DTI-MRI at 2 days after spinal cord injury accurately predicts long-term locomotor function recovery in rats.

OBJECTIVE: Spinal cord injury (SCI) damages an individual's sensory, motor, and autonomic functions and represents a social emergency, mostly in developed countries. Accurate and timely diagnosis of the severity of SCI must be carried out as quickly as possible to allow time for drug and therapy testing in the early stages after injury. MATERIALS AND METHODS: Male Dark Agouti (DA) rats underwent spinal cord cryoinjury at the T13 level of the spine. Under typical conditions, in vivo magnetic resonance imaging (MRI) T2 and echo-planar imaging - diffusion tensor imaging (EPI-DTI) examinations were conducted. This involved the reconstruction of nerve tracts and the measurement of the fractional anisotropy (FA) index, as well as measurements of the ratio of Hyper/Hypo intensive areas and spinal cord injury severity scores. RESULTS: Our study shows that, after cryoinjury, the FA significantly decreased in all animals. An increase in FA level, derived from EPI-DTI within 2 days after SCI, accurately predicts long-term locomotor function recovery. In rats with higher FA, recorded on day 2 after injury, complete restoration of locomotor function was observed, while at low FA values, the animals maintained stable monoplegia. CONCLUSIONS: Our results, though validating the T2 10-grade MRI scale for SCI, indicate that FA would represent the MRI technical instrument, which would better monitor the evolution of SCI and, accordingly, better objectively evaluate the impact of potentially therapeutic protocols for spinal cord traumatic injury. Despite the results achieved, significant difficulties must be overcome on the way to successful clinical implementation of the findings in humans.

Atypical dermoid cyst of the corpus callosum: a case report.

BACKGROUND: Intracranial dermoid cysts (DCs) represent an infrequent subset of congenital ectodermal inclusion cysts predominantly observed near the midline structures. In spite of their benign nature, they can cause clinical manifestations, necessitating surgical removal as the main therapeutic measure. CASE REPORT: We present here an extremely rare case characterized by a radiologically atypical dermoid cyst located within the corpus callosum, an extremely rare location for such tumors. Successful surgical excision resulted in good clinical outcomes. CONCLUSIONS: This paper underscores the importance of a timely, proper radiological diagnostic process, which sees magnetic resonance imaging (MRI) as the main step, as well as the fact that interpretation of MRI data can sometimes be challenging, as it was in the patient of this report.

CSF - injected contrast medium enhances post-traumatic spinal cord cysts. An experimental study in rats.

OBJECTIVE: Spinal cord injury (SCI) is still one of the most challenging problems in neurosurgical practice. One of the major obstacles to neural regeneration following trauma is the formation of glial scarring and post-traumatic cysts which acts against proper growth of axons through the site of injury. Cerebrospinal fluid (CSF) delivery of bioactive agents into cystic cavities could represent a promising therapeutic strategy. In the present study, we investigated specifically the dynamics of intradural delivery of contrast medium and its relocation into post-traumatic cysts in an experimental model of spinal cord cryoinjury in rats. MATERIALS AND METHODS: 32 male Sprague Dawley SPF rats were submitted to injury as previously described. Omnipaque-240 was injected either into the cisterna magna or at the level of the cauda equina. Subsequently, cerebral CT scan examinations were performed in order to check the CSF dynamics of the contrast medium. RESULTS: There was a steady accumulation of contrast medium into post-traumatic cysts as early as five minutes after injection. A dosage of 65 mg of iodine per kilogram ensured an adequate feeling of the cysts at an average of 30 minutes. CONCLUSIONS: Our data indicate that intraspinal injection of bioactive agents can easily reach the site of injury and fill post-traumatic cysts. This could represent an interesting potential therapeutic protocol for SCI.

The use of epidural spinal cord stimulation in patients with chronic disorders of consciousness - neuroimaging and clinical results.

OBJECTIVE: Chronic disorders of consciousness are considered as a serious unresolved problem complicated by significant medical, social, and economic burden. Therefore, improving the conditions and facilitating the rehabilitation management of these patients is of particular interest. In recent years, interesting results of the use of spinal cord stimulation in patients with chronic disorders of consciousness appeared in the world literature, which makes the use of this technique promising in this category of patients. PATIENTS AND METHODS: We analyzed the results of high cervical spinal cord stimulation, both, in tonic and "Burst" modes, in 21 patients with chronic disorders of consciousness and severe spasticity managed in the last two years in FRCC ICMR. In 9 of them pre- and post-stimulation fMRI before and right after the stimulation was also performed for brain functional connectivity assessment. RESULTS: Improvement of the consciousness level was observed in 38.1% (n = 8) and a decrease in spasticity was obtained in 52.4% (n=11) of the patients. The difference in CRS-R score before and after spinal cord stimulation was statistically significant (p=0.028). The fMRI results revealed an increase in functional connectivity of the right anterior insula with several areas that are part of the Dorsal Attention, Visual and Default Mode networks after spinal cord stimulation. CONCLUSIONS: Epidural spinal stimulation at the upper cervical spine level demonstrated its effectiveness in patients with chronic diseases of consciousness of various etiology. Evaluation of the effect of specific stimulation modes requires further controlled study in larger group of patients.

