Pedicled multifidus muscle flaps to treat dural tears due to penetrating spinal stab wounds: Two case reports and a literature review.

Background: Penetrating spinal injuries occasionally lead to dural tears (DT) and cerebrospinal fluid (CSF) leaks that risk both infectious and neurological complications. Here, we reviewed two cases and the literature regarding the safety/efficacy and limitations of repairing traumatic DT utilizing pedicled multifidus muscle flaps. Case Description: Two males, ages 73 and 50, presented with Brown-Sequard syndromes and DT/CSF fistulas attributed to knife-induced spinal injuries at the D3-D4 and D11-D12 levels. Intraoperatively, DT was repaired utilizing pedicle multifidus muscle flaps. Postoperatively, both patients demonstrated partial recovery of neurological function along with no residual symptoms/signs of DT/CSF fistulas. Conclusion: Penetrating traumatic spinal injuries may result in DT/CSF fistulas that can be adequately repaired utilizing pedicle multifidus muscle flaps.

Utility and Feasibility of a Low-Cost System to Simulate Clipping Strategy for Cerebral Aneurysms Using Three-Dimensional Computed Tomography Angiography with Virtual Craniotomy.

OBJECTIVE: To assess utility and feasibility of a low-cost system to simulate clipping strategy for cerebral aneurysms using patient-specific surgically oriented three-dimensional (3D) computed tomography angiography with virtual craniotomy. METHODS: From 2017 to 2021, 53 consecutive patients scheduled for aneurysm clipping underwent preoperative planning using 3D computed tomography angiography with virtual craniotomy. The model was oriented in the surgical position to observe the anatomy through surgical corridors. Clipping was planned considering 3 parameters: shape of the clip, clip type (standard vs. fenestrated), and clipping strategy (simple vs. multiple). We used a scoring system (0-3) to assess the concordance of virtual planning with real surgery by assigning 1 point for each correctly predicted parameter. Qualitative assessment of 3D models was a secondary end point. RESULTS: In 51 patients, 3D images perfectly matched the real anatomy shown in surgical videos. Concordance scores of 0, 1, 2, and 3 occurred with a frequency of 5%, 14%, 38%, and 43%, respectively. Concerning the shape of the clip, clip type, and clipping strategy, the concordance occurred in 73%, 80%, and 59%, respectively. Compared with simple clipping, strategies with multiple clippings were more difficult to predict correctly. Concordance scores of 0, 1, 2, and 3 occurred with a frequency of 5.7%, 5.7%, 31.4%, and 57.1%, respectively, in simple clipping and 4.8%, 28.6%, 47.6%, and 19%, respectively, in multiple clipping. CONCLUSIONS: In our experience, use of 3D computed tomography angiography with virtual craniotomy is an easy and useful solution to plan clipping strategy. The surgeon's awareness of the surgical anatomy is improved. Although this method has some technical limitations, it represents a low-cost alternative if complex and expensive simulation systems are not available.

Atypical and aggressive diffuse leptomeningeal glioneuronal tumor in a young adult: A case report and review of the literature.

Background: DLGNT is a rare tumor, commonly diagnosed in pediatric age; in most cases, the pathology presents a slow and indolent evolution. We present a case report of a young adult affected by DLGNT characterized by aggressive and atypical behavior. Case Description: A 21-year-old male presented with mild paraparesis and hypoesthesia with a D2 level. MRI scan of the brain and spine showed a dorsal intramedullary lesion; a diffuse craniospinal leptomeningeal thickening was also present. After a week, the neurological status deteriorated rapidly with paraparesis worsening and onset of acute hydrocephalus. The patient underwent external ventricular drain positioning; a C7-D4 laminectomy was subsequently performed with partial tumor resection. Histological examination revealed a DLGNT with aggressive aspects (Ki67 30%). Postoperatively, the patient showed an immediate mild worsening of the lower limbs deficit. After a few days, severe further neurological deterioration occurred with progressive motor deficit to the upper limbs and ultimately respiratory failure. Mechanical ventilation was necessary and the patient was transferred to the ICU; during the following weeks, he developed tetraplegia and underwent ventriculoperitoneal shunt positioning. By the time, the histological diagnosis was available, the clinical status would not allow radiotherapy or chemotherapy. The patient deceased approximately 90 days after hospitalization due to respiratory complications. Conclusion: DLGNT is a rare tumor; diagnosis requires a high index of suspicion and confirmation with biopsy. Although most cases have an indolent course, some patients may have aggressive forms. High proliferation index, hydrocephalus occurrence, and massive craniospinal leptomeningeal spread appear to be associated with worse prognosis.

