Tuberculum Sellae Meningioma: Report of Two Cases and Literature Review of Limits of the Transcranial and Endonasal Endoscopic Approaches.

BACKGROUND: Tuberculum sellae (TS) meningioma is one of the most frequent meningiomas of the anterior skull base. Herein we perform a review of the literature concerning the preferred surgical approaches to TS meningiomas; in addition, we describe two explicative cases, operated on by our group using different approaches, with the aim to critically revise surgical indications and contraindications. METHODS: In October 2021, two female patients with tuberculum sellae meningioma were treated at the Policlinico Gemelli of Rome. The patients presented with visual deterioration. Surgery was performed using the fronto-temporal approach and transsphenoidal approach. The visual function before and after surgery was evaluated as the main outcome parameter of the surgical treatment of these tumors. CONCLUSIONS: Tuberculum sellae meningioma can be safely resected using the transcranial approach and the transsphenoidal endoscopic approach with preservation and even improvement of visual function after surgery. The relationship of the tumor with the optic nerves, optic canal, and anterior cerebral artery complex are important issues that have to be considered when dealing with tuberculum sellae meningioma. Both transcranial and endonasal approaches, in experienced hands, can allow complete resection of the lesion.

Toward the End of the Funnel: The Ventriculus Terminalis-The State of Art of an Ancient Entity with a Recent History.

PURPOSE: The ventriculus terminalis (VT), also called the fifth ventricle, is a small cavity containing cerebrospinal fluid (CSF) that is in the conus medullaris in continuity with the central canal of the spinal cord. In adults, persistent VT is a very rare entity, and the diagnosis is incidental in most cases. Rarely, VT may become symptomatic for still-uncertain reasons but most often for its cystic dilatation. The management of these selected cases is still controversial and sometimes associated with unsatisfactory outcomes. METHODS: We performed a critical review of the existing literature on the management of symptomatic VT in adults. The etiology, pathophysiology, and treatment of VT are presented and discussed, focusing on the best timing for surgery. RESULTS: Conservative management, marsupialization, or the placement of a T drain have been reported. The existing classifications describe the most correct approach for each clinical presentation, but scarce importance has been given to the delay from symptoms' onset to surgical treatment. CONCLUSION: Although different cases have been described in the literature, this rare pathology remains unknown to most neurosurgeons.

Cystic Dilatation of the Ventriculus Terminalis: Examining the Relevance of the Revised Operative Classification Through a Systematic Review of the Literature, 2011-2021.

The literature features limited evidence on the natural history of the cystic dilatation of the ventriculus terminalis (CDVT) and its response to treatment. The goal of this study is to ascertain which impact the revised operative classification of CDVT had on the management of patients diagnosed over the past 10 years.Ten new clinical articles presenting a total of 30 cases of CDVT were identified and included for qualitative analysis. Two take-home messages can be identified: (1) Adequate consideration should be given to designing national pathways for referral to tertiary centers with relevant expertise in the management of lesions of the conus medullaris, and (2) we suggest that type Ia should be, at least initially, treated conservatively, whereas we reckon that the signs and symptoms described in types Ib, II, and III seem to benefit, although in some patients only partially, from surgical decompression in the form of cystic fenestration, cyst-subarachnoid shunting, or both.While the level of evidence gathered in this systematic review remains low because the literature on CDVT consists only of retrospective studies based on single-center series (level of evidence 4 according to the Oxford Centre for Evidence-Based Medicine (OCEBM)), the strength of recommendation for adopting the revised operative classification of CDVT is moderate.

Quantitative Anatomical Studies in Neurosurgery: A Systematic and Critical Review of Research Methods.

BACKGROUND: The anatomy laboratory can provide the ideal setting for the preclinical phase of neurosurgical research. Our purpose is to comprehensively and critically review the preclinical anatomical quantification methods used in cranial neurosurgery. METHODS: A systematic review was conducted following the PRISMA guidelines. The PubMed, Ovid MEDLINE, and Ovid EMBASE databases were searched, yielding 1667 papers. A statistical analysis was performed using R. RESULTS: The included studies were published from 1996 to 2023. The risk of bias assessment indicated high-quality studies. Target exposure was the most studied feature (81.7%), mainly with area quantification (64.9%). The surgical corridor was quantified in 60.9% of studies, more commonly with the quantification of the angle of view (60%). Neuronavigation-based methods benefit from quantifying the surgical pyramid features that define a cranial neurosurgical approach and allowing post-dissection data analyses. Direct measurements might diminish the error that is inherent to navigation methods and are useful to collect a small amount of data. CONCLUSION: Quantifying neurosurgical approaches in the anatomy laboratory provides an objective assessment of the surgical corridor and target exposure. There is currently limited comparability among quantitative neurosurgical anatomy studies; sharing common research methods will provide comparable data that might also be investigated with artificial intelligence methods.