Long term results of the use of a fusion-promoting, new generation interspinous processes device (IPD), Bacfuse®: a monocentric prospective study.

OBJECTIVE: Lumbar micro instability is a diffuse problem mostly in elderly population. Interspinous processes devices (IPDs) have been introduced in the clinical practice for relieving the dynamic compression on the nerve roots due to instability. First-generation IPDs did not achieve bone fusion so their good immediate postoperative results did not last in the long term. More recently, a new version of IPD, Bacfuse®, has been introduced with the aim of achieving postoperative fusion. SUBJECTS AND METHODS: We started using this new device in 2015. We investigated prospectively the long-term results of a series of 41 patients with small-to-moderate lumbar instability. In 29 of them the IPD was placed as an adjunct to decompressive surgery whilst in 12 patients it was implemented as a stand-alone technique. RESULTS: Immediate post-operative results showed significant clinical improvement in all cases. This improvement was still present in 32 of them at the last follow-up, 2.5 to 4 years following surgery. The dynamics of clinical symptoms did not change after two years of observation, a fact that indicates that no changes are to be expected afterward. Spinal fusion was obtained in more than 2/3 of the patients and not surprisingly was correlated with better clinical results. Excessive body weight appeared to be a negative factor for achieving both spinal fusion and good results. CONCLUSIONS: Bacfuse® seems to be a very good surgical tool for patients bearing small to moderate lumbar instability whether or not submitted to direct decompressive surgery.

[«Burr hole¼ microsurgery for vestibular schwannoma]. / «Burr hole¼ mikrokhirurgiya vestibulyarnykh shvannom.

OBJECTIVE: To evaluate the efficacy and safety of minimally invasive «burr hole¼ microsurgery for vestibular schwannoma. MATERIAL AND METHODS: A retrospective analysis of postoperative outcomes in 50 consecutive patients with vestibular schwannoma was performed. All patients underwent burr hole microsurgery between 2016 and 2020. RESULTS: All patients satisfactorily tolerated surgical treatment. Total resection was carried out in 21 (42%) cases, almost total resection - in 21 (42%) patients (>95% of baseline volume). Subtotal resection was performed in 8 (16%) cases. Mean surgery time was 132 min (range 60-340). Postoperative deterioration of facial nerve function occurred in 20 (40%) patients. Severe dysfunction (House-Brackmann grade V-VI) was observed only in three patients. Other 17 patients had moderate dysfunction of the facial nerve (House-Brackmann grade III-IV). Useful hearing was preserved in 6 (50%) out of 12 patients with preoperative useful hearing. CONCLUSION: Minimally invasive burr hole microsurgery is an effective method for vestibular schwannoma. Moreover, the proposed technique reduces surgery time due to simpler craniotomy and wound closure.

The Fallout of Catastrophic Technogenic Emissions of Toxic Gases Can Negatively Affect Covid-19 Clinical Course.

The coronavirus D-19 (Covid-19) pandemic has shaken almost every country in the world: as we stand, 6,3 million deaths from the infection have already been recorded, 167,000 and 380,000 of which are in Italy and the Russian Federation, respectively. In the first wave of the pandemic, Italy suffered an abnormally high death toll. A detailed analysis of available epidemiological data suggests that that rate was shockingly high in the Northern regions and in Lombardy, in particular, whilst in the southern region the situation was less dire. This inexplicably high mortality rate in conditions of a very well-developed health care system such as the one in Lombardy - recognized as one of the best in Italy - certainly cries for a convincing explanation. In 1976, the small city of Seveso, Lombardy, experienced a release of dioxin into the atmosphere after a massive technogenic accident. The immediate effects of the industrial disaster did not become apparent until a surge in the number of tumors in the affected population in the subsequent years. In this paper, we endeavor to prove our hypothesis that the release of dioxin was a negative cofactor that contributed to a worsening of the clinical course of COVID-19 in Lombardy.

Surgical Treatment of Chiari Malformation in Adults: Comparison of Surgical Techniques Described in the Literature and Our Experience.

