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Introduction: Decompressive craniectomy (DC) is the most common surgical procedure to manage increased intracranial pressure (ICP). Hinge craniotomy (HC), which consists of fixing the bone operculum with a pivot, is an alternative method conceived to avoid some DC-related complications; nonetheless, it is debated whether it can provide enough volume expansion. In this study, we aimed to analyze the volume and ICP obtained with HC using an experimental cadaver-based preclinical model and compare the results to baseline and DC. Methods: Baseline conditions, HC, and DC were compared on both sides of five anatomical specimens. Volume and ICP values were measured with a custom-made system. Local polynomial regression was used to investigate volume differences. Results: The area of the bone opercula resulting from measurements was 115.55 cm2; the mean supratentorial volume was 955 mL. HC led to intermediate results compared to baseline and DC. At an ICP of 50 mmHg, HC offers 130 mL extra space but 172 mL less than a DC. Based on local polynomial regression, the mean volume difference between HC and the standard craniotomy was 10%; 14% between DC and HC; both are higher than the volume of brain herniation reported in the literature in the clinical setting. The volume leading to an ICP of 50 mmHg at baseline was less than the volume needed to reach an ICP of 20 mmHg after HC (10.05% and 14.95% from baseline, respectively). Conclusions: These data confirm the efficacy of HC in providing sufficient volume expansion. HC is a valid intermediate alternative in case of potentially evolutionary lesions and non-massive edema, especially in developing countries. [ABSTRACT FROM AUTHOR]

Objective Tentorial meningiomas represent a heterogeneous group of tumors. Most of the published series deal with either a small number of patients or consider different locations as a whole, making indications for treatment and prognosis difficult to drawn. We analyzed the surgical management of the lateral tentorial meningiomas, a homogenous and rare subgroup. Methods Fifty-two later tentorial meningiomas were operated on between 1990 and 2010. Clinical and radiologic features and surgical management of these patients were reviewed. Tumors were further subcategorized in to posterior/intermediate and in to supra-/infratentorial subgroups. Surgical outcome, long-term results, and prognostic factors are described. Results Mean age was 57 years (41 female, 11 male). Mean tumor size was 46 mm; most had an infratentorial location (36 vs. 16). Prevailing presenting symptoms were headache ( n = 28), vertigo/gait disturbances ( n = 25), and confusion and visual disturbances ( n = 16). The infratentorial group presented with a poorer clinical condition before as well as after operation. Extent of tumor resection was Simpson I in 10 patients, II in 26, III in 6, and IV in 10. Subtotal resection was statistically correlated with sinus invasion and tumor size. There was no surgical mortality. Permanent complications occurred in 3 patients. At latest follow-up (mean, 119 months) 42/46 had resumed their normal daily activity. Six cases recurred and remained stable after radiosurgery. Conclusions Lateral tentorial meningiomas are a homogeneous entity characterized by simple surgical approaches and favorable outcome (no mortality and low overall morbidity). Infratentorial location was more frequent and was characterized by poorer outcome. The limiting factors for surgical removal were tumor size and sinus invasion. The latter point strengthens the rationale for their classification into posterior and intermediate. [ABSTRACT FROM AUTHOR]

Background: To the authors' knowledge, meningiomas of the posterior third of the falx and the parasagittal sinus have never been specifically described to date and correlated visual outcome remains unclear. With this retrospective study we describe the clinical characteristics of these tumours, their surgical management, and the improvement in visual disturbances after surgery. Methods: Twenty-six consecutive patients (22 females, 4 males; mean age, 54 years) operated on for parasagittal ( n = 22) and falcine ( n = 4) meningioma between 1990 and 2010 were analysed retrospectively. Preoperative planning included magnetic resonance imaging (MRI) and magnetic resonance venography (MRV) or angiography. Sinus invasion was classified as normal, stenotic or occluded from the imaging findings and according to the Sindou classification from the intraoperative notes. Results: Visual disturbances and headache (in 21 and 14 cases, respectively) were the most commonly referred symptoms; visual field deficit was present in 19 patients. Simpson grade I was obtained in four patients, grade II in 15, grade III in three, and grade IV in four. The main limiting factor for total removal was sinus involvement. No perioperative deaths or relevant postoperative complications occurred. The mean follow-up was 107 months. Visual field deficit improved or resolved in almost half of the patients during the follow-up period. Three (12%) patients relapsed, two were treated with Gamma Knife surgery (stable at current writing) and the third died of disease progression. Conclusions: Outcome after surgery compares favourably with other parasagittal meningioma localisations and overall morbidity is negligible. Visual function is crucial for clinical outcome. Since an improvement of the deficit might still be possible, every effort should be undertaken to preserve the visual cortex. [ABSTRACT FROM AUTHOR]

