Intraoperative Ultrasonography for Surgery of Cranial Traumatic Acute Subdural Hematoma: Technical Note.

BACKGROUND: Intraoperative ultrasonography (IOUS) in traumatic brain injury is a fast, easy, and low-cost technique that has been poorly investigated so far even though it could potentially answer many of the intraoperative needs of the surgeon. The aim of this study was to investigate the role of IOUS in patients undergoing surgery for traumatic acute subdural hematoma (aSDH), focusing on its influence on intraoperative surgical strategy, particularly regarding the management of intracerebral contusions (ICCs) associated with aSDH. METHODS: Data of patients who consecutively underwent surgical evacuation of traumatic aSDH with IOUS assistance at our institution from May 2017 to December 2020 were retrospectively analyzed. Patients were dichotomized into an ICC group (ICCs associated with aSDH on preoperative computed tomography scan) and no ICC group (no ICCs associated with aSDH on preoperative computed tomography scan). RESULTS: The study included 41 patients. Before aSDH evacuation, IOUS findings were similar to preoperative computed tomography data. After aSDH evacuation, IOUS detected a new-onset ICC in 13% of patients in the no ICC group and a volume increase of the known ICCs in 22% of patients in the ICC group. Therefore, IOUS made it possible to evacuate these new-onset or expanding hematomas in the same operation, changing our surgical strategy and avoiding a delayed reintervention. CONCLUSIONS: Our study suggests that IOUS in patients undergoing surgery for traumatic aSDH can promptly identify possible evolution of a primary head injury, leading to early and effective treatment.

Alzheimer's Disease CSF Biomarker Profiles in Idiopathic Normal Pressure Hydrocephalus.

Patients with idiopathic normal pressure hydrocephalus (iNPH) frequently show pathologic CSF Aß42 levels, comparable with Alzheimer's Disease (AD). Nevertheless, the clinical meaning of these findings has not been fully explained. We aimed to assess the role of AD CSF biomarkers (Aß42, Aß42/Aß40, p-tau, t-tau) in iNPH. To this purpose, we enrolled 44 patients diagnosed with iNPH and 101 with AD. All the patients underwent CSF sampling. We compared CSF biomarker levels in iNPH and AD: Aß42 levels were not different between iNPH and AD, while Aß42/Aß40, p-tau, and t-tau were significantly different and showed excellent accuracy in distinguishing iNPH and AD. A multiple logistic regression analysis showed that Aß42/Aß40 was the variable that most contributed to differentiating the two groups. Furthermore, iNPH patients with positive Aß42/Aß40 had higher p-tau and t-tau than iNPH patients with negative Aß42/Aß40. Those iNPH patients who showed cognitive impairment had lower Aß42/Aß40 and higher p-tau than patients without cognitive impairment. We concluded that positive CSF Aß42 with negative Aß42/Aß40, p-tau, and t-tau is a typical CSF profile of iNPH. On the contrary, positive Aß42/Aß40 in iNPH patients, especially when associated with positive p-tau, may lead to suspicion of a coexistent AD pathology.

Use of the Subdural Hematoma in the Elderly (SHE) Score to Predict 30-Day Mortality After Chronic Subdural Hematoma Evacuation.

BACKGROUND: The Subdural Hematoma in the Elderly (SHE) score has been recently developed to assess the 30-day mortality in acute and chronic subdural hematomas in patients >65 years and has shown good reliability. We aimed to validate the SHE score's accuracy to predict 30-day mortality on a homogeneous cohort of patients undergoing surgical chronic subdural hematoma evacuation at our Institution. We also investigated whether the SHE score could reliably predict the occurrence of 30-day chronic subdural hematoma recurrence needing surgery. METHODS: We included patients from our prospectively collected database from January 2018 to January 2021. Patients with the availability of the following information were enrolled: age, Glasgow Coma Scale score on admission, hematoma volume, medical history, and outcome at 30 days. The SHE score was calculated for each patient, and the association between greater scores and 30-day mortality was investigated and its ability to predict 30-day and disease recurrence. Statistical significance was assessed for P < 0.05. RESULTS: Three hundred twenty-one patients were included. Of them, 40 (12.5%) displayed mortality within 30-day: specifically, 0% of the group of patients with SHE score = 0, 4.3% of SHE score = 1, 14.5% of SHE score = 2, 39.3% of SHE score = 3, and 37.5% of SHE score = 4, with a statistically significant linear trend between greater SHE scores and 30-day mortality rates (P < 0.001, area under the curve 0.75 [0.67-0.82]). No significant association of the SHE score with the risk of recurrence needing surgery was detected (P = 0.4). CONCLUSIONS: The SHE score proved helpful in predicting 30-day mortality in patients with chronic subdural hematomas, but no utility was observed to predict disease recurrence.

Impact of decompressive craniectomy on functional outcome of severe acquired brain injuries patients, at discharge from intensive inpatient rehabilitation.