This paper has been edited for clarity, correctness and consistency with our house style. Please check it carefully to make sure the intended meaning has been preserved. If the intended meaning has been inadvertently altered by the editing changes, please make any corrections needed.

[Li-Fraumeni syndrome in a patient with multiple anaplastic oligodendrogliomas of the brain (a case report and literature review)]. / Sindrom Li-Fraumeni u patsienta so mnozhestvennymi anaplasticheskimi oligodendrogliomami golovnogo mozga (klinicheskoe nabliudenie i obzor literatury).

Li-Fraumeni syndrome (LFS) is a clinically and genetically heterogeneous hereditary syndrome with predominantly oncological manifestations, which is associated with mutations in the TP53, MDM2, and CHEK2 genes. The most common variant is a TP53 mutation. OBJECTIVE: To analyze the literature and present a clinical case of a patient with Li-Fraumeni syndrome and multiple anaplastic oligodendrogliomas of the brain. CLINICAL CASE: A 42-year-old male patient presented with complaints of headaches, word finding difficulty, memory loss, right hemianopsia, and generalized convulsive attacks. For 10 years, he underwent multiple interventions and chemotherapy courses for colon adenocarcinoma and recurrent B-cell lymphoma. MRI revealed multiple space-occupying lesions of the cerebraln hemispheres, which were located in the left temporo-occipital and right frontal regions. RESULTS: The patient underwent resection of multiple space-occupying lesions of the left temporo-occipital and right frontal regions. The postoperative period proceeded without complications. The histological diagnosis was WHO grade III anaplastic oligodendroglioma. The patient and one of his sons were detected with a R248W missense mutation in the TP53 gene. The patient underwent six courses of temozolomide chemotherapy. At a follow-up examination 20 months after surgery and chemotherapy, the patient's condition was satisfactory; he returned to work. Control MRI of the brain revealed no signs of continued tumor growth. CONCLUSION: An analysis of the literature and the clinical case indicate the success of multiple surgical interventions and chemotherapy courses performed for a long time in the patient with Li-Fraumeni syndrome manifested by colon adenocarcinoma, recurrent B-cell lymphoma, and multiple anaplastic oligodendroglioma of the brain. The patient had a good quality of life and returned to professional activity.

[Intraoperative fluorescence diagnostics in surgery of intracranial meningiomas: analysis of 101 cases]. / Intraoperatsionnaia fluorestsentnaia diagnostika v khirurgii intrakranial'nykh meningiom: analiz 101 nabliudeniia.

Fluorescence diagnostics has been extensively applied in surgery of malignant brain gliomas. However, the use of this technique in surgery of intracranial meningiomas has remained controversial. OBJECTIVE: The study objective was to assess the sensitivity of 5-aminolevulinic acid-based (5-ALA) fluorescence diagnostics in surgery of brain meningiomas and to clarify the clinical and biological factors that may influence the fluorescent effect. MATERIAL AND METHODS: The study consistently included 101 patients with intracranial meningiomas of various locations who were operated on using 5-ALA. There were 28 (27.72%) males and 73 (72.27%) females (median age, 54 years). In all patients, surgery was performed using an operating microscope equipped with a fluorescent module; in 24 of these, laser spectroscopy was used. For comparison of chances to observe the fluorescent effect of 5-ALA in patients having meningiomas with different WHO histological grades (Grade I vs Grade II-III), we performed a meta-analysis that included 10 studies (the largest series) on outcomes of surgical treatment of meningiomas using intraoperative fluorescence diagnostics. RESULTS: Of 101 patients included in this series, observable fluorescence was detected in 95 (94.1%) patients: weak fluorescence in 12 (11.9%), moderate fluorescence in 23 (22.8%) cases, and strong fluorescence in 60 (59.4%) patients. There was no statistically significant relationship (p>0.05) between the rate and intensity of observable fluorescence and the tumor growth pattern (primary/continued), location, WHO grade of malignancy, and histological subtype. In the absence of intraoperative bleeding, tumor fluorescence was statistically significantly brighter (p=0.02). Of 26 patients with hyperostosis, bone fluorescence was observed in 11 (42.3%) cases. There was no statistically significant relationship between administration of dexamethasone, its dose, administration of anticonvulsants, gastrointestinal tract diseases, as well as diabetes mellitus and the fluorescence intensity. There was also no significant relationship between the extent of tumor resection (Simpson scale) and the presence of fluorescence as well as its intensity. Comparison of the observable fluorescence intensity and the laser spectroscopy indicators revealed a significant correlation (r=0.75; p=0.005). CONCLUSION: Meningioma is a well fluorescent tumor, with the technique sensitivity being 94.1%. In some cases, the use of fluorescence diagnostics in surgery of meningiomas improves identification of residual tumor fragments and enables correction of a surgical approach. To assess the effect of fluorescence diagnostics on the recurrence rate and disease-free duration, further research is required.