Sacrifice of Involved Nerve Root during Surgical Resection of Foraminal and/or Dumbbell Spinal Neurinomas.

Even if usually needed to achieve the gross total resection (GTR) of spinal benign nerve sheath tumors (NSTs), nerve root sacrifice remains controversial regarding the risk of neurological deficit. For foraminal NSTs, we hypothesize that the involved root is poorly functional and thus can be safely sacrificed. All spinal benign NSTs with foraminal extension that underwent surgery from 2013 to 2021 were reviewed. The impacts of preoperative clinical status and patient and tumor characteristics on long-term outcomes were analyzed. Twenty-six patients were included, with a mean follow-up (FU) of 22.4 months. Functional motor roots (C5-T1, L3-S1) were involved in 14 cases. The involved nerve root was routinely sacrificed during surgery and GTR was obtained in 84.6% of cases. In the functional root subgroup, for patients with a pre-existing deficit (n = 5/14), neurological aggravation persisted in one case at last FU (n = 1/5), whereas for those with no preop deficit (n = 9/14), a postoperative deficit persisted in one patient only (n = 1/9). Preoperative radicular pain was the only characteristic significantly associated with an immediate postoperative motor deficit (p = 0.03). The sacrifice of an involved nerve root in foraminal NSTs seems to represent a reasonable and relevant option to resect these tumors, permitting one to achieve tumor resection in an oncologic fashion with a high rate of GTR.

Pure lumbar foraminal cavernous malformation in a patient with Cowden syndrome-a case report.

Background: Spinal cavernous malformations (CMs) are slow flow venous vascular malformations which can occur in vertebral body, epidural space or intramedullary. Only 7 cases were described confined in foraminal space. Cowden syndrome (CS) is an autosomal dominant genodermatosis that may present and develop vascular malformations, which include CM. They were found intracranial, and rarely visceral. No association with spinal CM and CS has been reported to date. Case Description: A 46-year-old patient with CS came to our attention with a L5 radiculopathy secondary to a slow-growing intra-foraminal mass lesion, with bony scalloping. The lesion mimicked a schwannoma at radiological imaging and intraoperative findings. En bloc resection with root sacrifice was performed. No excessive bleeding was observed. After surgical resection, anatomical pathology demonstrated a CM. Postoperative review of neuroimaging revealed features compatible with chronic resolved peripheral haemorrage. The patient had no intra- or post-operative complications, and an immediate relief of symptoms was observed. The follow-up spinal magnetic resonance imaging (MRI) obtained 3 months after surgery, demonstrated the total removal of the lesion. Conclusions: CMs can be confined to foraminal space and associated with CS. They may mimic peripheral nerve sheath tumors. Diagnosis may be challenging. No pathognomonic imaging features were found. Complete resection with root sacrifice seems to be a safe and efficient technique.

Machine learning model prediction of 6-month functional outcome in elderly patients with intracerebral hemorrhage.

Spontaneous intracerebral hemorrhage (ICH) has an increasing incidence and a worse outcome in elderly patients. The ability to predict the functional outcome in these patients can be helpful in supporting treatment decisions and establishing prognostic expectations. We evaluated the performance of a machine learning (ML) model to predict the 6-month functional status in elderly patients with ICH leveraging the predictive value of the clinical characteristics at hospital admission. Data were extracted by a retrospective multicentric database of patients ≥ 70 years of age consecutively admitted for the management of spontaneous ICH between January 1, 2014 and December 31, 2019. Relevant demographic, clinical, and radiological variables were selected by a feature selection algorithm (Boruta) and used to build a ML model. Outcome was determined according to the Glasgow Outcome Scale (GOS) at 6 months from ICH: dead (GOS 1), poor outcome (GOS 2-3: vegetative status/severe disability), and good outcome (GOS 4-5: moderate disability/good recovery). Ten features were selected by Boruta with the following relative importance order in the ML model: Glasgow Coma Scale, Charlson Comorbidity Index, ICH score, ICH volume, pupillary status, brainstem location, age, anticoagulant/antiplatelet agents, intraventricular hemorrhage, and cerebellar location. Random forest prediction model, evaluated on the hold-out test set, achieved an AUC of 0.96 (0.94-0.98), 0.89 (0.86-0.93), and 0.93 (0.90-0.95) for dead, poor, and good outcome classes, respectively, demonstrating high discriminative ability. A random forest classifier was successfully trained and internally validated to stratify elderly patients with spontaneous ICH into prognostic subclasses. The predictive value is enhanced by the ability of ML model to identify synergy among variables.

