasive technique allowing a direct route to the base of implant of clival lesions with reduced brain and neurovascular manipulation. On the other hand, it is associated with potentially severe complications related to the difficulties in reconstructing large skull base defects with a high risk of postoperative cerebrospinal fluid (CSF) leakage. The aim of this paper is to describe a precise layer by layer reconstruction in the EETCA including the suture of the mucosa as an additional reinforcing layer between cranial and nasal cavity in order to speed up the healing process and reduce the incidence of CSF leak. METHODS. This closure technique was applied to the last six cases of EETCA used for clival meningiomas (2), clival chordomas (2), clival metastasis (1), and craniopharyngioma with clival extension (1). RESULTS. After a mean follow-up of 6 months we had no one case of postoperative CSF leakage or infections. Seriated outpatient endoscopic endonasal controls showed a fast healing process of nasopharyngeal mucosa with less patient discomfort. CONCLUSIONS. Our preliminary experience confirms the importance of a precise reconstruction of all anatomical layers violated during the surgical approach, including the nasopharygeal mucosa.

Autologous vascularized dural wrapping for temporalis muscle preservation and reconstruction after decompressive craniectomy: report of twenty-five cases.

Temporalis muscle reconstruction is a necessary step during frontotemporal cranioplasty ensuing decompressive craniectomy (DC). During this procedure, scarring between the temporalis muscle and the dural layer may lead to complicated muscle dissection, which carries an increased risk of dura and muscle damage. At time of DC, temporalis muscle wrapping by an autologous vascularized dural flap can later on facilitate dissection and rebuilding during the subsequent cranioplasty. In a span of 2 years, we performed 57 DCs for different etiologies. In 30 cases, the temporalis muscle was isolated by wrapping its inner surface using the autologous dura. At cranioplasty, the muscle could easily be dissected from the duraplasty. The inner surface was easily freed from the autologous dural envelope, and reconstruction achieved in an almost physiological position. Follow-up examinations were held at regular intervals to disclose signs of temporalis muscle depletion. Twenty-five patients survived to undergo cranioplasty. Muscle dissection could always be performed with no injury to the dural layer. No complications related to temporalis muscle wrapping were recorded. Face asymmetry developed in four cases but it was always with bone resorption. None of the patients with a good neurological recovery reported functional or aesthetic complaints. In our experience, temporalis muscle wrapping by vascularized autologous dura proved to be effective in preserving its bulk and reducing its adhesion to duraplasty, thereby improving muscle dissection and reconstruction during cranioplasty. Functional and aesthetic results were satisfying, except in cases of bone resorption.

Subarachnoid hematoma of the craniocervical junction and upper cervical spine after traumatic cerebral contusion: case report.

Spinal subarachnoid hematoma (SSH) is a rare condition, more commonly occurring after lumbar puncture for diagnostic or anesthesiological procedures. It has also been observed after traumatic events, in patients under anticoagulation therapy or in case of arteriovenous malformation rupture. In a very small number of cases no causative agent can be identified and a diagnosis of spontaneous SSH is established. The lumbar and thoracic spine are the most frequently involved segments and only seven cases of cervical spine SSH have been described until now. Differential diagnosis between subdural and subarachnoid hematoma is complex because the common neuroradiological investigations, including a magnetic resonance imaging (MRI), are not enough sensitive to exactly define clot location. Actually, confirmation of the subarachnoid location of bleeding is obtained at surgery, which is necessary to resolve the fast and sometimes dramatic evolution of clinical symptoms. Nonetheless, there are occasional reports on successful conservative treatment of these lesions. We present a peculiar case of subarachnoid hematoma of the craniocervical junction, developing after the rupture of a right temporal lobe contusion within the adjacent arachnoidal spaces and the following clot migration along the right lateral aspect of the foramen magnum and the upper cervical spine, causing severe neurological impairment. After surgical removal of the hematoma, significant symptom improvement was observed.

The sinking bone syndrome?

