Effect of extracranial-intracranial bypass revascularization procedure in acute stroke after endovascular failure: the EIRASP study protocol.

BACKGROUND: Intravenous thrombolysis and endovascular reperfusion represent nowadays the standard treatment for acute ischemic stroke. However, ineffective reperfusion may occur, representing a major negative prognostic factor on clinical outcome. Extracranial-intracranial (EC-IC) bypass revascularization procedure in an acute setting appears as a promising tool to increase reperfusion rates and improve clinical outcome in a highly selected population refractory or ineligible for standard reperfusion therapies. METHODS: The Extracranial-Intracranial Revascularization for Acute Stroke - Parma (EIRASP) study is an observational, prospective, single-center, study (protocol 203/2020/OSS/AOUPR). Patients admitted for an acute ischemic anterior circulation stroke due to large vessels occlusion and refractory or ineligible for standard reperfusion therapies will be submitted to an extracranial-intracranial bypass revascularization procedure when fulfilling all clinical and radiological inclusion criteria. The primary outcome will be the functional outcome (modified Rankin Scale and NIHSS score) at 3 months after the surgical procedure. Secondary outcome will include the evaluation of clinical and surgical complications rates, quantitative monitoring of perfusion parameters, and further functional and survival rates. RESULTS: Despite promising data regarding the feasibility and the favorable outcome of urgent EC-IC bypass revascularization procedure in selected patients suffering an acute ischemic stroke are emerging in literature, no studies to date have prospectively explored the real potential of this technique. CONCLUSIONS: The EIRASP study aims to provide further and stronger methodological evidence of the benefit of urgent EC-IC bypass revascularization procedure in acute ischemic stroke.

Suboccipital telovelar approach for microsurgical resection of a hemorrhagic brainstem cavernous malformation in an infant - how I do it.

BACKGROUND: The resection of brainstem cavernous malformations pose an extreme neurosurgical challenge, especially in infants as very few cases are reported in the literature. The optimal management still needs to be defined, demanding a tailored approach on an individual basis. METHOD: Herein, we report our management and surgical technique for the resection of hemorrhagic pontine cavernous malformation in a 9-month-old infant through a suboccipital telovelar approach. CONCLUSION: The resection of hemorrhagic brainstem cavernomas is feasible and safe even in selected infant patients. The timing and the microsurgical technique are of paramount importance for the prevention of postoperative deficits.

Remodulation of neurosurgical activities in an Italian region (Emilia-Romagna) under COVID-19 emergency: maintaining the standard of care during the crisis.

BACKGROUND: The impact of COVID-19 outbreak in the neurosurgical practice has been dramatic, imposing several limitations. The aim of this study is to present how the neurosurgical departments of Emilia-Romagna, a northern Italian region, have re-set their organization to maintain the higher standard of care as possible. METHODS: All operative room and outpatient activities performed during the COVID-19 emergency in the neurosurgical department of Emilia-Romagna have been collected and compared to the means of the same timeframe in 2018 and 2019. RESULTS: In 2020, 205 surgical procedures and 466 outpatient consultations have been performed, representing respectively 28.8% and 26.4% of the previous biennium. The most of OR procedures had been emergencies/urgencies and oncological patients (113 and 66 vs. 164.5 and 84.5, respectively, of the previous biennium), while elective surgeries decrease up to -97.1%, as for spinal nerves and endoscopic skull base procedures. The patients phone contacts and telemedicine evaluations of their examinations have permitted to reduce the hospital access for outpatients of 75.6%, but these modalities have, also, permitted to follow-up a large number of cases. CONCLUSIONS: The outbreak of COVID-19 has imposed several limits to our current practice, however this should not represent an excuse to reduce the standard of care. In our experience, the net integration of different local centers has permitted for each of them to effectively cope the crisis, managing the local cases requiring a prompt surgery and keeping the care continuity with already discharged patients.

Capillary Venous Malformation With Secondary Aneurysmal Bone Cyst of Temporal Bone.

Aneurysmal bone cysts (ABCs) arising from vascular malformation are extremely rare, and none have been reported in the literature in English till now. We report a very rare case of secondary ABC of left temporal bone in a 5-year-old Caucasian boy who presented with a left sudden facial palsy associated with a painless non-tender mass of the left temporo-parietal region. The computed tomography (CT) and magnetic resonance imaging (MRI) features were suggestive of ABC secondary to a capillary venous malformation, with concurrent involvement of the squamous, mastoid, and petrous portions of the temporal bone. Surgical resection was performed. On follow-up, the patient was found to be doing well.

Subtemporal-Transtentorial Approach for Microsurgical Resection of Hemorrhagic Ambient Cistern Arteriovenous Malformation.

Arteriovenous malformations (AVMs) of the ambient cistern are an extremely rare and complex subgroup of vascular malformation, representing a clinical challenge due to the deep-seated, highly eloquent anatomic location and the debilitating, life-threatening consequences related to hemorrhagic presentation and surgical morbidity. Ultimately, a tailored treatment, based on the presenting symptoms, AVM angioarchitecture, and annual risk of hemorrhage should be discussed among a multidisciplinary team to find the best individualized strategy balancing between the pros and cons of each approach. In Video 1, we present the case of a 60-year-old man with a hemorrhaged AVM of the right ambient cistern, present the pros and cons of each possible treatment strategy, and illustrate the successful resection of this lesion through a subtemporal-transtentorial microsurgical approach.

