Safety and practicality study of using an exoskeleton in acute neurosurgery patients.

INTRODUCTION: Early mobilization is key in neurologically impaired persons, limiting complications and improving long-term recovery. Self-balanced exoskeletons are used in rehabilitation departments to help patients stand and walk. We report the first case series of exoskeleton use in acute neurosurgery and intensive care patients, evaluating safety, clinical feasibility and patients' satisfaction. METHODS: We report a retrospective observational study including individuals hospitalized in the neurosurgical intensive care and neurosurgery departments. We included patients with a medical prescription for an exoskeleton session, and who met no contraindication. Patients benefited from standing sessions using a self-balanced exoskeleton (Atalante, Wandercraft, France). Patients and sessions data were collected. Safety, feasibility and adherence were evaluated. RESULTS: Seventeen patients were scheduled for 70 standing sessions, of which 27 (39%) were completed. They were typically hospitalized for intracranial hemorrhage (74%) and presented with unilateral motor impairments, able to stand but with very insufficient weight shifting to the hemiplegic limb, requiring support (MRC 36.2 ± 3.70, SPB 2.0 ± 1.3, SPD 0.7 ± 0.5). The average duration of standing sessions was 16 ± 9 min. The only side effect was orthostatic hypotension (18.5%), which resolved with returning to seating position. The most frequent reason for not completing a session was understaffing (75%). All patients were satisfied and expressed a desire to repeat it. CONCLUSIONS: Physiotherapy using the exoskeleton is safe and feasible in the acute neurosurgery setting, although it requires adaptation from the staff to organize the sessions. An efficacy study is ongoing to evaluate the benefits for the patients.

A realistic aneurysm clipping simulation combining 3D-printed and placenta-based models-how I do it.

INTRODUCTION: Neurovascular surgery, particularly aneurysm clipping, is a critical skill for aspiring neurosurgeons. However, hands-on training opportunities are limited, especially with the growing popularity of endovascular techniques. To address this challenge, we present a novel neurovascular surgical training station that combines synthetic 3D-printed models with placental vascular structures to create a semi-realistic surgical field. METHODS: Our model consists of three components: a 3D-printed skull replica with anatomical landmarks, a malleable silicone parenchyma with a Sylvian fissure, and vascular layers (placenta). The placental vascular layer is catheterized and perfused to replicate pulsatile flow, offering a realistic aneurysm simulation. This innovative training station provides a cost-effective solution (approximately 200 USD once) without ethical constraints. Surgeons can practice essential skills such as Sylvian fissure dissection, managing anatomical constraints like bone, and achieving proximal vascular control. The model's realism allows for training in various scenarios, including clipping with different hand orientations and handling ruptures realistically. CONCLUSION: Our neurovascular surgical station bridges the gap between existing training models, offering affordability, ecological considerations, and minimal ethical concerns. It empowers neurosurgery residents to refine their skills in handling both emergencies and elective cases under close-to-real surgical conditions, with the potential for independent practice and senior supervision.

Achieving Gross Total Resection in Neurosurgery: A Review of Intraoperative Techniques and Their Influence on Surgical Goals.

The definition of complete resection in neurosurgery depends on tumor type, surgical aims, and postoperative investigations, directly guiding the choice of intraoperative tools. Most common tumor types present challenges in achieving complete resection due to their infiltrative nature and anatomical constraints. The development of adjuvant treatments has altered the balance between oncological aims and surgical risks. We review local recurrence associated with incomplete resection based on different definitions and emphasize the importance of achieving maximal safe resection in all tumor types. Intraoperative techniques that aid surgeons in identifying tumor boundaries are used in practice and in preclinical or clinical research settings. They encompass both conservative and invasive techniques. Among them, morphological tools include imaging modalities such as intraoperative magnetic resonance imaging, ultrasound, and optical coherence tomography. Fluorescence-guided surgery, mainly using 5-aminolevulinic acid, enhances gross total resection in glioblastomas. Nuclear methods, including positron emission tomography probes, provide tumor detection based on beta or gamma emission after a radiotracer injection. Mass spectrometry- and spectroscopy-based methods offer molecular insights. The adoption of these techniques depends on their relevance, effectiveness, and feasibility. With the emergence of positron emission tomography imaging for use in recurrence benchmarking, positron emission tomography probes raise particular interest among those tools. While all such tools provide valuable insights, their clinical benefits need further evaluation.