Minimally Invasive Decompression with Posterior Elements Preservation Versus Laminectomy and Fusion For Lumbar Degenerative Spondylolisthesis: A Systematic Review and Meta-Analysis of Surgical, Clinical and Radiological Outcomes.

INTRODUCTION: Chronic low back pain can be due to many different causes, including degenerative spondylolisthesis (DS). For patients who do not respond to conservative management, surgery remains the most effective treatment. Open laminectomy alone and laminectomy and fusion (LF) for DS have been widely investigated, however, no meta-analyses have compared minimally invasive decompression with posterior elements preservation (MID) techniques and LF. Minimally invasive techniques might provide specific advantages that were not recognized in previous studies that pooled different decompression strategies together. MATERIALS AND METHODS: This was a systematic review and meta-analysis, according to the PRISMA statement, of comparative studies reporting surgical, clinical and radiological outcomes of MID and LF for DS. RESULTS: A total of 3202 papers were screened and 7 were finally included in the meta-analysis. MID is associated with a shorter surgical duration and hospitalization stay, and a lower intraoperative blood loss and residual low back pain; however, the residual disability grade was lower in the LF group. Complication rates were similar between the two groups. The rate of adjacent segment degeneration was lower in the MID group, whereas data on radiological outcomes were heterogeneous and not suitable for data-pooling. CONCLUSIONS: This meta-analysis suggests that MID might be considered as an effective alternative to LF for DS. Further clinical trials will be needed to confirm our results, better investigate radiological outcomes, and identify patient subgroups that may benefit the most from specific techniques.

X-ray exposure in odontoid screwing for Anderson type II fracture: comparison between O-arm and C-arm-assisted procedures.

BACKGROUND: Since the odontoid fractures become increasingly common in the aging population, technical improvements are even more needed. The odontoid screwing has been progressively preferred by many surgeons in type II fractures according to the Anderson-D'Alonzo classification system. However, X-ray exposure remains an issue for surgeons and OR staff members. The aim of the present study was to investigate the feasibility of using the O-Arm for odontoid screwing comparing the radiation exposure to the standard C-Arm. METHODS: Patients consequently referred to our center for odontoid type II fractures, from January 2018 to April 2019, eligible for odontoid screwing were enrolled in the present study. They were operated on using either C-Arm or O-Arm-assisted procedures. The surgical duration, number of acquisitions, global X-ray exposure for the OR staff and patients, and screw placement accuracy were evaluated. RESULTS: No differences in terms of patients' demographical characteristics and surgical duration were reported. The number of acquisitions, intraoperative and global X-ray dose, for the OR staff and patients, was lower in O-Arm-assisted procedures (p < 0.05). The screws were all well positioned. CONCLUSIONS: Since the surgical outcomes seem to be similar using the O-Arm for odontoid screwing, the lower X-ray exposure and the possibility for checking the instrumentation positioning with 3D reconstructions before leaving the OR should be considered.

Multimodal Management of Aggressive Recurrent Aneurysmal Bone Cyst of Spine: Case Report and Review of Literature.

BACKGROUND: Different treatment options have been proposed for aneurysmal bone cysts (ABCs) with sclerotherapy favored as primary treatment and surgery remaining the mainstay of treatment in case of compression of neural structures. Recurrent spinal ABCs are burdened by increased risk of spinal deformity and instability, further complicating the management of these cases. CASE DESCRIPTION: A 15-year-old boy presented with acute symptoms and signs of spinal cord compression due to a large thoracic ABC. Subtotal resection of the lesion achieved optimal decompression of neural structures with good neurologic recovery, but the remnant of the lesion rapidly grew with recurrent spinal cord compression after 40 days. The patient underwent total surgical resection with full neurologic recovery. Unfortunately, recurrence of the lesion was documented at 3-months' follow-up. This was successfully treated with percutaneous injection of hydroxyapatite cement. Two years' follow-up ruled out any further recurrence of the lesion. Furthermore, spinal deformity and instability were also excluded. CONCLUSIONS: Percutaneous sclerotherapy with hydroxyapatite cement proved to be highly effective and safe in the treatment of spinal ABC, though surgery remains mandatory in case of spinal cord compression. The main advantage of sclerotherapy with hydroxyapatite cement seems to be the capacity to regenerate bone with normal radiologic features.