A novel, reusable, realistic neurosurgical training simulator for cerebrovascular bypass surgery: Iatrotek® bypass simulator validation study and literature review.

Background: Microanastomosis is a challenging technique requiring continuous training to be mastered. Several models have been proposed, but few effectively reflect a real bypass surgery; even fewer are reusable, most are not easily accessible, and the setting is often quite long. We aim to validate a simplified, ready-to-use, reusable, ergonomic bypass simulator. Methods: Twelve novice and two expert neurosurgeons completed eight End-to-End (EE), eight End-to-Side (ES), and eight Side-to-Side (SS) microanastomoses using 2-mm synthetic vessels. Data on time to perform bypass (TPB), number of sutures and time required to stop potential leaks were collected. After the last training, participants completed a Likert Like Survey for bypass simulator evaluation. Each participant was assessed using the Northwestern Objective Microanastomosis Assessment Tool (NOMAT). Results: When comparing the first and last attempts, an improvement of the mean TPB was registered in both groups for the three types of microanastomosis. The improvement was always statistically significant in the novice group, while in the expert group, it was only significant for ES bypass. The NOMAT score improved in both groups, displaying statistical significance in the novices for EE bypass. The mean number of leakages, and the relative time for their resolution, also tended to progressively reduce in both groups by increasing the attempts. The Likert score expressed by the experts was slightly higher (25 vs. 24.58 by the novices). Conclusions: Our proposed bypass training model may represent a simplified, ready-to-use, reusable, ergonomic, and efficient system to improve eye-hand coordination and dexterity in performing microanastomoses.

Calcified Epidural Hematoma after Conservative Treatment of Acute Epidural Hematoma in the Pediatric Population: A Systematic Review.

BACKGROUND: Acute traumatic epidural hematoma (EDH) is a complication in 2-3% of pediatric head injuries. Surgery is mandatory in symptomatic cases; otherwise, conservative treatment is a valid approach, especially in the pediatric population. Ossified epidural hematomas (OEHs) have been reported in the pediatric population as a rare complication of conservative EDH management, although the exact incidence remains unknown. The progressive increase in conservative management may lead to increases in the OEH incidence over the next few years. Our study aimed to systematically review OEH incidence, management strategies, characteristics (thickness, inner/outer calcifications), complication rates, time to surgery after the EDH diagnosis, and clinical outcomes. SUMMARY: A systematic review was conducted in accordance with the PRISMA guidelines. Studies reporting diagnoses and clear descriptions of OEH after EDH in pediatric patients were considered eligible. Sixteen studies, including 18 pediatric patients aged 0-18 years, were included. Head trauma was the most common cause of OEH. Seven (38.8%) OEHs were treated less than 1 month after EDH diagnosis. Surgery was performed in 17 cases (94.44%), while 1 asymptomatic case (5.56%) was managed conservatively. KEY MESSAGES: Surgery was the most commonly used treatment for OEH. Data for conservative treatment of OEH are limited. Magnetic resonance imaging or ultrasound within the first 2 months, to check for EDH resolution, may be crucial to rule out complications in pediatric patients.

Long term results of Dorsal Root Entry Zone (DREZ) lesions for the treatment of intractable pain: A systematic review of the literature on 1242 cases.

BACKGROUND: Different Dorsal root entry zone (DREZ) lesion techniques have been reported as effective treatment for intractable painful conditions, though with contradictory results. Overall, good results were reported especially in specific conditions, such as pain due to brachial plexus avulsion, spinal cord injuries and oncological pain management. However, data on long term results in different clinical conditions are still missing. OBJECTIVE: This study aims to systematically review the pertinent literature to evaluate indications, clinical outcomes, and complications of DREZ lesion (DREZotomy), in chronic pain management. METHODS: A systematic literature review was conducted according to the PRISMA statement. Papers on DREZotomy for chronic pain in cancer, brachial plexus avulsion, spinal cord injury, post herpetic neuralgia, and phantom limb pain were considered for eligibility. For each category we further identified two sub-group according to the length of follow up: medium term and long term follow up (more than 3 years) respectively. RESULTS: 46 papers, and 1242 patients, were included in the present investigation. When considering long term results DREZotomy provided favorable clinical outcomes in brachial plexus avulsion and spinal cord injury, in 60.8% and 55.8% of the cases respectively. Conversely, the success rate was 35.3% in phantom limb pain and 28.2% in post herpetic neuralgia. A poor clinical outcome was reported in over than 25% of the patients suffering from phantom limb pain, post herpetic neuralgia and spinal cord injury. The mean complications rate was 23.58%. While BPA and SCI patients presented stable improvement over time, good outcomes among PHN and PLP groups dropped by - 46.2%; and - 14.7% at long term follow up respectively. CONCLUSION: DREZotomy seems to be an effective treatment for chronic pain conditions, especially for brachial plexus avulsion, spinal cord injury and intractable cancer/post-radiation pain. According to the low level of evidence of the pertinent literature, further studies are strongly recommended, to better define potential benefits and limitations of this technique.