Embolization of the middle meningeal artery for the prevention of chronic subdural hematoma recurrence in high-risk patients: a randomized controlled trial-the EMPROTECT study protocol.

BACKGROUND: Middle meningeal artery (MMA) embolization has been proposed as a treatment of chronic subdural hematoma (CSDH). The benefit of the procedure has yet to be demonstrated in a randomized controlled trial. We aim to assess the efficacy of MMA embolization in reducing the risk of CSDH recurrence 6 months after burr-hole surgery compared with standard medical treatment in patients at high risk of postoperative recurrence. METHODS: The EMPROTECT trial is a multicenter open label randomized controlled trial (RCT) involving 12 French centers. Adult patients (≥18 years) operated for CSDH recurrence or for a first episode with a predefined recurrence risk factor are randomized 1:1 to receive either MMA embolization within 7 days of the burr-hole surgery (experimental group) or standard medical care (control group). The number of patients to be included is 342. RESULTS: The primary outcome is the rate of CSDH recurrence at 6 months. Secondary outcomes include the rate of repeated surgery for a homolateral CSDH recurrence during the 6-month follow-up period, the rate of disability and dependency at 1 and 6 months, defined by a modified Rankin Scale (mRS) score ≥4, mortality at 1 and 6 months, total cumulative duration of hospital stay during the 6-month follow-up period, directly or indirectly related to the CSDH and embolization procedure-related complication rates. CONCLUSIONS: The EMPROTECT trial is the first RCT evaluating the benefit of MMA embolization as a surgical adjunct for the prevention of CSDH recurrence. If positive, this trial will have a significant impact on patient care. TRIAL REGISTRATION NUMBER: NCT04372147.

Disseminated Tuberculosis Revealed by Conus Medullaris Tuberculoma.

A 29-year-old man from Comoros presented with rapidly progressive paraplegia and sexual dysfunction. Magnetic resonance imaging (MRI) showed a contrast-enhanced conus medullaris lesion. Differential diagnoses included tumors, abscesses, and inflammatory diseases. Neurosurgery was delayed to complete examinations. Cerebral MRI showed three abscesses. Body computed tomography scan showed supracentimetric polyadenopathies, pulmonary nodules, prostatic lesion, and enhanced seminal vesicle, with hypermetabolism on positron emission tomography with 2-deoxy-2-[fluorine-18]fluoro-D-glucose scan. Histology of lymph node biopsy showed granulomatous infiltration without acid-fast bacilli, and positive polymerase chain reaction for Mycobacterium tuberculosis. Lymph node culture was positive after 2 months, urine culture after 3 weeks, but cerebrospinal fluid and sputum cultures were negative. A 1-year antituberculosis therapy was initiated, associated with corticosteroids because the patient developed tuberculosis-immune reconstitution syndrome, revealed by the recurrence of neurological symptoms. After 2 months the patient completely recovered and could run. MRI showed stability of the voluminous tuberculoma with decrease of medullary edema. Avoiding surgery in those cases may prevent iatrogenic neurological deterioration.

Surgical treatment of hemifacial spasms: how to predict failure and complications through a series of 200 patients.

Primary hemifacial spasm (pHFS) is a benign but disabling movement disorder caused by a neurovascular conflict involving the facial nerve. Surgical treatment by microvascular decompression (MVD) is the most effective therapeutic. Predictors of surgical failure and surgical complications are still lacking. The aim of this study is to identify such predictors through the retrospective analysis of a series of 200 consecutive patients. All patients who underwent MVD for pHFS from January 1991 to December 2017 were included. All patients had at least two years follow-up. In addition to the demographic data, the outcome and the complications were collected. The primary outcome analysis showed that 7.5% of patients had a recurrence. Multiple and AICA related neurovascular conflicts were statistically associated to a higher recurrence rate after MVD (respectively p < 0.001 and p = 0.02). Permanent facial palsy occurred in 2.5% of patients, hearing loss in 9.0% (2.0% of complete unilateral impairment) and dizziness in 2.5%. The risk of each of these peripheral neurological impairments was statistically increased by a long duration between the first pHFS symptom and the MVD (p < 0.001). In case of recurrence, a second MDV was offered. Long term follow-up showed that all patients had a complete resolution of the HFS. Post-operative complication rate was not significantly increased after a second MVD. Multiple and AICA related neurovascular conflicts are associated to a higher risk of surgical failure. When a pHFS recurrence occurs, a second surgical procedure is associated with excellent outcome without significant increase of post-operative complications and should therefore be recommended.