PURPOSE: Decompressive craniectomy (DC) is a life-saving procedure conducted to treat refractory intracranial hypertension. Although DC reduces mortality of severe Acquired Brain Injury (sABI) survivors, it has been associated with severe long-term disability. This observational study compares functional outcomes at discharge from an Intensive Rehabilitative Unit (IRU) between sABI patients with and without DC. MATERIAL AND METHODS: sABI patients undergoing DC before entering the Don Gnocchi Foundation IRU were compared with a group of sABI patients who did not undergo DC (No-DC group), after matching it by age, sex, aetiology, time post-onset, and clinical status. Inclusion criteria were: diagnosis of sABI, age 18+, time from the event <90 days. RESULTS: A total of 87 (DC: 47) patients were included (median age: 60.5 [IQR = 17.47]). The two groups did not differ for admission clinical features except for the tracheostomy presence (more frequent in DC, p < 0.001). No significant differences were also found at discharge. DC group presented a significantly longer length-of-stay than No-DC group (p < 0.001) and a longer time to tracheostomy removal (p = 0.036). DC was not found to influence outcomes as consciousness improvement, tracheostomy removal, oral intake and functional independence. CONCLUSIONS: sABI patients with DC improved after rehabilitation as much as No-DC patients did but they required a longer stay.Implications for RehabilitationDecompressive craniectomy (DC) is practiced during the acute phase after hemorrhagic, ischemic, traumatic severe brain injury as a life-saving procedure to treat refractory intracranial hypertensionDC has been associated with follow-up severe long-term disability, but no study yet addressed whether DC may affect intensive rehabilitation outcomes.Undergoing a DC is not a negative prognostic factor for achieving rehabilitation goals after a severe acquired brain injuryDC must be taken into account when customizing rehabilitation pathway especially because these patients required a longer time to reach the outcomes.

Lipoastrocytoma: Case report and review of the literature.

Lipoastrocytoma is an extremely rare tumor, with only six cases described. We report the case of an astrocytoma involving the upper part of the cerebellar-pontine angle and the right portion of the clivus starting from the brainstem with a diffuse lipomatous component in a 39 year-old man. The patient was admitted with headache of 1 year's duration and diplopia over the previous 3 months. MRI revealed a ponto-cerebellar lesion that showed irregular enhancement after contrast administration. Subtotal excision of the tumor was accomplished. Adjuvant chemotherapy and radiation therapy were not administered. Histologically the tumor showed the classical histology of low-grade astrocytoma and a portion of the lesion was composed of lipid-laden cells. Immunohistochemistry for glial fibrillary acid and S-100 proteins clearly demonstrated the glial nature of these cells. Ki-67/Mib-1 labeling index was low (2%). The patient remains in good neurological conditions after 10 months. Our case has a benign postoperative behavior, also after subtotal excision, with restrictions due to the short follow-up. It is important to record each new case of this rare tumor to produce a better characterization of this lesion.

An incidentally detected third ventricle chordoid glioma.

Chordoid glioma is a rare low-grade tumor located in the third ventricle-hypothalamic region. Since its first report, 37 cases have been described in the literature. We report on an additional case that we considered significant because of its incidental detection and its uneventful surgical removal.

Spinal neurinomas: retrospective analysis and long-term outcome of 179 consecutively operated cases and review of the literature.

BACKGROUND: We present a series of 179 spinal neurinomas consecutively observed at the Department of Neurosurgery at the University of Florence for a period of 30 years (between 1967 and 1997). We decided to limit the retrospective study to obtain at least 5 years of follow-up. Therefore, 20 additional neurinomas treated between 1997 and 2002 were excluded. METHODS: All the cases are evaluated under statistical, clinical, neuroradiological, and surgically technical profiles based on data from clinical records and from periodic check-ups after surgery. In particular, the results are analyzed on the basis of an accurate pre- and postsurgical evaluation using Karnofsky's scale and Kleklamp-Samii's scoring system. RESULTS: We treated 179 spinal neurinomas in 152 (93 male and 59 female) patients. The mean age was 44.3. In 33 cases the neurinoma was sited in the cervical tract, in 59 cases in the dorsal tract, and in 87 cases in the lumbo-sacral tract. Eleven patients harbored Recklinghausen's neurofibromatosis (7 NF1 and 4 NF2 of which 1 was intramedullary). In 123 cases the neurinoma was intradural, in 11 cases it was extradural, in 2 intra/extradural, in 9 it had a dumbbell form, and in 2 cases it was intramedullary; the remaining cases had neurofibromatosis. The most common presurgical symptom was segmental pain. Total removal of the lesion was possible in the first operation for 174 neurinomas. We encountered 3 cases of malignant neurinoma of which 1 was in NF2. The result of surgery was recovery in 108 cases; 2 patients with NF2 died, and local recurrence occurred even after total exeresis (excision) and radiotherapy in the cases of malignant neurinoma. CONCLUSIONS: Schwannomas represent the most frequent tumor lesions of the spine with prevalence for the cervical-inferior tract and the dorso-lumbar passage. Intramedullary neurinomas are rarely observed. The total surgical removal of neurinomas is often an attainable goal, and clinical improvement is the common outcome with exception to malignant forms and NF2 neurofibromatosis. We describe a series of 179 treated schwannomas.