Bone resorption is a known complication of cranioplasty after decompressive craniectomy (DC). A peculiar group of insidious, progressive, invalidating neurological symptoms was observed in patients presenting with incomplete resorption and abnormal mobility of the re-implanted bone. Such symptoms were similar, but with time more severe, to those encountered in the sinking flap syndrome. Are we facing a sort of Sinking Bone Syndrome? We accurately analyze these cases and review the literature. Over a 7-years period, 312 DCs were performed at our Institution. In 7 patients, headache, vertigo, gait ataxia, confusion, blurred speech, short-term memory impairment, hemiparesis, sudden loss of consciousness, and third cranial nerve palsy were observed in a time period ranging from 18 months to 5 years after cranioplasty. Clinical and neuroradiological examinations were performed to disclose the possible etiopathogenesis of this condition. Collected data showed partial resorption of the repositioned bone and its unnatural inward movements during postural changes. Bone movements were interpreted as the major cause of the symptoms. A new cranioplasty was then performed in every case, using porous hydroxyapatite in 6 patients and polyetherketone implant in the other. Full resolution of symptoms was always obtained 3 to 20 days after the second surgery. No further complications were reported. We believe that long-term follow up in patients operated on by cranioplasty after DC will be needed regularly for years after skull reconstruction and that newly appearing symptoms should never go underestimated or simply interpreted as a long-term consequence of previous brain damage.

Endoscopic endonasal odontoidectomy with anterior C1 arch preservation in elderly patients affected by rheumatoid arthritis.

BACKGROUND CONTEXT: Rheumatoid arthritis is the most common inflammatory disease involving the spine with predilection for the craniovertebral segment. Surgery is usually reserved to patients with symptomatic craniovertebral junction (CVJ) instability, basilar invagination, or upper spinal cord compression by rheumatoid pannus. Anterior approaches are indicated in cases of irreducible ventral bulbo-medullary compression. Classically performed through the transoral approach, the exposure of this region can be now achieved by a minimally invasive endonasal endoscopic approach (EEA). PURPOSE: The aim of this article is to demonstrate the feasibility of performing an odontoidectomy and a rheumatoid pannus removal by a minimally invasive EEA, preserving the anterior C1 arch continuity and avoiding a posterior fixation procedure. STUDY DESIGN: Technical description and cohort report. METHODS: We report three cases of elderly patients with a long history of rheumatoid arthritis and irreducible anterior bulbo-medullary compression secondary to basilar invagination and/or rheumatoid pannus. Anterior decompression was achieved by an endonasal image-guided fully endoscopic approach. RESULTS: Neurological improvement and adequate bulbo-medullary decompression were obtained in all cases. The anterior C1 arch continuity was preserved, and none of the patients required a subsequent posterior fixation. CONCLUSIONS: Anterior decompression by a minimally invasive EEA could represent an innovative option for the treatment of irreducible ventral CVJ lesions in elderly patients with rheumatoid arthritis. This approach permits the preservation of the anterior C1 arch and the avoidance of a posterior fixation, thus preserving the rotational movement at C0-C2 segment and reducing the risk of a subaxial instability development.

Endoscopic endonasal approach for the treatment of a large clival giant cell tumor complicated by an intraoperative internal carotid artery rupture.

Giant cell tumors (GCTs) are primary bone neoplasms that rarely involve the skull base. These lesions are usually locally aggressive and require complete removal, including the surrounding apparently healthy bone, to provide the best chance of cure. GCTs, as well as other lesions located in the clivus, can nowadays be treated by a minimally invasive fully endoscopic extended endonasal approach. This approach ensures a more direct route to the craniovertebral junction than other possible approaches (transfacial, extended lateral, and posterolateral approaches). The case reported is a clival GCT operated on by an extended endonasal approach that provides another contribution on how to address one of the most feared complications attributed to this approach: a massive bleed due to an internal carotid artery injury.

Microsurgical endoscopy-assisted presigmoid retrolabyrinthine approach as a minimally invasive surgical option for the treatment of medium to large vestibular schwannomas.

BACKGROUND: Treatment of vestibular schwannomas presents many controversial aspects, from the indication to the selection of the best treatment option. In the era of stereotactic radiotherapy, microsurgery has to be competitive in terms of providing the best chances of functional preservation and complete tumor removal. The two most commonly used surgical approaches are the retrosigmoid suboccipital and the presigmoid translabyrinthine. We describe the endoscopy-assisted presigmoid retrolabyrinthine approach (EAPRA) aiming at combining the advantages of the retrosigmoid and translabyrinthine techniques. METHODS: For 2 years (from May 2009 to June 2011), the EAPRA was used to remove medium to large sporadic vestibular schwannomas in ten patients. RESULTS: Complete tumor removal was obtained in eight patients, postoperative transient facial nerve function impairment or worsening was observed in two, and one had hearing deterioration postoperatively. No threatening complications occurred after surgery, and the length of hospitalization was usually less than 10 days. CONCLUSIONS: The EAPRA can provide direct access to the CPA along with labyrinthine complex conservation, allowing hearing function preservation and minimal cerebellar retraction. Endoscopic assistance is a crucial adjunct in the presigmoid retrolabyrinthine approach in order to address the limits imposed by labyrinthine complex preservation. It ensures complete visualization of the intracanalicular portion of the schwannoma, thus improving the rate of a radical tumor resection. The EAPRA could represent a valid surgical option in vestibular schwannoma surgery.