Spontaneous Subarachnoid Haemorrhage in Spinal Hemangioblastoma: Illustrative Case and Discussion of a Pathophysiological Hypothesis.

Spontaneous non-aneurysmal subarachnoid haemorrhage (naSAH) is an unusual finding that could be burdened by significant mortality and morbidity rates. Rare pathologies and delayed diagnosis could be advocated as responsible of unfavourable outcomes. Herein, we describe an exceedingly rare giant lumbar spinal hemangioblastoma (80 × 23 mm) presenting as an intracranial naSAH. Based on our radiological and clinical findings a pathophysiological hypothesis linking intracranial naSAH to venous hypertension was discussed for the first time even among lumbar spinal tumors. Although rare, unusual causes should be investigated in presence of radiological atypical finding as a prompt evaluation and treatment could be needed.

Custom-made trabecular titanium implants for the treatment of lumbar degenerative discopathy via ALIF/XLIF techniques: rationale for use and preliminary results.

PURPOSE: Related to the development and diffusion of ALIF and XLIF, it is possible to correct sagittal malalignment in selected cases of lumbar degenerative discopathy with a relatively low invasiveness. Still, the malposition or the inappropriate size of the implanted cages may lead to the subsidence of the vertebral endplates with loss of correction as well as a decrease in the potential to restore spinal biomechanics in the long run. The aim of this study is to evaluate safety, feasibility, and preliminary clinical and radiological results when using custom-made, trabecular titanium cages in ALIF and XLIF procedures. METHODS: We prospectively evaluated 18 consecutive patients who underwent either an ALIF or an XLIF procedure with the implant of a custom-made, trabecular titanium cage for lumbar degenerative disease with sagittal imbalance, with a minimum of 1-year clinical and radiological follow-up. RESULTS: After a mean follow-up of 14 months, the Oswestry score dropped to a mean of 13 from a preoperative value of 48 (p < 0.0001). Lumbar lordosis was significantly improved, especially in the lower lumbar segment L4-S1 (+ 11 ± 7°; p < 0.0001). No cases of subsidence were noted. CONCLUSIONS: Custom-made, trabecular titanium cages allowed a segmental, steady, durable sagittal correction via ALIF and XLIF approaches. The absence of cage subsidence at 1 year encourages further studies on a larger cohort with longer follow-up. These slides can be retrieved under Electronic Supplementary Material.

Strokectomy and Extensive Cerebrospinal Fluid Drainage for the Treatment of Space-Occupying Cerebellar Ischemic Stroke.

BACKGROUND: Cerebellar ischemia may lead to space-occupying edema, resulting in potentially fatal complications. Different surgical procedures are available to create space for the swollen ischemic brain; however, the type and timing of surgical treatments remain topics of debate in the literature. Here we report a case series of patients treated with a unilateral craniotomy to perform a cerebellar strokectomy and extensive cerebrospinal fluid (CSF) drainage without osteodural posterior fossa decompression. METHODS: We retrospectively analyzed the clinical and radiographic data of 11 patients with posterior fossa ischemia who underwent surgery at one of our institutions. A statistical analysis was performed to identify potential predictive factors for functional outcome. RESULTS: The mean patient age was 64.7 years. The involved vascular territory was the Posterior inferior cerebellar artery in 9 patients (82%) and the anterior inferior cerebellar artery/superior cerebellar artery in 2 patients (18%). The mean Glasgow Coma Scale score was 13.6 on admission, but 9.3 immediately before surgery. The surgical procedure was performed in a mean of 36.8 minutes after the radiologic diagnosis of space-occupying edema. Clinical outcome at 6 months was good (modified Rankin Scale [mRS] score ≤2) in 9 patients (82%). Surgery-related complications occurred in 2 patients (18%), and these was a single death (9%) not related to the procedure or posterior fossa compression. Matching patients with their mRS outcome evaluation, the sole variable significantly associated with good outcome was age at admission (62.1 vs. 76.5 years; P < 0.05). CONCLUSIONS: Unilateral suboccipital craniotomy with strokectomy and extensive CSF drainage may allow for satisfactory decompression of the ischemic posterior fossa with acceptable morbidity and mortality rates, especially in younger patients.

The Prognostic Roles of Gender and O6-Methylguanine-DNA Methyltransferase Methylation Status in Glioblastoma Patients: The Female Power.