Laser biospectroscopy and 5-ALA fluorescence navigation as a helpful tool in the meningioma resection.

5-aminolevulinic acid (5-ALA) is a natural precursor of protoporphyrin IX (PP IX), which possesses fluorescent properties and is more intensively accumulated in tumor cells than in normal tissue. Therefore, the use of 5-ALA in the surgical treatment of intracranial tumors, particularly gliomas, has gained popularity in the last years, whereas its use in other intracranial pathological entities including meningiomas has been reported occasionally. This study describes a series of 28 patients with intracranial meningiomas, who were administered 5-ALA for a better visualization of tumor boundaries. Twelve patients underwent also laser spectroscopic analysis in order to confirm the visual impression of tumor tissue visualization. Bone infiltration was readily demonstrated. In one case, the tumor recurrence could have been prevented by removal of a tumor remnant, which would possibly have been better recognized if spectroscopic analysis had been used. Fluorescent navigation (FN) is a useful method for maximizing the radicality of meningioma surgery, particularly if the tumor infiltrates the bone, the skull base, and/or the surrounding structures.

[Navigation systems in neurosurgery]. / Navigatsionnye sistemy v neirokhirurgii.

When preparing the review, we analyzed publications available at the Medline database; a total of 1,083 publications related to the review's subject were analyzed. After more careful analysis, we selected 117 publications devoted to the development of neuronavigation in craniocerebral surgery, historical prerequisites of neuronavigation emergence, current trends, and future perspectives of the technique.

[Orbitozygomatic approaches to skull base tumors spreading into the orbit, paranasal sinuses, nasal cavity, and pterygopalatine and infratemporal fossae].

The paper analyzes application of orbitozygomatic approaches at the Department of Skull Base and Craniofacial Surgery of the Burdenko Neurosurgical Institute for a 14-year period. During this time, 723 patients were operated on using the orbitozygomatic approach, which has become the workhorse of surgery for skull base tumors spreading into the orbit, paranasal sinuses, and pterygopalatine and infratemporal fossae. The authors describe seven major modifications of the orbitozygomatic approach that they have used in their practice.

10 Levels thoracic no-intrumented laminectomy for huge spontaneous spinal subdural hematoma removal. Report of the first case and literature review.

INTRODUCTION: Spontaneous idiopathic acute spinal subdural hematoma (SSDH) is a rare cause of acute back pain followed by signs and symptoms of nerve root and/or spinal cord compression, frequently associated with coagulopathies, blood dyscrasias and arterio-venous malformations. Standard management includes non-operative treatment and timely (within 24h) surgical decompression. PRESENTATION OF CASE: We report on the case of a huge 10 levels SSDH treated with decompressive thoracic no-instrumented laminectomy in a 45-year-old woman with good neurological recovery (from ASIA A to D). DISCUSSION: Spontaneous SSDHs without detectable structural lesion or anticoagulant therapy are very rare. Among 26 cases documented the literature harbouring SSDHs, the thoracic spine was found to be the preferred site, and the compression was usually extending over several vertebral levels. Nonoperative treatment for SSDH may be justified in presence of minimal neurologic deficits, otherwise, early decompressive laminectomy along with evacuation of hematoma are considered the treatment of choice in presence of major deficits. CONCLUSION: To our knowledge, the present case is the most extensive laminectomy for a SSDH removal never described before. No postoperative instability occurs in 10 levels thoracic laminectomy in case the articular processes are spared. When major neurological deficits are documented, early decompressive laminectomy with evacuation of hematoma should be considered the best treatment for SSDH.

From less to maximally invasiveness in cervical spine surgery: A "nightmare" case who deserve consideration.

INTRODUCTION: Multilevel cervical myelopathy without surgical treatment is generally poor in the neurological deficit without surgical decompression. The two main surgical strategies used for the treatment of multilevel cervical myelopathy are anterior decompression via anterior corpectomy or posterior decompression via laminctomy/laminoplasty. PRESENTATION OF CASE: We present the case of a 62 year-old lady, harboring rheumatoid artritis (RA) with gait disturbances, pain, and weakness in both arms. A C5 and C6 somatectomy, C4-C7 discectomy and, instrumentation and fusion with telescopic distractor "piston like", anterior plate and expandable screws were performed. Two days later the patient complained dysfagia, and a cervical X-ray showed hardware dislocation. So a C4 somatectomy, telescopic extension of the construct up to C3 with expandible screws was performed. After one week the patient complained again soft dysfagia. New cervical X-ray showed the pull out of the cranial screws (C3). So the third surgery "one stage combined" an anterior decompression with fusion along with posterior instrumentation, and fusion was performed. DISCUSSION: There is a considerable controversy over which surgical approach will receive the best clinical outcome for the minimum cost in the compressive cervical myelopathy. However, the most important factors in patient selection for a particular procedure are the clinical symptoms and the radiographic alignment of the spine. the goals of surgery for cervical multilevel stenosis include the restoration of height, alignment, and stability. CONCLUSION: We stress the importance of a careful patients selection, and invocated still the importance for 360° cervical fixation.

