Development of a Novel Device for Decompressive Craniectomy: An Experimental and Cadaveric Study and Preliminary Clinical Application.

BACKGROUND: Decompressive craniectomy is an intervention of established efficacy in patients with intractable cerebral edema. OBJECTIVE: To evaluate a new device used in alternative to decompressive craniectomy. This device is designed to perform an augmentative craniotomy by keeping the bone flap elevated using specific cranial suspension titanium plates and giving the brain enough room to swell. METHODS: We tested the mechanical characteristics of the cranial brackets on dried skulls, on 3D-printed skull models, and on a preserved cadaver head. The resistance of the device was examined through dynamometric testing, and the feasibility of the surgical technique, including the suspension of the bone flap and the skin closure, was investigated on the cadaveric model. A preliminary clinical series of 2 patients is also reported. RESULTS: The laboratory tests have shown that this system allows an adequate expansion of the intracranial volume and it could withstand a force up to 637 ± 13 N in the synthetic model and up to 658 ± 9 N in the human skull without dislocation or failure of the brackets nor fractures of the bone ridges. Preliminary application in the clinical setting has shown that augmentative craniotomy is effective in the control of intracranial hypertension and could reduce the costs and complications associated with the classical decompressive craniectomy technique. CONCLUSION: Preliminary laboratory and clinical results show augmentative craniotomy to be a promising, alternative technique to decompressive craniectomy. Further clinical studies will be needed to validate its efficacy.

Sacral Nerves Reconstruction After Surgical Resection of a Large Sacral Chordoma Restores the Urinary and Sexual Function and the Anal Continence.

OBJECTIVE: Chordomas are slow-growing tumors, with a high tendency to local relapse. En bloc resection is related to the most favorable outcome in terms of survival but is frequently associated with permanent neurological deficits involving sphincters and sexual functions. In the present article, we describe an innovative technique of en bloc resection followed by reconstruction of the sacral nerves with nerve grafts. METHODS: The chordoma was excised through a posterior approach after dividing the proximal and distal sacral nerves using the established technique. After that, a microsurgical S2-S3-S4 nerve reconstruction was performed connecting the proximal and distal stumps with sural nerve grafts withdrawn from both lower limbs. RESULTS: Immediately after surgery, the patient experienced complete impairment of sexual function and sphincters with urinary and fecal incontinence. After 6 months, there was a progressive recovery of sexual function and sphincter control. One year after the operation, the patient achieved an adequate sexual life (erection and ejaculation) and complete control of the bladder and anal sphincter. CONCLUSION: Reconstruction of nerves sacrificed during sacral tumor removal has been shown to be effective in restoring sphincter and sexual function and is a promising technique that may significantly improve patients' quality of life.

Dorsal epidural "Spindle Cell Lipoma" in a pregnant female.

BACKGROUND: Spindle cell lipoma (SCL) constitutes just 1.5% of all lipomatous tumors. They typically occur in the upper back and shoulders. Here, we report a 37-year-old female presenting with a SCL in the dorsal epidural thoracic spine, during her 9th month of pregnancy. CASE DESCRIPTION: A 37-year-old female presented with a subacute (2 months) progressive paraparesis during her 9th month of pregnancy. The MR showed a dorsal epidural mass at the D8 level. Following a cesarean section, the patient underwent a laminectomy for tumor excision. Microscopically, the lesion proved to be a SCL. At 5-year follow-up, there was no tumor recurrence. CONCLUSION: SCL represents a variant of benign lipomas that may occur in the dorsal thoracic spine. Gross total excision may be followed by a benign clinical course without recurrence or malignant degeneration. Very atypical SCLs need closer follow-up to avoid the misdiagnosis of liposarcoma.

A rare case of Meckel's cave primary lymphoma: a case report and elaboration of the diagnostic algorithm.