Preservation of frontal white matter tracts in ventricular surgery: favoring an anterior interhemispheric transcallosal approach vs a transcortical transfrontal transventricular approach.

Secondary to the creation of a surgical corridor and retraction, white matter tracts degenerate, causing long-term scarring with potential neurological consequences. Third and lateral ventricle tumors require surgery that may lead to cognitive impairment. Our objective is to compare the long-term consequences of a transcortical transfrontal approach and an interhemispheric transcallosal approach on corpus callosum and frontal white matter tracts degeneration. Surgical patients with ventricular tumor accessible through both approaches were included and clinico-radiological data were retrospectively analyzed. The primary endpoint was the callosotomy length at 3-month post-operative T1 MRI, corrected by the extension of the tumor and the use of neuronavigation. Secondary outcomes included perioperative criteria such as bleeding, use of retractors and duration, FLAIR hypersignal on 3-month MRI, and re-do surgeries. To assess white matter tract interruption, 3-month FLAIR hypersignal was superposed to a tractography atlas. Seventy patients were included, 57 (81%) in the transfrontal group and 13 (19%) in the interhemispheric group. There was no difference in the mean callosotomy length on 3-month MRI (12.3 mm ± 5.60 transfrontal vs 11.7 mm ± 3.92 interhemispheric, p = 0.79) on univariate and multivariate analyses. The callosotomy length was inferior by - 3.13 mm for tumors located exclusively in the third ventricle (p = 0.016), independent of the approach. Retractors were used more often in transfrontal approaches (60% vs 33%, p < 0.001). The extent of frontal FLAIR hypersignal was higher after transfrontal approach (14.1 mm vs 0.525 mm, p < 0.001), correlated to the use of retractors (p < 0.05). After the interhemispheric approach, no tract other than corpus callosum was interrupted, whereas, after the transfrontal approach, frontal arcuate fibers and projections from the thalamus were interrupted in all patients, the cingulum in 19 (33%), the superior fronto-occipital fasciculus in 15 (26%), and the superior longitudinal fasciculus in 2 (3%). Transfrontal and interhemispheric approaches to the third and lateral ventricles both lead to the same long-term damage to the corpus callosum, but the transfrontal approach interrupts several white matter tracts essential to cognitive tasks such as attention and planning, even in the non-dominant hemisphere. These results encourage all neurosurgeons to be familiar with both approaches and favor the interhemispheric approach when both can give access to the tumor with a comparable risk. Neuropsychological studies are necessary to correlate these anatomical findings to cognitive outcomes.

Spinal Solitary Fibrous Tumors: An Original Multicenter Series and Systematic Review of Presentation, Management, and Prognosis.

All solitary fibrous tumors (SFT), now histologically diagnosed by a positive nuclear STAT6 immunostaining, represent less than 2% of soft tissue sarcomas, with spinal SFT constituting a maximum of 2% of them, making these tumors extremely rare. We provide an up-to-date overview of their diagnosis, treatment, and prognosis. We included 10 primary STAT6-positive SFT from our retrospective cohort and 31 from a systematic review. Spinal pain was the most common symptom, in 69% of patients, and the only one in 34%, followed by spinal cord compression in 41%, radicular compression, including pain or deficit, in 36%, and urinary dysfunction specifically in 18%. Preoperative diagnosis was never obtained. Gross total resection was achieved in 71%, in the absence of spinal cord invasion or excessive bleeding. Histologically, they were 35% grade I, 25% grade II, and 40% grade III. Recurrence was observed in 43% after a mean 5.8 years (1 to 25). No significant risk factor was identified, but adjuvant radiotherapy improved the recurrence-free survival after subtotal resection. In conclusion, spinal SFT must be treated by neurosurgeons as part of a multidisciplinary team. Owing to their close relationship with the spinal cord, radiotherapy should be considered when gross total resection cannot be achieved, to lower the risk of recurrence.

Changes in Brain Neuroimmunology Following Injury and Disease.

The nervous and immune systems are intimately related in the brain and in the periphery, where changes to one affect the other and vice-versa. Immune cells are responsible for sculpting and pruning neuronal synapses, and play key roles in neuro-development and neurological disease pathology. The immune composition of the brain is tightly regulated from the periphery through the blood-brain barrier (BBB), whose maintenance is driven to a significant extent by extracellular matrix (ECM) components. After a brain insult, the BBB can become disrupted and the composition of the ECM can change. These changes, and the resulting immune infiltration, can have detrimental effects on neurophysiology and are the hallmarks of several diseases. In this review, we discuss some processes that may occur after insult, and potential consequences to brain neuroimmunology and disease progression. We then highlight future research directions and opportunities for further tool development to probe the neuro-immune interface.