Anterior cervical discectomy and fusion with "mini-invasive" harvesting of iliac crest graft versus polyetheretherketone (PEEK) cages: a retrospective outcome analysis.

BACKGROUND: Limited outcome data suggested a minimal evidence for better clinical and radiographic outcome of polyetheretherketone cages compared with bone grafts in the anterior cervical discectomy and fusion. We proposed a "mini-invasive" surgical technique for harvesting iliac crest grafts that provides bicortical autografts of sufficient size to be used in multilevel cervical procedures and is not associated with long-term significant donor site pain. METHODS: All patients undergoing discectomy and fusion during a three years period were consecutively extracted from computer database and retrospectively evaluated by means of telephonic interview, independently from surgical procedure (iliac crest autograph or prosthesis). Two procedure-blinded neurologists retrieved baseline clinical-demographic data and pre-surgical scores of routinely performed scales for pain and functional abilities. Afterwards, a third blinded neurologist performed clinical follow up by a semi-structured interview including Verbal Analog Scale for pain and Neck Disability Scale for discomfort. RESULTS: 80 patients out of 115 selected cases completed the follow up. 40 patients had been treated by mini-invasive bone graft harvesting and 40 with PEEK cages for cervical fusion. VAS for both neck and arm pain were significantly reduced within groups. Patients did not complaint any significant pain and/or paraesthesias at donor site from the first week after intervention. Neck Disability Scale was significantly lower at the end of follow up in both groups. CONCLUSIONS: "Miniinvasive" bicortical autografts is a less invasive, inexpensive technique to harvest iliac graft that may produce a reduced amount of general and local donor-site complications without outcome differences with prosthetic cages.

[Surgery of skull base tumors extending into the orbit, paranasal sinuses, nasal cavity, pterygopalatine and infratemporal fossas: treatment principles in certain types of tumors].

Following the paper focused on surgery of skull base tumors invading the orbit, paranasal sinuses, nasal cavities, pterygopalatine and infratemporal fossae, the authors discuss particular issues of surgical treatment of the most common craniofacial mass lesions, including meningiomas, juvenile angiofibromas, trigeminal nerve tumors, chondroid tumors, and others.

[Intraoperative fluorescence diagnostics upon recurrent operations for brain gliomas].

UNLABELLED: The method of fluorescent diagnosis (FD) using 5-ALA has been widely employed in surgery of primary intracerebral tumors over the last years. The issue of FD application in surgery of gliomas with continued growth has remained less studied. OBJECTIVE: To investigate the efficacy of using FD with 5-ALA and laser spectral analysis in surgery of brain gliomas with continued growth. MATERIAL AND METHODS: 19 patients with Grade II-IV (WHO) gliomas with continued growth of different localization were studied. All tumors localized supratentorially. 5-Aminolevulinic acid hydrochloride "Alasens" (SSC "NIOPIK", Moscow, Russia) was used in the study. The equipment used during surgery included an operating microscope with an attachment for fluorescent navigation. Apart from expert qualitative assessment of a fluorescence extent, computer analysis of the fluorescence and light scattering (diffuse reflection) spectra was performed on a LESA-01-BIOSPEK spectrum analyzer (Russia). RESULTS: Detectable fluorescence was obtained in all the cases. PP IX fluorescence indices from 9.05 to 53.97 (the study was conducted in 12 cases) were determined by quantitative analysis of the spectrograms. The analysis of light scattering revealed its inverse relationship with respect to the fluorescence index. High sensitivity of the method in surgery of gliomas with continued growth requires clarification of method specificity because non-specific accumulation of PP IX in the area of post-radiation necrosis may occur in these patients. CONCLUSIONS: The FD method can be used for intraoperative demarcation of tumor resection boundaries in surgery of cerebral gliomas with continued growth. However, it is necessary to be critical of the high sensitivity of the method in patients with postradiation pathomorphism due to possible non-specific accumulation of PP IX in tissues. A light scattering study may provide additional information about the structure of tissues in the surgical wound.