Subpial technique in supratentorial glioma resection: state of the art and analysis of costs and effectiveness in a single institute experience.

BACKGROUND: Many neurosurgeons advocate subpial technique as the best technique to remove supratentorial gliomas. However, few authors clearly defined advantages and features of this technique. The aim of our study is to describe microsurgical subpial technique related to glioma surgery, with regard to its safety and cost effectiveness. METHODS: We analyzed retrospectively all consecutive patients surgically treated for supratentorial glioma from January 2017 to April 2018 at Neurosurgery Department of Neuromed Institute. All patients underwent to surgical glioma resection performing microsurgical subpial technique. Extent of resection and neurological complications were evaluated as primary outcomes; Karnofsky Performance Status and postoperative edema extent were secondary outcomes. Statistical analysis was obtained. RESULTS: The study included 70 patients. Gross Total Removal was obtained in 91.3% of patients with low grade glioma (LGG) and in 81% of patients with high grade glioma. Neurological complications amounted to 34% at early assessment in LGG patients, which were permanent at 3 months in 17% of patients. In high grade glioma patients, neurological complications amounted to 51% at early assessment, which were permanent at 3 months in 25% of them. CONCLUSIONS: We obtained good postoperative results with regard to the extent of tumor resection using this technique. Subpial resection is an effective surgical technique to get a safer and more complete tumor resection. It should be combined with other modern neurosurgical tools such as neuronavigation, ultrasound and cortical mapping to obtain the best tumor resection and functional neurological preservation.

Continuous subcortical monitoring of motor pathways during glioma surgery with ultrasonic surgical aspirator: technical description in a single institute experience.

BACKGROUND: Actual challenge in surgical treatment of intra-axial gliomas involving eloquent areas is maximal safe resection. Mapping and monitoring of cortical and subcortical motor functionsare important tools to avoid postoperative deficits. In the present study, we present our experiencewith a continuous dynamic motor mapping technique pairing a traditional monopolar stimulatorwith a Cavitron Ultrasonic Surgical Aspirator (CUSA) to perform a continuous stimulation ofthe white matter avoiding removal interruption. METHODS: We describe a single center retrospective analysis of 1-year consecutive patients with intraxial tumors located adjacent to corticospinal tract and treated with surgical resection adopting "continuous dynamic mapping technique". With the support of a reconstruction software (3D Slicer), we classified the Extent Of Resection (EOR) as Gross Total Resection (GTR) (>98%), Sub-Total Resection (STR) (from 90% to 97%), and Partial Resection (<90%). Medical Research Council (MRC) grading was adopted to evaluate neurological outcomes (from 0 to 5), assessed on 1st post-operative day, at 1 week, 1 month and 3 months. RESULTS: From July 2017 to July 2018, 29 patients underwent to surgical removal of intraxial tumor adjacent to motor areas, using continuous dynamic subcortical mapping. Median age was 54 years old (range 12-75 years). At pre-operative MRI tractography reconstruction, mean distance between tumor and corticospinal tract was 4,4 mm (range At 1 week post-operative assessment, motor deficits were still present in 12 patients (41%). At 1 month, 10 patients (35%) had persisting deficits, which required admission to rehabilitation department. At 3 months, 4 patients (14%) had persistent motor impairment and overall 28 patients (98%) were able to walk by themselves. CONCLUSIONS: Our early experience showed that a combination of dynamic subcortical mapping with transcranial and cortical strip MEP (Motor Evoked Potentials) monitoring is useful in tumors close to motor eloquent areas to extend surgical resection avoiding permanent consequences. However, we need for further experience to consolidate and improve this technique.

Intracranial soft-tissue glomus tumor (glomangioma) in a young-woman. A case report and review of the literature.

BACKGROUND: Glomus tumors, or glomangiomas, are benign vascular tumors typically seen at distal extremities. These tumors differ from paragangliomas and classically present in the female population between the 4th and 5th decade. Intracranial localizations have not been described in literature in the adult population. CASE DESCRIPTION: We present a case of a 32 year-old woman with a 3 months history of progressive left-sided visual loss and headache. A pre-operative MRI showed a homogeneously enhancing lesion extending from the left cavernous sinus to middle cranial fossa at first suspected to be a cavernous sinus meningioma. Eventually, histopathological analysis concluded for a glomangioma diagnosis. Post-operative RT was also performed. CONCLUSIONS: From our experience it is very important for clinical management considering glomangiomas in differential diagnosis of a homogeneously enhancing extra axial mass. Subtotal resection followed by radiation therapy determined no recurrence of the disease up to 7 years. KEY WORDS: Glomangioma, Glomus tumor, Soft-tissue tumor.

Multiple brain metastases: a surgical series and neurosurgical perspective.

Despite review papers claim for radical treatment of oligometastatic patients, only few surgical series have been published. In this study, we analyze results and actual role of surgical resection for the management of patients with multiple brain metastases. This retrospective study compares surgical results of two groups of patients consecutively treated in our Institute from January 2004 to June 2015. The first group comprises all 32 patients with multiple brain metastases with only 2-3 lesions who underwent surgical resection of all lesions; the second group comprises 30 patients with a single surgically treated brain mestastasis compatible with the first group (match-paired control series). Median survival was 14.6 months for patients with multiple brain metastases (range 1-28 months) and 17.4 months for patients with a single brain metastasis (range 4-38 months); the difference was not statistically significant (P = 0.2). Neurological condition improved in 59.4% of patients with multiple metastases, it remained unchanged in 37.5% and worsened in 3.1%. In our series, selected patients with only 2-3 lesions with well-controlled systemic disease, life expectancy of more than 3 months, Karnofsky's performance status > 60, and surgically accessible lesions, benefited from surgical treatment in terms of survival and quality of life, with reduction or disappearance of significant neurological deficits. The prognosis for these patients is similar to that of patients with a single metastasis. It seems that patients with breast cancer included in our series had the worst prognosis if compared to other histotypes.