Piezosurgery for osteotomies in orbital surgery: Our experience and review of the literature.

INTRODUCTION: Piezoelectric bone surgery, simply known as Piezosurgery(®), is a new promising technique for bone cutting based on ultrasonic microvibrations that allows to perform precise and thin osteotomies with soft tissue sparing. PRESENTATION OF CASE: A 45-years-old woman presenting with progressive left ocular pain, diplopia on the lateral left gaze, and visible exophthalmos was admitted to our department. CT scan and MRI images documented a left supero-lateral orbital lesion. A left lateral orbitotomy using the piezoelectric scalpel was performed. The tumour (lacrimal gland lymphoma) was completely removed with no injuries to the orbital structures and with a perfect realignment of the bone stumps. DISCUSSION: High powered pneumatic osteotome are commonly used to perform craniotomies. Large bone cutting groove and high temperatures developing at the contact site could produce an uneasy bone healing. The use of a piezoelectric scalpel allows to realize precise and thin osteotomies, facilitating craniotomy's borders ossification and avoiding injuries to non-osseous structures. CONCLUSION: Widely used in Oral and Maxillofacial Surgery, Piezosurgery(®) can also be useful in neurosurgical approaches in order to obtain a faster bone flap re-ossification, a better aesthetic result, and a lower risks of dural layer and soft tissue damage.

Minimally invasive surgery for benign intradural extramedullary spinal meningiomas: experience of a single institution in a cohort of elderly patients and review of the literature.

Meningiomas of the spine are the most common benign intradural extramedullary lesions and account for 25%-46% of all spinal cord tumors in adults. The goal of treatment is complete surgical resection while preserving spinal stability. Usually, these lesions occur in the thoracic region and in middle-aged women. Clinical presentation is usually nonspecific and the symptoms could precede the diagnosis by several months to years, especially in older people, in whom associated age-related diseases can mask the tumor for a long time. We report a series of 30 patients, aged 70 years or more, harboring intradural extramedullary spinal meningiomas. No subjects had major contraindications to surgery. A minimally invasive approach ( hemilaminectomy and preservation of the outer dural layer) was used to remove the tumor, while preserving spinal stability and improving the watertight dural closure. We retrospectively compared the outcomes in these patients with those in a control group subjected to laminectomy or laminotomy with different dural management. In our experience, the minimally invasive approach allows the same chances of complete tumor removal, while providing a better postoperative course than in a control group.

Endoscopy-verified occult subependymal dissemination of glioblastoma and brain metastasis undetected by MRI: prognostic significance.

Although various prognostic indices exist for patients with malignant brain tumors, the prognostic significance of the subependymal spread of intracranial tumors is still a matter of debate. In this paper, we report the cases of two intraventricular lesions, a recurrent glioblastoma multiforme (GBM) and a brain metastasis, each successfully treated with a neuroendoscopic approach. Thanks to this minimally invasive approach, we achieved good therapeutic results: we obtained a histological diagnosis; we controlled intracranial hypertension by treating the associated hydrocephalus and, above all, compared with a microsurgical approach, we reduced the risks related to dissection and brain retraction. Moreover, in both cases, neuroendoscopy enabled us to identify an initial, precocious subependymal tumor spreading below the threshold of magnetic resonance imaging (MRI) detection. This finding, undetected in pre-operative MRI scans, was then evident during follow-up neuroimaging studies. In light of these data, a neuroendoscopic approach might play a leading role in better defining the prognosis and optimally tailored management protocols for GBM and brain metastasis.

An unusual instrumentation-related s1 radiculopathy in a patient treated for a primary vertebral (l3) lymphoma.

Paravertebral titanium rod migration represents an unusual and potentially fatal complication of vertebral stabilization surgical procedures. This condition, which requires a prompt and rapid diagnosis, is often mistaken for other more common diseases, or scotomized. We present a case of a 69 years old female affected by a non-Hodgkin lymphoma with evidence of migration of both rods five years after the posterior stabilization procedure for a pathological L3 fracture. Unusual clinical onset was represented by a left S1 radiculopathy without other symptoms. For several months, the symptoms were attributed to a possible radicular infiltration by the lymphoma. We conclude that paravertebral rod migration could happen not only within the spinal canal, but could also rarely damage blood vessels or parenchymal organs. This is generally a long-term complication, probably due to an insufficient fixation. Strict long-term follow-up monitoring is mandatory since this unusual complication can mimic other more common pathological conditions.