Avoiding the Blinded Funnel: A Combined Single Piece Fronto-Temporo-Orbito-Zygomatic Craniotomy Endoscopic-Assisted Approach with Multimodal Assistance for an Epidermoid Tumor of Meckel's Cave-Case Report.

A Meckel's cave tumor poses a great challenge because of the peculiar neurovascular structure of the area and the deep location. Multiple surgical approaches have been designed for this area. In this report, we describe a case treated with a combined one step single piece fronto-temporo-orbito-zygomatic craniotomy (FTOZ) endoscopic-assisted approach for the treatment of an epidermoid tumor of Meckel's cave. A 51-year-old woman presented with a clinical history of left trigeminal neuralgia and paresthesia. CT imaging revealed a left basal temporal tumor. MR showed a tumor located in Meckel's cave near the cavernous sinus, with a good enhancement after gadolinium administration. The tumor was resected through a lateral basal subtemporal extradural approach followed by an intradural approach using intraoperative neuronavigation, endoscopic assistance, neurophysiological monitoring, and an intraoperative ultrasound probe. The lesion was completely removed. No new onset neurological damage has occurred. The symptoms improved following surgery. The aesthetic appearance of the patient was respected. The combined approach with a single piece fronto-temporo-orbito-zygomatic craniotomy has enabled us to work on a wider operating field to completely remove the lesion avoiding blind spots.

Neuronavigated Retropharyngeal Anterior Screw Fixation of the Odontoid for the Treatment of C2 Type II Fractures: Case Report.

Odontoid fractures, frequently observed in patients over the age of 70, often involve the base of the axis (Anderson-D'Alonzo type 2). For surgical treatment, posterior C1-C2 fixation is the traditional method, whose fusion rates range between 93 and 100%. However, morbidity and mortality rates are high. In addition, cervical motion, especially axial rotation, is postoperatively reduced. Nakanishi and Bohler introduced the anterior screw fixation approach for the surgical treatment of odontoid fracture type II. This procedure preserves the atlantoaxial complex motion, provides immediate stability and high fracture healing rates, and, most importantly, has a low incidence of complications with good fusion rates. The surgical strategy must take into account the patient's anatomy, the morphological characteristics of the fracture, the quality of the bone, and any concomitant injuries. In this chapter, we describe a C2 type II fracture treated via a neuronavigated anterior retropharyngeal approach.

Molecular Investigation of DKK3 in Cerebral Ischemic/Reperfusion Injury.

Dickkopf-3 (Dkk3) is an atypical member of the Dkk family of Wnt inhibitors, which has been implicated in the pathophysiology of neurodegenerative disorders. Its role in the mechanisms of cellular degeneration and protection is still unknown. The aim of our work is to investigate the endogenous activation of the DKK3 pathway in a model of transient occlusion of the middle cerebral artery in rats. In particular, the animals were subjected to 1 h of ischemia followed by different reperfusion times (1 h, 6 h, 12 h and 24 h) to evaluate the downstream pathway and the time course of its activation. Western blot analysis showed increased Dkk3 expression in animals with the highest time of reperfusion. The increased levels of Dkk3 were accompanied by reduced Wnt3a, Frz1 and PIWI1a expression in the cytosol while FOXM1 and ß-catenin decreased in the nucleus. These molecular changes led to an increase in the apoptotic pathway, as showed by the increased expression of Caspase 3 and Bax and the reduced levels of Bcl-2, and to a decrease in neurogenesis, as shown by the decreased expression of Tbr2, Ngn2 and Pax6. In the second part of the study, we decided to employ curcumin, an activator of the Wnt/ß-catenin signaling, to investigate its effect on Dkk3. In particular, curcumin was administered 1 and 6 h after ischemia, and animals were sacrificed 24 h later when the expression of Dkk3 was higher. Our data displayed that curcumin administration decreased Dkk3 expression, and increased Wnt3a, Frz1 and PIWI1a levels. Well in line with these data, curcumin administration increased nuclear ß-catenin and FOXM1 expression. The down-regulation of Dkk3 by curcumin led to reduced apoptosis and increased neurogenesis. Summarizing, our results showed that Dkk3 acts as an inhibitor of Wnt/ß-catenin signaling during cerebral ischemia. Additionally, its inhibition and the contextual activation of the Wnt/ß-catenin pathway are protective against ischemic stroke.

Surgical management of Glioma Grade 4: technical update from the neuro-oncology section of the Italian Society of Neurosurgery (SINch®): a systematic review.

PURPOSE: The extent of resection (EOR) is an independent prognostic factor for overall survival (OS) in adult patients with Glioma Grade 4 (GG4). The aim of the neuro-oncology section of the Italian Society of Neurosurgery (SINch®) was to provide a general overview of the current trends and technical tools to reach this goal. METHODS: A systematic review was performed. The results were divided and ordered, by an expert team of surgeons, to assess the Class of Evidence (CE) and Strength of Recommendation (SR) of perioperative drugs management, imaging, surgery, intraoperative imaging, estimation of EOR, surgery at tumor progression and surgery in elderly patients. RESULTS: A total of 352 studies were identified, including 299 retrospective studies and 53 reviews/meta-analysis. The use of Dexamethasone and the avoidance of prophylaxis with anti-seizure medications reached a CE I and SR A. A preoperative imaging standard protocol was defined with CE II and SR B and usefulness of an early postoperative MRI, with CE II and SR B. The EOR was defined the strongest independent risk factor for both OS and tumor recurrence with CE II and SR B. For intraoperative imaging only the use of 5-ALA reached a CE II and SR B. The estimation of EOR was established to be fundamental in planning postoperative adjuvant treatments with CE II and SR B and the stereotactic image-guided brain biopsy to be the procedure of choice when an extensive surgical resection is not feasible (CE II and SR B). CONCLUSIONS: A growing number of evidences evidence support the role of maximal safe resection as primary OS predictor in GG4 patients. The ongoing development of intraoperative techniques for a precise real-time identification of peritumoral functional pathways enables surgeons to maximize EOR minimizing the post-operative morbidity.

Provocation and prediction of visual peripersonal neglect-like symptoms in preoperative planning and during awake brain surgery.

Neglect is a severe neuropsychological/neurological deficit that usually develops due to lesions of the posterior inferior parietal area of the right hemisphere and is characterized by a lack of attention to the left side. Our case is a proven right-handed, 30-year-old female patient with a low-grade glioma, which was located in the temporo-opercular region and also in the superior temporal gyrus of the right hemisphere. Upon presurgical planning, the motor, language, and visuospatial functions were mapped. In order to achieve this, the protocol for routine magnetic resonance imaging and navigated transcranial magnetic stimulation has been expanded, accordingly.