Multimodal Surgical Management of Cerebral Lesions in Motor-Eloquent Areas Combining Intraoperative 3D Ultrasound with Neurophysiological Mapping.

BACKGROUND: Resection of tumors adjacent to motor pathways carries risks of both postoperative motor deficit and incomplete resection. Our aim was to assess usefulness and limitations of a multimodal strategy that combines intraoperative ultrasound (iUS) guided resection with intraoperative neurophysiology. METHODOLOGY: This is a prospective study of 25 patients with brain lesions adjacent to motor areas who underwent intracranial surgery with assistance of the iUS guidance system and intraoperative neurophysiological monitoring and mapping. Pathologies treated included 19 gliomas, 3 metastases, 1 anaplastic meningioma, 1 arteriovenous malformation (AVM), and 1 ependymoma. The iUS-guided lesion removal accuracy and the extent of resection were estimated and compared with a 30-day postoperative brain MRI. The results were assessed considering the extent of resection related to 6-month motor function outcome. RESULTS: iUS was accurate in checking the extent of resection in 17 patients, whereas in 8 cases the decline of the iUS images quality did not allow a valuable assessment. Positive mapping was obtained in 16 patients. Gross total resection was achieved in 16 patients. In five of nine cases with subtotal resection, surgery was stopped because a functional area was reached. In four patients, tumor removal was limited due to the difficulty of identifying neoplastic tissue. Motor function worsening was transient in six patients and permanent in two. CONCLUSIONS: The integrated use of intraoperative neuromonitoring to identify motor areas and iUS to identify tumor-tissue interface could help increase the rate of radical resection respecting the eloquent areas.

Comparison of two different titanium cranioplasty methods: Custom-made titanium prostheses versus precurved titanium mesh.

BACKGROUND: The aim of this study was to compare the results of two different titanium cranioplasties for reconstructing skull defects: standard precurved mesh versus custom-made prostheses. METHODS: Retrospective analysis of 23 patients submitted to titanium cranioplasty between January 2014 and January 2019. Ten patients underwent delayed cranioplasty using custom-made prostheses; and 13 patients were treated using precurved titanium mesh (ten delayed cranioplasties, and three single-stage resection- reconstructions). Demographic, clinical, and radiological data were recorded. Results and complications of the two methods were compared, including duration of surgery, cosmetic results (visual analog scale for cosmesis [VASC]), and costs of the implants. RESULTS: Complications: one epidural hematoma in the custom-made group, one delayed failure in precurved group due to wound dehiscence with mesh exposure. There were no infections in either group. All custom-made prostheses perfectly fitted on the defect; eight of 13 precurved mesh prostheses incompletely covered the defect. Custom-made cranioplasty obtained better cosmetic results (average VASC 94 vs. 68), shorter surgical time (141min vs. 186min), and -fewer screws was needed to fix the prostheses in place (6 vs. 15). However, satisfactory results were obtained using precurved mesh in cases of small defects and in single-stage reconstruction. Precurved mesh was found to be cheaper (€1,500 vs. €5,500). CONCLUSION: Custom-made cranioplasty obtained better results and we would suggest that this should be a first choice, particularly for young patients with a large cranial defect. Precurved mesh was cheaper and useful for single-stage resection-reconstruction. Depending on the individual conditions, both prostheses have their place in cranioplasty therapies.

Ethical and therapeutic dilemmas in glioblastoma management during pregnancy: Two case reports and review of the literature.