Molecular description of meningeal solitary fibrous tumors/hemangiopericytomas compared to meningiomas: two completely separate entities.

INTRODUCTION: Meningeal solitary fibrous tumors (SFT), like all SFT, are defined by NAB2-STAT6 fusion and share clinicopathologic similarities with meningiomas, the most frequent meningeal tumors. Our aim is to establish the molecular identity of meningeal SFT and seek molecular prognostic factors. METHODS: RNA sequencing and whole exome sequencing were performed in STAT6-positive SFT and grade 2-3 meningiomas, and data concerning other soft tissues tumors was obtained from the local database. Uniform manifold approximation and projection, individual gene expression and Gene Set Enrichment Analysis were performed. RESULTS: RNA clustering shows that SFT share a common molecular signature, different from any other type of tumoral tissue. Meningeal SFT aggregate with other SFT, with no clinical or histological subgroup. Comparison of genes expressions suggests significant over-expressions of ZIC2, ZIC3, ZIC5, GABBR2, TP53 in CNS-SFT. The pathogenic TP53 c.743G>T variant, previously undescribed in SFT, was found in one sample of meningeal SFT during malignant progression. CONCLUSIONS: Meningeal SFT are molecular counterparts of extra-meningeal SFT, completely separate from meningiomas. They might develop from the same tissues and benefit from the same treatments as SFT.

Fear Avoidance Beliefs and Outcome After Surgery for Degenerative Lumbar Spine.

STUDY DESIGN: This was a prospective cohort study. OBJECTIVE: The aim of this study is to question the influence of fear avoidance beliefs on functional outcome following surgery for degenerative lumbar spine. BACKGROUND: Fear avoidance beliefs are well-studied modifiers of low back pain. Nonetheless, the influence of fear avoidance beliefs on the outcome of spinal surgery remains controversial. METHODS: We conducted a prospective cohort study including patients undergoing surgery for degenerative lumbar discopathy, spondylolisthesis, and stenosis. Patients completed a preoperative questionnaire including the Fear Avoidance Beliefs Questionnaire (FABQ) as well as Visual Analog Scales for radicular and lumbar pain (VAS-R/L), Oswestry Disability Index (ODI), and Short-Form 36 health survey (SF36). Functional outcome was measured at least 6 months after surgery using ODI. RESULTS: Sixty-three patients with a mean follow-up of 254 days (8.5 mo, minimum=179 d, maximum=534 d) were included in the study. Women showed stronger work-related fear avoidance beliefs but there was no other difference in baseline characteristics and functional outcome between patients with low or high (>75th percentile) baseline FABQ-P or FABQ-W scores. Individual variables associated with whether patients reached minimal clinically important difference for ODI were: working status [odds ratio (OR)=0.13; 95% confidence interval (95% CI), 0.03-0.62; P =0.01], American Society of Anesthesiologists classification score (OR=0.32; 95% CI, 0.11-0.92; P =0.03), preoperative duration of symptoms (OR=0.94; 95% CI, 0.89-0.99; P =0.03), and preoperative ODI (OR=1.03; 95% CI, 1.00-1.07; P =0.05). Neither physical nor work-related preoperative FABQ scores were predictors of functional results. CONCLUSIONS: In our study, the FABQ was not associated with functional outcome following surgery for degenerative lumbar spine. Other psychological patient-reported measures are needed to refine selection of patients undergoing spine surgery in order to ensure better outcomes.

Interhemispheric transcallosal approach: going further based on the vascular anatomy.

Preserving cortical frontal bridging veins draining into the superior sagittal sinus is a factor of good neurological outcome in anterior interhemispheric transcallosal approaches, classically performed to reach intraventricular tumors. Challenging the idea that veins are utterly variable, we propose a statistical analysis of 100 selective cerebral angiographies to determine where to place the craniotomy in order to expose the most probable vein-free area. The mean distance to the first pre-coronal vein was 6.66 cm (± 1.73, 1.80 to 13.00) and to the first post-coronal vein 0.94 cm (± 0.92, 0 to 3.00) (p < 0.001). The probability of absence of bridging veins was 92.0% at 4 cm anterior to the coronal suture versus 37.5% at 1 cm and 12.5% at 2 cm posteriorly. The length of the surgical corridor (distance between the first pre-coronal and post-coronal vein) was 7.60 cm (± 1.72, 3.00 to 14.10). Overall, the ideal centering point of the craniotomy was 2.86 cm (± 1.08, - 0.65 to 6.50) ahead of the coronal suture. The mean number of veins within 6 cm behind the coronal suture was 8.47 (± 2.11, from 3 to 15) versus 0.530 (± 0.82, from 0 to 3) ahead of the coronal suture (p < 0.001). These findings support a purely pre-coronal 5 cm craniotomy for interhemispheric approaches.