"Single-step" resection and cranio-orbital reconstruction for spheno-orbital metastasis with custom made implant. A case report and review of the literature.

INTRODUCTION AND IMPORTANCE: Brain metastasis involving the skull base is a rare complication of malignant tumors. Besides radiotherapy, surgical treatment is a therapeutical option even though it may apply complex technical procedures that may delay complementary therapies. However, in recent days, the innovation of custom-made implants allows treating selected patients with fewer complications and better results. CASE PRESENTATION: We describe a single case of a complex fronto-orbital skull base metastasis requiring skull bone reconstruction that we treated with a single-step surgery and custom-made implant. Our procedure consists of two steps: in the first one, we perform a "virtual" craniotomy on a 3D phantom model previously built on a high-resolution bone CT scan. In the second step, the actual surgical procedure, the patient undergoes the resection and reconstruction of the cranial defect with an implant of PMMA custom-made cranioplasty. A three-month clinical and radiological follow-up is reported, which documented the extent of resection and good aesthetic results. CLINICAL DISCUSSION: In our case, we performed a skull reconstruction of cranio-orbital region with macroscopic gross-total resection of the tumor. Complementary radiotherapy was obtained after one month. Three-month follow-up showed good esthetic results and progression-free disease. A recent review of the literature is provided to discuss different reconstruction techniques. CONCLUSION: "Single-Step" resection and custom-made reconstruction is a relatively new technique that could be helpful not only for benign tumors, which remains its main application but also in selected cases of malignant tumors when immediate reconstruction and faster complementary treatments are needed.

Synchronized "One-Step" Resection and Cranio-Orbital Reconstruction for Spheno-Orbital Lesions With Custom Made Implant.

BACKGROUND: In the last few years, skull base tumors involving the fronto-orbital region have been approached with complex, invasive, and time-consuming cranial reconstruction techniques. On the other hand, recent custom-made implants allow easier and faster procedures, with excellent aesthetic results. The authors propose an easy surgical-planned protocol with a synchronized "one-step" resection and reconstruction of these complex lesions, with a preformed poly-methyilmethacrylate (PMMA) cranioplasty. METHODS: Our technique consists of a 2-phases procedure. In the first one, the so-called "virtual" phase, the authors get a tailored 3D-PMMA model based on high-resolution (HR) CT-scans of the patient's skull. Afterward, the authors perform the planned craniotomy on the 3D-PMMA model with the assistance of intraoperative navigation system. Therefore, a further CT-scan of the resected model is performed to develop the final implant. In the second phase, the "surgical phase," a single procedure consisting in a cranial resection and custom reconstruction is performed with the assistance of stealth-navigation. The authors describe 6 cases of complex fronto-orbital-sphenoidal benign tumors that required skull reconstruction. All patients were examined 3 months after surgery through cosmetic (facial and eyes symmetry and globe position) and ophthalmology tests (visual field, visual impairment, and diplopia). Postsurgical HR CT-scans of the head and MRI-scans of the brain documented a total resection of the tumor and an optimal accuracy of skull reconstruction. RESULTS: In all cases, the authors obtained a highly accurate skull reconstruction following cranio-orbital tumor resection, with a less aggressive and faster procedure compared to autologous bone graft. Final cosmetic and functional results were excellent, with good results in cases of presurgical exophthalmos and orbital asymmetry. None of the patients developed implant-related complications. CONCLUSIONS: The "one-step" resection and reconstruction of benign tumors involving the spheno-orbital region with neuronavigation assistance is a technique that allows an accurate tumor removal and a cranial-bone reconstruction within a single surgical procedure, with fewer complications and excellent cosmetic and functional results.

Incidence of hemorrhagic cerebrovascular disease due to vascular malformations during the COVID-19 national quarantine in Italy.

