Subarachnoid hemorrhage in the eighties: to treat or not to treat.

BACKGROUND: Life expectancy has in the last few years increased and, as a consequence, also the number of elderly patients admitted to an Emergency Department with aneurysmal subarachnoid hemorrhage. We wanted to detect any difference in term of outcomes and adverse events between two groups of patients of different age, in relation to types of treatment and clinical status at presentation. METHODS: We selected and analyzed two groups of patients (group A and group B) among 458 retrospectively collected cases admitted to two neurosurgical centers with a diagnosis of aneurysmal subarachnoid hemorrhage over a 7.5-year period. Group A included 46 patients equal or older than 80 years and group B all the rest. Data were collected on age, sex, aneurysm location, size, comorbidities, clinical condition at presentation and at follow-up. RESULTS: In group A, 19 patients underwent surgery, 16 were embolized, 7 were treated conservatively and 4 died very soon after admission. After a median follow-up of 12 months 45.7% of patients had a good outcome, 24% were in poor conditions and 21.7% had died. When we compared these results with the youngest group, we found some important statistically significant differences. Older patients were more prone to have surgical and medical related complications, whereas endovascular treatment seemed to be a more sustainable treatment in the elderly age group. CONCLUSIONS: Elderly patients suffering from aneurysmal subarachnoid hemorrhage should be considered for treatment despite age, with endovascular embolization as the most preferable option. Without the treatment, the natural history can be very poor.

Lumbar canal stenosis: can we treat it endoscopically?

BACKGROUND: The common treatment for lumbar canal stenosis involves an open surgical decompression with laminectomy and foraminotomy, even if spinal surgery is moving towards minimal invasiveness procedures. Minimally-invasive surgery initially and recently spinal endoscopic techniques are becoming the standard procedures for lumbar disk prolapsed in consideration of the less surgical invasiveness with a considerable reducing in the amount of normal anatomy violation, in less risk of iatrogenic postoperative instability, minimal scar tissue formation and negligible blood loss when compared to the standard open approach. These techniques also reduce the postoperative pain with consequent less need of using pain medications as well as reduced hospital stay. METHODS: From August 2016 to July 2017, we prospectively collected data on 20 patients operated on for a lumbar canal stenosis using a pure interlaminar endoscopic route. This series includes 2 unilateral and 3 bilateral L5-S1 stenosis; ten L4-L5 stenosis (8 bilateral and 2 unilateral); four L3-L4 bilateral stenosis and one bilateral L2-L3 stenosis. Among these, six were two adjacent multiple levels stenosis: L4-L5-S1 two cases; L3-L4-L5 three cases and L2-L3-L4 one case. We reviewed the demographic data as well as the pre and postoperative Visual Analogue Score and Oswestry Disability Index at 3, 6 and 12 months. We also collected the surgical complications and the result of a six-month questionnaire on patients' satisfaction. RESULTS: The median operative time was 125 minutes (range between 45 and 300 minutes). Twenty-two (90%) of the patients were satisfied with the treatment received in terms of clinical results at one year follow-up. Two patients (10%) had been converted to an open procedure. CONCLUSIONS: The use of the endoscopic technique for the treatment of lumbar canal stenosis seems to be correlated with good results and can be a valid alternative to the classic, more invasive, open technique.

Full-Endoscopic Removal of Lumbar Juxtafacet Cysts: A Prospective Multicentric Study.

BACKGROUND: Lumbar juxtafacet cysts are benign lesions that grow at the level of facet joints or within neighboring structures. Recently, there is an ongoing trend toward less invasive procedures for treating degenerative spine diseases. Here we report a multicenter study of full-endoscopic surgery for juxtafacet cyst removal. METHODS: We prospectively collected patients with a diagnosis of lumbar juxtafacet cyst surgically treated in 3 institutions between January 2017 and August 2019. Patients of any sex and age were eligible if they had a single level unilateral lumbar juxtafacet cyst, invalidating radicular pain lasting >6 weeks, adequate imaging, and failed percutaneous or conservative treatment. Age at diagnosis; sex; preoperative, postoperative, and 6-month leg pain; surgical and medical complications; spine instability (preoperatively and at 6 and 12 months); and follow-up time were collected. RESULTS: Thirty-five patients were enrolled. Median operative time was 78 minutes, and mean leg pain went from a preoperative value of 6.8 (standard deviation [SD] = 1.2) to a postoperative value of 3.4 (SD = 1.1, P < 0.001) to 2.1 (SD = 1.7, P < 0.001) at 6 months. At a median follow-up of 15 months, approximately 89% of patients were pain-free or improved. We had 2 recurrences of radicular pain, treated conservatively. Only 2 surgical complications (6%) occurred: 2 small dural tears, both resolved without further intervention. CONCLUSIONS: Full-endoscopic surgery is feasible and safe for juxtafacet cyst removal. Our results are consistent with findings from recent full-endoscopic and series, with outcomes overlapping those reported for open or tubular techniques.