Management of lesions involving Meckel's cave can represent a challenge for neurosurgeons, because of the deep-seated location and the surrounding complex neurovascular structures. Very small lesions arising from MC are generally asymptomatic and radiological follow-up with head MRI and PET-CT is sufficient to control these lesions. In rare cases, the rapid increase in the size of lesions and the alteration of the neurologic status make early histological characterization mandatory in the plethora of lesions arising from Meckel's cave; a very small percentage is represented by central nervous system lymphomas. Primary diffuse large B-cell lymphoma is the most commonly found. Aggressive surgery, in case of suspicious Meckel's cave lesions, is strongly discouraged, because this procedure may increase the risk of postoperative deficit and provides no survival benefit compared with biopsy alone. The aim of the present paper is to report a very rare case of primary Meckel's cave diffuse large B-cell lymphoma (only seven cases were described in literature) and standardize an operative algorithm to avoid the risks of an incorrect surgical conduct.

Endoscope-Assisted Microneurosurgery for Neurovascular Compression Syndromes: Basic Principles, Methodology, and Technical Notes.

BACKGROUND: Microscopic microvascular decompression (MVD) has a low but not negligible failure rate due to some missed conflicts, especially in case of multiple offending vessels. The reported study is aimed to assess the principles, methodology, technical notes, and effectiveness of the endoscope-assisted (EA) MVD for neurovascular compression syndromes (NVCS) in the posterior fossa. MATERIALS AND METHODS: A series of 43 patients suffering from an NVCS and undergone to an EA MVD were retrospectively reviewed. Syndromes were trigeminal neuralgia in 25 cases, hemifacial spasm in nine cases, positional vertigo in six cases, glossopharyngeal neuralgia in two cases, and spasmodic torticollis in one case. In all cases, a 0°-30° specially designed endoscope was inserted into the surgical field to find/treat those conflicts missed by the microscopic exploration. Each procedure was judged in terms of the effectiveness of the adjunct of the endoscope according to a three types classification system: Type I - improvement in the visualization of the nerve's root entry/exit zone; Type II - endoscopic detection of one or more conflicts involving the ventral aspects of the nerve and missed by the microscope; Type III - endoscope-controlled release of the neurovascular conflict otherwise difficult to treat under the only microscopic view. RESULTS: A total of 55 conflicts were found and treated. Twenty-eight procedures were classified as Type I, nine as Type II, and six as Type III. All the patients had a full recovery from their symptoms. CONCLUSIONS: In selected cases, EA MVD offers some advantages in the detection and treatment of neurovascular conflicts in the posterior fossa.

Surgical management of falcine meningiomas: Experience of 95 patients.

Falcine meningiomas, defined as a meningiomas arising from the falx not involving the superior sagittal sinus, account for 9% of all intracranial meningiomas. We analyzed 95 patients with falcine meningiomas who underwent surgical removal of their lesion at our institution between 2001 and 2014. Surgical management of these patients, focusing on anatomical and clinical features is described. Thus, based on our series, a surgical algorithm, classifying the falcine meningioma into four types, according to location at the falx, and using an ipsilateral interhemispheric approach in supine or prone position, is described. The median length of follow-up was 7.1years (range 1.6-12.3years). Approximately one-third of all patients was asymptomatic, headaches occurred in 27 patients, seizures in 14 cases, and lower-extremity weakness in 9 cases. In this series, the middle third of the falx was the most frequently involved site (55,78%), while the anterior third (26,31%) and the posterior type (17,89%) were less common. The transitional and meningothelial types occurred in 69 of patients and a high grade in only two patients. Compared with previous series in literature, there was no mortality and Gross Total Resection was obtained in 83 (87,5%) cases. Three of 95 patients experienced new or worsened neurological deficits after surgery while other complications were relatively in only 6 cases. This study presents our good results about removal of the tumor while preserving major cortical veins and the sinus using advanced microsurgical tools.

Intramedullary non-specific inflammatory lesion of thoracic spine: a case report.