Foramen magnum meningioma poses a challenge for neurosurgeons. Prognosis has generally improved with diagnostic and surgical advances over the past two decades; however, it may ultimately depend more on the surgeon's ability to tailor the approach and interpret intraoperative risks in single cases. The series comprised 64 patients operated on for ventral and ventrolateral foramen magnum meningioma. All patients underwent preoperative magnetic resonance imaging and received surgery via the dorsolateral route, rendering the series homogeneous in neuroradiological workup and surgical treatment. Particular to this series was that the majority of patients were of advanced age ( n = 29; age, >65 years), had serious functional impairment ( n = 30, Karnofski score <70), and large tumors (mean diameter, 3.5 cm). Total tumor removal was achieved in 52 (81 %) patients; operative mortality was nil. Early outcome varied depending on difficulties encountered at surgery (cranial nerve position and type of involvement in particular) and type of preoperative dysfunction. Long-tract signs and cerebellar deficits improved in 74 and 77 % of cases, respectively, but only 27 % of cranial nerve deficits did so. Surgical complications most often involved the cranial nerves: cranial nerve impairment, especially of the 9th through the 12th cranial nerves, due to stretching or encasement was noted in 44 cases. At final outcome assessment, two thirds of the cranial nerve deficits cleared, and all but two patients returned to a normal productive life. One patient was reoperated on during the follow-up period. Foramen magnum meningiomas behave like clival or spinal tumors depending on their prevalent extension. A dorsolateral approach tailored to tumor position and extension and meticulous surgical technique allow for definitive control of surgical complications. Scrupulous postoperative care may prevent dysphagia, a major persistent complication of surgery. Long-term observation of indolent tumor behavior at follow-up suggests that incomplete resection may be a viable surgical treatment option. [ABSTRACT FROM AUTHOR]

Brain metastases arise in 10%--40% of all cancer patients. Up to one third of the patients do not have previous cancer history. We report a case of a 67-years-old male patient who presented with confusion, tremor, and apraxia. A brain MRI revealed an isolated right temporal lobe lesion. A thorax-abdomen-pelvis CT scan showed no primary lesion. The patient underwent a craniotomy with gross-total resection. Histopathology revealed an intestinal-type adenocarcinoma. A colonoscopy found no primary lesion, but a PET-CT scan showed elevated FDG uptake in the appendiceal nodule. A right hemicolectomy was performed, and the specimen showed a moderately differentiated mucinous appendiceal adenocarcinoma. Whole brain radiotherapy was administrated. A subsequent thorax-abdomen CT scan revealed multiple lung and hepatic metastasis. Seven months later, the patient died of disease progression. In cases of undiagnosed primary lesions, patients present in better general condition, but overall survival does not change. Eventual identification of the primary tumor does not affect survival. PET/CT might be a helpful tool in detecting lesions of the appendiceal region. To the best of our knowledge, such a case was never reported in the literature, and an appendiceal malignancy should be suspected in patients with brain metastasis from an undiagnosed primary tumor. [ABSTRACT FROM AUTHOR]

Background Falcotentorial meningiomas (FTM) stand out for their rarity, inconsistent definition, and surgical complexity. It is appropriate to deal with them in the context of medial tentorial meningiomas (TMs). Methods Clinical and radiologic characteristics of medial TMs, comprising the typical features of FTM and TM, along with surgical management and short-term and long-term outcomes, are reported. Results FTM ( n = 16) were typically supratentorial, large, edematous tumors that caused mainly headache and hemianopia; TM ( n = 12) were infratentorial, smaller not edematous tumors that caused mainly headache and gait ataxia. The most frequent venous pattern was straight sinus infiltration in one third of cases of FTM and occlusion in one half of cases of TM. Total removal (Simpson grade I–II) was obtained in 46.4% of cases and subtotal removal (Simpson grade III–IV) in 53.6%. Suprainfratentorial extension in FTM and incomplete venous invasion in TM were the factors most likely opposing complete removal. The overall acute complications rate was 32.1% (higher for FTM), transient for most cases. Patients with supratentorial meningiomas performed significantly worse preoperatively (Karnofsky Performance Status ≤70 in 75% of cases); patients with infratentorial symptoms/signs recovered worse postoperatively. Stereotactic radiosurgery with subtotal removal was used as adjuvant treatment in 8 cases. Only 2 recurrences, both atypical tumors, occurred at 57.6 months (mean) follow-up. Conclusions As a general rule, careful venous management, tailored surgical approach for FTM, and cautious tumor removal for TM can yield good and stable results. Total removal accounts for half the cases in both groups, whereas FTM was associated with worse postoperative complications. [ABSTRACT FROM AUTHOR]

Background: Purulent intracranial infections are threatening conditions. Different surgical approaches have been described, respecting the rationale of evacuating the fluid component of the purulent collection. Emerging evidence supports the use of the endoscope for the treatment of cerebral abscesses and subdural empyemas; especially the peculiarities of flexible endoscopes could potentially offer a more effective and conclusive management as compared with the drainage through catheters. We describe our experience in the treatment of intracranial purulent collections with flexible endoscopy, comparing it with the most recent literature. Methods: Ten patients affected by intracranial suppuration were treated with endoscopy at our institution. The neurosurgical technique is thoroughly described. The related literature is reviewed, providing a comprehensive overview on the endoscopic treatment of intracranial suppuration so far. Results: All the patients had a good clinical outcome, with no peri-operative complications. The postoperative scans showed significant radiological improvement, with important reduction of the pus volume. In all cases, the microbiological cultures showed positivity. Conclusions: In our experience, the use of the flexible scope proved feasible and effective in the treatment of intracranial purulent collections. Visual awareness of the internal capsule is not limited to a direct inspection of the fluid pus; it rather allows an active removal of the more solid (and perhaps more microbiologically significant) fibrinoid component, and also assists in final bleeding control and in assessing the extent of the evacuation. The steering capabilities of the fiberscope are particularly suitable for such purposes, allowing sampling the solid internal layer of the pyogenic membrane, and potentially shedding light on the actual clinical significance of this component of the abscess. [ABSTRACT FROM AUTHOR]