INTRODUCTION: There are no guidelines about the management of glioblastoma multiforme (GBM) during pregnancy: treatment of these patients presents therapeutic and ethical challenges. CASE DESCRIPTION: Two patients, respectively, 28 years old at the 14th week of gestation with a thalamic GBM and 38 years old at the 28th week of gestation with fronto-mesial GBM. Patients and their relatives were deeply informed about the natural history of GBM and potential risks and benefits of surgery, radiotherapy (XRT), and chemotherapy (CTX) for both, mother and fetus. The first patient's will was to preserve her fetus from any related, even minimal, risk of XRT, and CTX until safe delivery despite progression of GBM, accepting only surgery (tumor debulking and shunting of hydrocephalus). The second one asked to deliver the baby as soon as possible (despite the risks of prematurity) to receive the standard treatments of GBM. The two patients survived, respectively, 16 and 46 months after delivery. The first patient's son is in good clinical conditions; the second one suffered problems linked to prematurity. CONCLUSIONS: Standard treatment of GBM in a pregnant woman could improve the mother's survival but can expose the fetus to several potential risks. Ethically, relatives should understand that mother has anyway a poor prognosis and, at the same time, fetus prognosis depends on mother's condition and therapy. It is not possible to warrant absence of risk for both. Considering the absence of guidelines and the relatively poor current data available about management of GBM in a pregnant woman, after a deep explanation of the situation, we think that the will of the mother and her relatives should prevail.

Flexible Fiber CO2 Laser in Microsurgical Treatment of Intraventricular Tumors: Usefulness and Limitations.

OBJECTIVE: To assess usefulness and limitations of flexible fiber carbon dioxide (CO2) laser in the microsurgical treatment of intraventricular tumors. METHODS: We reviewed a series of 9 patients treated with microsurgical resection of intraventricular tumors using a flexible fiber CO2 laser. The lesions involved the third ventricle (8) and the frontal horn of the right lateral ventricle (1). Histology revealed 6 craniopharyngiomas, 1 pituitary macroadenoma, 1 subependymoma, and 1 neurocytoma. In all cases, an interhemispheric transcallosal approach was performed. The laser was used during callosotomy, fornix column sectioning, tumor debulking, and to facilitate tumor dissection. We used a 5-tiered score system to assess laser's efficacy in each surgical step (approach, dissection, debulking): grade 1: laser was not at all helpful, grade 5: laser was extremely helpful. Limits of the instrument also are discussed. RESULTS: Gross total resection was achieved in 6 cases and subtotal resection in the remaining 3. Three patients had pulmonary complications treated without clinical sequelae. No laser-related complication was described. Mean utility score observed was 4.2 (range 3-5) during approach, 2.8 (range 2-4) during tumor dissection; and 3.3 (range 2-5) during tumor debulking. Main limits were low hemostatic effect and inefficiency versus calcified and highly vascularized tumors. CONCLUSIONS: The CO2 laser proved to be a useful and safe tool that could be used for intraventricular pathology; its design is suitable for narrow surgical corridors like interhemispheric fissure and foramen of Monro; its main utility is the ability to create precise and relatively bloodless cut (callosotomy, tumor debulking); low hemostatic effect is its main limit.

Delayed diagnosis of post-traumatic aneurysm of distal anterior cerebral artery.

BACKGROUND: Traumatic intracranial aneurysms (TICA) are often associated with poor prognosis and should be diagnosed as soon as possible to prevent delayed intracranial hemorrhage and high rates of morbidity/mortality related to bleeding. Diagnosis requires a high index of suspicion. The goal of treatment is to exclude the aneurysm issue with surgical or endovascular methods. CASE DESCRIPTION: We report the case of a 19-year-old boy who suffered a cranio-orbital trauma; 2 weeks after initial trauma he deteriorates with a new intracranial bleeding. Immediate angiography resulted negative. Delayed follow-up by magnetic resonance angiography showed an unruptured aneurysm of anterior cerebral artery that was successfully clipped. CONCLUSIONS: A TICA should be suspected in case of delayed deterioration in head-injured patient, prompt diagnosis and treatment could improve prognosis and reduce morbidity and mortality.