Skin Glue for Wounds Closure in Brain Surgery: Our Updated Experience.

BACKGROUND: Traditional wound closure techniques include skin sutures and metal clips. Cyanoacrylate has good neovascularization, epithelialization, and antimicrobial activity properties and a fast application procedure. This study presents our long-term experience. METHODS: We retrospectively selected 362 patients who underwent brain surgery from January 2007 to March 2017. Exclusion criteria were applied for repeat surgeries, emergency/posttraumatic procedures, wound infections, wounds longer than 16 cm, skull base cases, and postoperative patients who stayed in the intensive care unit more than 1 day. We collected data from 250 cases of supratentorial procedures and 112 cases of infratentorial procedures. The median wound length was 11 cm (range, 4-15 cm); the median age was 51 years. We followed-up all patients for 1, 3, and 12 months focusing on wound complications, cosmetic results, based on the Hollander Wound Evaluation Scale (HWES), and patient satisfaction using a visual analog scale. RESULTS: Cosmetic results were very good (HWES score of 5-6) in 99.5% of cases at 12 months. Patient satisfaction reached almost 100% at 12 months. We experienced 2 cases of wound dehiscence and 2 others with poor cosmetic results. The main complaint was a feeling of discomfort, during the first 2 weeks after surgery, because of the dried glue along the wound's edges. CONCLUSIONS: With additional research, we can confirm that cyanoacrylate glue may be a valid and useful alternative to traditional techniques for wound closure in brain surgery, carrying several advantages. However, a randomized controlled trial with a large number of patients is warranted to confirm our findings.

Surgical treatment of anterior cranial fossa dural arterio-venous fistulas (DAVFs): a two-centre experience.

BACKGROUND: Anterior cranial fossa dural arterio-venous fistulas (DAVFs) represent 6% of all intracranial DAVFs; characteristically they show an aggressive behaviour with high risk of intracranial haemorrhage. Peculiar anatomical features, such as feeding by the ethmoidal arteries and the pattern of venous drainage (frequently with varices that mimic aneurysmal dilatation), can be evaluated in detail only by digital subtraction angiography (DSA), which represents the "gold standard" in the diagnosis of such cranial fistulas. Recent technological developments in endovascular management of this type of DAVF have partially reduced the morbidity risk related to this modality of treatment. Our purpose is to present our experience in the surgical management of 14 patients with anterior cranial fossa DAVFs, with attention paid to the possible role of preoperative embolisation in these cases and to the surgical technique. METHOD: Between 1999 and 2015, 14 patients with anterior cranial fossa DAVFs were submitted to surgery in two neurosurgical departments; the mean age was 63 years old; nine DAVFs caused intracranial haemorrhage (subarachnoid haemorrhage in three cases, intracerebral haemorrhage in six cases). Pre-operative embolisation was attempted in an early case and was successfully done in one recent case. In all patients, the surgical approach chosen was a pterional craniotomy with a low margin on the frontal bone in order to gain the exposure of the anterior cranial fossa and especially of the olphactory groove region; the resection of the falx at its insertion on the crista galli was needed in five cases in order to get access to the contralateral afferent vessels. Cauterisation of all the dural feeders on and around the lamina cribrosa was needed in all cases; venous dilatations were evident in eight patients (in seven out of nine patients with ruptured DAVF and in one out of five patients with unruptured DAVF) and were removed in all cases. One patient harboured an ophthalmic artery aneurysm, which was excluded by clipping. RESULTS: One patient died 5 days after surgery due to the severity of the pre-operative haemorrhage. Postoperative DSA showed the disappearance of the DAVF and of the venous pseudo-aneurysms in all cases. Clinical outcome was favourable (without neurological deficits) in 11 patients; three patients presented an unfavourable clinical outcome, due to the severity of the initial haemorrhage. CONCLUSIONS: Surgical exclusion of the anterior cranial fossa DAVFs still represents the gold standard for such lesions, due to low post-operative morbidity and to complete protection against future rebleedings; endovascular techniques may help the surgeon in complex cases.