BACKGROUND: hemorrhagic cerebrovascular disease due to vascular malformations represents an emergency for neurosurgery and neuro-interventional departments. During the COVID-19 pandemic, a dramatic reduction in the number of hospitalizations for acute myocardial infarction or stroke and a larger time interval from symptom onset to first medical contact have been reported. This study aims to verify the hypothesis that there would also have been a reduction of admissions for hemorrhagic cerebrovascular disease during the Italian lockdown. MATERIAL AND METHOD: s A multicenter, observational survey was conducted to collect data on hospital admissions for hemorrhagic cerebrovascular disease due to vascular malformations throughout two-months (March 15th to May 15th); the years 2020 (COVID-19 Italian lockdown), 2019 and 2018 were compared. Cases were identified by ICD-9 codes 430, 431, 432.1, 432.9, 747.81 of each hospital database. The statistical significance of the difference between the event rate of one year versus the others was evaluated using Poisson Means test, assuming a constant population. RESULTS: During the 2020 lockdown, the total number of admissions for hemorrhagic cerebrovascular disease was 92 compared with 116 in 2019 and 95 in 2018. This difference was not significant. GCS upon admission was 3-8 in 44 % of cases in 2020 (41 patients), 39.7 % in 2019 (46 patients) and 28 % in 2018 (27 patients). CONCLUSION: Reduction of admissions for hemorrhagic cerebrovascular disease due to vascular malformations during the COVID-19 lockdown was not confirmed. Nevertheless, some patients reached the emergency rooms only several days after symptoms onset, resulting in a worse clinical condition at admission.

Ruptured Isolated Aneurysm of a Coronal Branch of the Anterior Spinal Artery: Case Report and Discussion of Treatment Strategies.

BACKGROUND: Isolated spinal artery aneurysms are an extremely rare cause of subarachnoid hemorrhage. A limited number of case reports and case series have been reported in the literature. Treatment options include conservative management, surgical clipping/trapping, and endovascular procedures. Owing to the uncertain natural history of these lesions, there is no consensus about the optimal treatment. CASE DESCRIPTION: A 64-year-old man presented with subarachnoid hemorrhage from a ruptured anterior spinal artery aneurysm at the C1 level. Following initial conservative management, surgical treatment was proposed owing to an increase in lesion size at angiographic follow-up. A partially thrombosed aneurysm was found during surgery, suggesting that spontaneous resolution of the aneurysm was occurring. Despite initial worsening of neurological symptoms, the patient gradually recovered after rehabilitation. CONCLUSIONS: Treatment decisions for spinal aneurysms should be made on a case-by-case basis, the goal being to offer the patient the best option, while avoiding exposure to unnecessary invasive procedures. As spontaneous resolution of a spinal artery aneurysm is unpredictable, our case highlights the importance of performing a perioperative vascular study if surgery is planned.

Epidermoid cyst of the anterior clinoid process: report of a unique finding and literature review of the middle cranial fossa locations.

BACKGROUND: Epidermoids cysts are relatively rare, benign, congenital tumours, representing from 0.3% to 1.8% of all intracranial lesions. When extradural, they are most commonly reported in the temporal or parietal bones as intradiploic lesions; when intradural their most common location is the cerebellopontine angle and less frequently the middle cranial fossa. Herein we present a unique case of an extradural-intraosseous epidermoid cyst of the anterior clinoid process, integrating our single-case experience into a focused literature review of these lesions, when located in the middle cranial fossa. CASE DESCRIPTION: A 49 years old man came to our attention with history of head trauma. Urgent brain CT and elective brain MRI showed imaging suggestive for an anterior clinoid process epidermoid cyst. Through a pterional approach, the lesion was completely removed with microsurgical endoscope assisted technique. MRI at one year follow up showed no recurrence. METHODS: Current literature on epidermoid cysts located in middle cranial fossa was reviewed. A total of 22 papers, containing 70 epidermoid cyst were selected for the review. Symptoms at presentation; anatomic location; surgical approach; extent of resection and recurrence; outcome after surgery and at follow up were analysed for each case. CONCLUSIONS: In the 70 published cases of middle fossa epidermoid cysts, the majority presented with trigeminal neuralgia. Most of the cases were operated through a pterional approach, while recent literature showed an increasing interest in endonasal endoscopic techniques. Subtotal resection is not a straight predictive value for recurrence; post-operative neurological deficits incidence is low and generally resolve at follow-up.