Covidom, a Telesurveillance Solution for Home Monitoring Patients With COVID-19.

In a matter of months, COVID-19 has escalated from a cluster of cases in Wuhan, China, to a global pandemic. As the number of patients with COVID-19 grew, solutions for the home monitoring of infected patients became critical. This viewpoint presents a telesurveillance solution-Covidom-deployed in the greater Paris area to monitor patients with COVID-19 in their homes. The system was rapidly developed and is being used on a large scale with more than 65,000 registered patients to date. The Covidom solution combines an easy-to-use and free web application for patients (through which patients fill out short questionnaires on their health status) with a regional control center that monitors and manages alerts (triggered by questionnaire responses) from patients whose health may be deteriorating. This innovative solution could alleviate the burden of health care professionals and systems while allowing for rapid response when patients trigger an alert.

First Report of a Pineal Cyst Associated with Corpus Callosum Lipoma.

A 37-year-old man with no medical history, apart from a lifelong horizontal diplopia, underwent brain magnetic resonance imaging, which revealed a curvilinear posterior pericallosal lipoma and a pineal cyst. Corpus callosum lipomas, with an incidence of 0.1%-0.5%, do not require neurosurgical treatment, except in rare cases of malformations causing epilepsy. The indications for surgery of pineal cysts, whose incidence is 0.6%, are controversial, except in case of hydrocephalus. In this case, ophthalmologic examination and magnetic resonance imaging were not consistent for a tectal plate compression and the findings were considered incidental. The association of these 2 abnormalities, which has not been described before, might reflect an interrelated embryologic development for pineal gland and midline lipomas, which derive from aberrant mesenchymal primitive meninx.

Female gender and exogenous progesterone exposition as risk factors for spheno-orbital meningiomas.

OBJECTIVE: The great heterogeneity of meningiomas is challenging and we need to distinguish relevant subgroups. Spheno-orbital osteomeningiomas (SOOM) constitute a clinically specific entity, with slow-growing benign osteo-meningiomatous tumors, which recur after surgery in one fourth of cases. Neurosurgical daily practice, supported by the literature, shows that the vast majority of patients with SOOM are women, and we explored whether their epidemiological and hormonal profiles suggest a progesterone influence. METHODS: We retrospectively documented all radiologically and histologically confirmed cases of SOOM operated in 2005-2019 in our institution. We completed the clinical and hormone history by systematic telephone interviews. RESULTS: In the literature, SOOM occur significantly more often in women than other meningiomas (749/847, 86.4% versus 73.8%, p = 0.002). Among 175 cases, we included 124 patients, 93.5% were women, younger than men (51 ± 5 versus 63 ± 8, p = 0.02). Women' meningiomas showed more progesterone receptors (96.4% versus 50%, p < 0.001). Exogenous hormonal intake, reliable in 82 cases, concerned 83.3% (64/78) of women, with frequent progesterone intake: 13 oestroprogestogenic treatment only, with old-generation progesterone analogs, 41 progesterone analogs (cyproterone acetate, nomegestrol acetate, chlormadinone, promegestone, etonogestrel, levonogestrel), 7 substitutive hormonal therapy for menopause, 3 others. Duration of treatment was 2-40 years, median 10 years. CONCLUSIONS: SOOM develop preferentially in women in their fifties, who often received progesterone analogs, and show progesterone receptors. Progesterone analogs are incriminated in skull base meningiomas, and this is the first report on the prevalence of exogenous hormone therapy specifically in SOOM. Whether SOOM reduce after treatment discontinuation, in particular the osteoma part, needs to be explored. Anti-progesterone treatments may represent an avenue for future research in soom.

Reliability of Bony Landmarks to Predict Intradural Location of Paraclinoid Aneurysms.