Leksell Gamma Knife for pediatric and adolescent cerebral arteriovenous malformations: results of 100 cases followed up for at least 36 months.

OBJECT: The goal of this study was to evaluate advantages, risks, and failures of Gamma Knife radiosurgery (GKRS) in a large series of pediatric and adolescent patients with cerebral arteriovenous malformations (cAVMs) who were followed up for at least 36 months. METHODS: Since February 1993, 100 pediatric and adolescent patients (≤ 18 years of age) with cAVMs have undergone GKRS at the authors' institution and were followed up for at least 36 months. Forty-six patients were boys and 54 were girls; the mean age was 12.8 years (range 3-18 years). Hemorrhage, either alone or combined with seizure, was the clinical onset in 70% of cases. The mean pre-GK cAVM volume was 2.8 ml; 92% of cAVMs were Spetzler-Martin (S-M) Grades I-III. Most lesions (94%) were in eloquent or deep-seated brain regions, according to S-M classification. The parameters for mean and range in treatment planning were prescription isodose 53.8% (40%-90%); prescription dose (PD) 20.2 Gy (9.0-26.4 Gy); maximal dose (MD) 37.8 Gy (18-50 Gy); and number of shots 4.7 (1-17). On the day of GKRS, stereotactic CT or stereotactic MRI and digital subtraction angiography were used. RESULTS: Obliteration rate (OR) was angiographically documented in 75 of 84 cases (89.3%) after single-session GKRS, with actuarial ORs at 3 and 5 years of 68.0% and 88.1%, respectively. A repeat treatment was performed in 7 patients (6 with obliteration), and 16 patients with cAVMs underwent staged treatment (9 of them were angiographically cured). Thus, the overall OR was 90%, with actuarial ORs at 3, 5, and 8 years of 59.0%, 76.0%, and 85.0%, respectively. Permanent symptomatic GK-related complications were observed in 11% of cases, with surgical removal of enlarged mass seen on post-RS imaging needed in 5 cases. Hemorrhage during the latency period occurred in 9% of patients, but surgical evacuation of the hematoma was required in only 1 patient. One patient died due to rebleeding of a brainstem cAVM. Radiosurgery outcomes varied according to cAVM sizes and doses: volumes ≤ 10 ml and PDs > 16 Gy were significantly associated with higher ORs and lower rates of permanent complication and bleeding during the latency period. CONCLUSIONS: The data from this study reinforce the conclusion that GKRS is a safe and effective treatment for pediatric and adolescent cAVMs, yielding a high OR with minimal permanent severe morbidity and no mortality. The very low frequency of severe hemorrhages during the latency period further encourages a widespread application of RS in such patients. Univariate analysis found that modified RS-based cAVM score, nidus volume, PD, integral dose, S-M grade, and preplanned treatment (the last 2 parameters were also confirmed on multivariate analysis) significantly influenced OR. Lower S-M grades and single-session planned treatments correlated with shorter treatment obliteration interval on univariate analysis. This statistical analysis suggests that a staged radiosurgical treatment should be planned when nidus volume > 10 ml and/or when the recommended PD is ≤ 16 Gy.

Complex developmental abnormality of the atlas mimicking a Jefferson fracture: Diagnostic tips and tricks.

Congenital atlas abnormalities are rare - often asymptomatic - findings, not requiring any specific treatment. They are frequently discovered, by chance, in trauma patients, in the course of the radiological work flow at the Emergency Department. In these cases they may represent a diagnostic challenge, since physicians are expected to differentiate them from complex C1 fractures (isolated Jefferson's fractures or associated with Anderson and d'Alonzo's fractures) requiring surgical treatment. Although difficult to identify, a correct diagnosis is mandatory in order to optimize the patient's treatment. In this article we report a case of congenital atlas abnormality, and discuss the tips and tricks to make a correct differential diagnosis through the most appropriate clinical and radiological work flow.

Optical crosstalk in single photon avalanche diode arrays: a new complete model.

One of the main issues of Single Photon Avalanche Diode arrays is optical crosstalk. Since its intensity increases with reducing the distance between devices, this phenomenon limits the density of integration within arrays. In the past optical crosstalk was ascribed essentially to the light propagating from one detector to another through direct optical paths. Accordingly, reflecting trenches between devices were proposed to prevent it, but they proved to be not completely effective. In this paper we will present experimental evidence that a significant contribution to optical crosstalk comes from light reflected internally off the bottom of the chip, thus being impossible to eliminate it completely by means of trenches. We will also propose an optical model to predict the dependence of crosstalk on the distance between devices.