BACKGROUND: Clinical and molecular factors are essential to define the prognosis in patients with glioblastoma (GBM). O6-methylguanine-DNA methyltransferase (MGMT) methylation status, age, Karnofsky Performance Status (KPS), and extent of surgical resection are the most relevant prognostic factors. Our investigation of the role of gender in predicting prognosis shows a slight survival advantage for female patients. METHODS: We performed a prospective evaluation of the Project of Emilia Romagna on Neuro-Oncology (PERNO) registry to identify prognostic factors in patients with GBM who received standard treatment. RESULTS: A total of 169 patients (99 males [58.6%] and 70 females [41.4%]) were evaluated prospectively. MGMT methylation was evaluable in 140 patients. Among the male patients, 36 were MGMT methylated (25.7%) and 47 were unmethylated (33.6%); among the female patients, 32 were methylated (22.9%) and 25 were unmethylated (17.9%). Survival was longer in the methylated females compared with the methylated males (P = 0.028) but was not significantly different between the unmethylated females and the unmethylated males (P = 0.395). In multivariate analysis, gender and MGMT methylation status considered together (methylated females vs. methylated males; hazard ratio [HR], 0.459; 95% confidence interval [CI], 0.242-0.827; P = 0.017), age (HR, 1.025; 95% CI, 1.002-1.049; P = 0.032), and KPS (HR, 0.965; 95% CI, 0.948-0.982; P < 0.001) were significantly correlated with survival. CONCLUSIONS: Survival was consistently longer among MGMT methylated females compared with males. Gender can be considered as a further prognostic factor.

Final results of the second prospective AIEOP protocol for pediatric intracranial ependymoma.

BACKGROUND: This prospective study stratified patients by surgical resection (complete = NED vs incomplete = ED) and centrally reviewed histology (World Health Organization [WHO] grade II vs III). METHODS: WHO grade II/NED patients received focal radiotherapy (RT) up to 59.4 Gy with 1.8 Gy/day. Grade III/NED received 4 courses of VEC (vincristine, etoposide, cyclophosphamide) after RT. ED patients received 1-4 VEC courses, second-look surgery, and 59.4 Gy followed by an 8-Gy boost in 2 fractions on still measurable residue. NED children aged 1-3 years with grade II tumors could receive 6 VEC courses alone. RESULTS: From January 2002 to December 2014, one hundred sixty consecutive children entered the protocol (median age, 4.9 y; males, 100). Follow-up was a median of 67 months. An infratentorial origin was identified in 110 cases. After surgery, 110 patients were NED, and 84 had grade III disease. Multiple resections were performed in 46/160 children (28.8%). A boost was given to 24/40 ED patients achieving progression-free survival (PFS) and overall survival (OS) rates of 58.1% and 68.7%, respectively, in this poor prognosis subgroup. For the whole series, 5-year PFS and OS rates were 65.4% and 81.1%, with no toxic deaths. On multivariable analysis, NED status and grade II were favorable for OS, and for PFS grade II remained favorable. CONCLUSIONS: In a multicenter collaboration, this trial accrued the highest number of patients published so far, and results are comparable to the best single-institution series. The RT boost, when feasible, seemed effective in improving prognosis. Even after multiple procedures, complete resection confirmed its prognostic strength, along with tumor grade. Biological parameters emerging in this series will be the object of future correlatives and reports.

Management of Subarachnoid Hemorrhage in Two Important Italian Political Leaders: A Paradigm of Ethical and Technological Evolution of Neurosurgery During the Past Half-Century.

For a curious and extraordinary coincidence, 5 of the 7 most relevant leaders of the Italian Communist Party (Partito Comunista Italiano, which was established in 1921, has been the biggest Communist Party in Western Countries) suffered a cerebral stroke. Cerebrovascular diseases afflicted also Stalin and Lenin, and a number of Presidents of the United States. We present the stories of 2 important Italian political leaders who shared both the leadership role of the major left Italian Party and the dramatic experience of a subarachnoid hemorrhage. Retracing their medical incidents, separated by 50 years of history, we show how a fatal medical disease has become neurosurgical and successfully cured thanks to the advances of neurosurgery, neuroradiology, and hospital organization. A neurologic disease that was disgraceful 50 years ago has lost any disquieting and embarrassing significance in the present time to the light of evolution of vascular neurosurgery.

Diagnostic potential of autofluorescence for an assisted intraoperative delineation of glioblastoma resection margins.

The intrinsic autofluorescence properties of biological tissues can be affected by the occurrence of histological and biochemical alterations induced by pathological processes. In this study the potential of autofluorescence to distinguish tumor from normal tissues was investigated with the view of a real-time diagnostic application in neurosurgery to delineate glioblastoma resection margins. The autofluorescence properties of nonneoplastic and neoplastic tissues were analyzed on tissue sections and homogenates by means of a microspectrofluorometer, and directly on patients affected by glioblastoma multiforme, during surgery, with a fiber-optic probe. Scan-microspectrofluorometric analysis on tissue sections evidenced a reduction of emission intensity and a broadening of the main emission band, along with a redshift of the peak position, from peritumoral nonneoplastic to neoplastic tissues. Differences in both spectral shape and signal amplitude were found in patients when the glioblastoma lesion autofluorescence was compared with those of cortex and white matter taken as healthy tissues. Both biochemical composition and histological organization contribute to modify the autofluorescence emission of neoplastic, with respect to nonneoplastic, brain tissues. The differences found in the in vivo analysis confirm the prospects for improving the efficacy of tumor resection margin delineation in neurosurgery.