PURPOSE: When dealing with paraclinoid carotid aneurysms, the distinction between intradural and extradural location is a major component for decision-making as only intradural aneurysms carry a risk of subarachnoid hemorrhage (SAH). The aim of this study was to test the accuracy and reliability of computed tomography (CT) bony landmarks for the distinction between intradural and extradural paraclinoid aneurysms. METHODS: All patients referred to this institution for a single paraclinoid aneurysm were retrospectively identified. The study included only the patients who presented with diffuse SAH, thus proving the intradural location of the aneurysm. The preoperative images were assessed by two physicians in order to locate the aneurysms using the tuberculum sellae (TS) and the optic strut (OS) landmarks. RESULTS: A total of 15 patients were included in the study. There were 4 cases (27%) of disagreement with the OS bony landmark and no cases of disagreement with the TS landmark. No aneurysm was consensually considered as extradural by both readers with both bony landmarks; however, five aneurysms (33%) were considered to be extradural by at least one of the physicians with at least one of the two bony landmarks. CONCLUSION: The results of the study showed several disagreements when using the OS landmark. More importantly, several aneurysms were considered as extradural with at least one of these two CT bony landmarks, even though they were all associated with an SAH. More reliable and accurate landmarks are warranted.

Cerebrospinal Fluid Fistula in the Frontal Sinus Secondary to Obstructive Hydrocephalus.

In some rare cases, long-standing hydrocephalus can cause "high-pressure" cerebrospinal fluid fistulas. We report the case of a young overweight woman with rhinorrhea secondary to hydrocephalus with a fistula into the frontal sinus. Brain imaging studies revealed aqueduct stenosis. Ventriculocisternostomy treated the hydrocephalus but did not cure the rhinorrhea, and additional multilayer surgical skull base repair was necessary. In these cases, the CSF leakage acts as a safety valve, and closure will worsen the patient's condition if the causative lesion has not been treated first. Moreover, identifying the exact location of the fistula can be challenging and will usually require high-resolution bone computed tomography.

Is Gross Total Resection Reasonable in Adults with Craniopharyngiomas with Hypothalamic Involvement?

OBJECTIVE: The treatment of hypothalamus-invading craniopharyngiomas, based on pediatric experience, is subtotal resection (STR) with radiotherapy. This strategy sometimes leads to uncontrollable tumor progression. In adults, with the use of endoscopic endonasal surgery (EES), does removing the hypothalamic part of the tumor-whenever possible-compromise the outcome of the patients? METHODS: We included adults with craniopharyngioma treated by a first EES in 2008-2016 by senior neurosurgeon (E.J.). Endocrine, ophthalmologic, and hypothalamic data were retrospectively collected, including body mass index (BMI), cognitive and social status, with a systematic follow-up interview. Magnetic resonance imaging scans were graded according to Puget classification: 0, no hypothalamic involvement; 1, hypothalamic displacement; and 2, hypothalamic involvement. Grade 2 tumors were separated into gross total resection (GTR) or STR. RESULTS: We included 22 patients aged 18-79 years. Presenting symptoms were visual (14, 64%), endocrine dysfunction (10, 45%), BMI >30 (8, 36%), and cognitive/psychiatric impairment (9, 41%). Fourteen (64%) were grade 2 craniopharyngiomas. GTR was performed in 14 (64%) patients. Postoperatively, 12/14 (86%) cases improved visually, and 20 (91%) needed hormone replacement therapy. There was no difference in BMI evolution in the GTR versus STR group, cognitive status was stable or improved in all patients except 1; 4/8 patients with STR experienced progression needing adjuvant treatment versus no patient with GTR. CONCLUSIONS: EES GTR of grade 2 craniopharyngiomas does not cause major hypothalamic worsening, in contrast with children operated by cranial approaches. The surgeon's experience is key in deciding when to stop the dissection. Offering GTR whenever possible aims at avoiding tumor progression and radiotherapy.

Could propranolol be beneficial in adult cerebral cavernous malformations?

Surgery is the only therapeutic option for cerebral cavernous malformations (CCM) and is proposed, whenever possible, after haemorrhagic events, neurological symptoms, or epilepsy, radiosurgery being a controversial alternative in some cases. However, there is no treatment for non-accessible lesions, such as brainstem CCM, multiple CCM, or those located in functional areas. Propranolol, a non-selective beta-blocker used as first-line treatment for infantile haemangiomas, has proved spectacularly effective in a few cases of adult patients with CCM. We herein review the histological, in vitro data and clinical findings that support the idea of propranolol as a potential treatment for CCM. Since one retrospective study has not been conclusive, we support the idea that prospective trials are necessary.