BACKGROUND: There are several non-neoplastic lesions which mimick intramedullary spinal cord neoplasm in their radiographic and clinical presentation. These can be classified as either infectious (TB, fungal, bacterial, parasytic, syphilis, CMV, HSV) and non-infectious (sarcoid, MS, myelitis, ADEM, SLE) inflammatory lesions, idiopathic necrotizing myelopathy, unusual vascular lesions and radiation myelopathy. Although biopsy may be indicated in many cases, an erroneous diagnosis of intramedullary neoplasm can often be eliminated pre-operatively. CASE DESCRIPTION: the authors report a very rare case of intramedullary non-specific inflammatory lesion of unknown origin, without signs of infection or demyelinization, in a woman who showed no other evidence of systemic disease. CONCLUSIONS: Intramedullary lesions that mimick a tumor can be various and difficult to interpret. Preoperative MRI does not allow a certain diagnosis because these lesions have a very similar signal intensity pattern. Specific tests for infective pathologies are useful for diagnosis, but histological examination is essential for establishing a certain diagnosis. In our case the final histological examination and the specific tests that we performed have not cleared our doubts regarding the nature of the lesion that remains controversial.

Gliosarcomas in the elderly: analysis of 7 cases and clinico-pathological remarks.

AIMS AND BACKGROUND: Gliosarcomas are rare malignant primary brain tumors that usually affect the fifth or sixth decades of life. The purpose of this study was to describe our experience with such lesions in elderly patients and to establish their prognosis factors. METHODS: Between 1993 and 2001, 7 patients over 60 years of age were treated at our institute for cerebral gliosarcomas. All patients underwent surgery for total or at least sub-total removal of a neoplastic mass. RESULTS: Owing to poor clinical conditions (Karnofsky performance score = 40), one patient was not treated postoperatively. Remaining patients were treated with whole-brain radiotherapy, whereas concomitant chemotherapy (temozolomide) was administrated only to 4 patients. Histological examination showed the prevalence of sarcomatous aspects in 3 patients; the gliomatous aspect prevailed in 4 patients. CONCLUSIONS: Sarcomatous aspects and multimodality treatment (surgery, radiotherapy and chemotherapy) were associated with a better prognosis and showed in these elderly patients a trend similar to that of young people.

Extradural spinal cavernous angiomas: report of seven cases.

The authors describe seven cases of extradural spinal cavernous angioma. Although cavernoma itself is not rare, the extradural spinal localization is uncommon and makes preoperative differential diagnosis difficult. Routine MRI investigation has aided neurosurgeons in evaluating the true incidence of these vascular malformations, which was understimated in the past. The data published so far have not entirely clarified the treatment of choice for these lesions. Considering their rarity in this site, their presenting symptoms and the difficulties involved in neuroradiological diagnosis, the authors discuss the role of surgery as the principal form of treatment and review the relevant literature. Seven patients (4 male, 3 female) were admitted to our Institute of Neurosurgery between 1992 and 2004, with a 5-6 month history (range=2-365 days) of low back pain or radicular pain, sometimes associated with paresthesia. All patients had a CT scan, as well as MRI with gadolinium when possible, which detected an extradural roundish lesion: differential diagnosis was very difficult, especially between neurinoma and cavernoma. Treatment was always surgical and resection of the lesion radical. Postoperatively, all patients presented complete regression of clinical symptoms. In all cases histological diagnosis was cavernous angioma. Postoperative MRI with gadolinium or CT scan with IV contrast, performed before discharge, confirmed radical removal of the vascular malformation in all cases. Our experience confirms that surgery should be the treatment of choice for these lesions, in view of both their tendency to bleed and their straightforward surgical removal.

Glioblastoma in irradiated elderly patients: two case reports.

We report our experience with two elderly patients with histologically proven diagnosis of glioblastoma multiforme who were treated 25 and 18 years earlier for tinea capitis and scalp cutaneous hemangioma respectively in the same areas where the glioblastoma multiforme had grown. These pathologies were benign, and nowadays can be treated with alternative approaches rather than radiotherapy. Radiotherapeutic treatment should be carefully considered before using it in young patients with benign pathologies who have a long life expectancy and subsequently a higher risk of developing radio-induced malignant lesions. Radio-induced gliomas are typical of patients younger than the ones with "spontaneous" glioblastomas; however, the subjects of our study were elderly (78 and 72 years).