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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S2-S3-S4 nerve reconstruction was performed connecting the proximal and distal stumps with sural nerve grafts withdrawn from both lower limbs.Results: Immediately after surgery, the patient experienced complete impairment of sexual function and sphincters with urinary and fecal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.

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.

It is known that intracranial tumors may trigger trigeminal neuralgia (TN) in some patients although the exact prevalence and occurrence is not completely defined yet. In the present study, we present a case series of patients with brain tumor and a clinical diagnosis of TN as the first and main manifestation of the disease. A retrospective analysis was performed involving patients diagnosed with brain tumor whose exclusive clinical feature our department focused on was TN. In addition, a review of all published cases was performed. From January 2017 to November 2018, 718 patients with brain tumor were admitted to our department, 17 of which suffered of TN, of which 8 patients presented with at least another neurologic symptom and 9 patients presented with TN alone, with typical symptoms of stubbing electric pain in 6 cases. In our series, we found that 2.3% of patients admitted for brain tumors had TN. In 0.8% of cases, TN was the main clinical symptom. The prevalence of tumor lesion in patients with facial neuropathic pain is not defined, but it is a well-known recognized initial symptom; however, early cerebral magnetic resonance imaging (MRI) is not yet strongly recommended in patients with newly diagnosed trigeminal neuralgia. The purpose of this article is, especially in unusual cases, to show that the application of such MR techniques and preoperative evaluation may contribute to diagnosis, indication, and surgery planning.

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.

Cerebrovascular malformations (CVMs) such as arteriovenous malformations (AVMs) or dural arteriovenous fistulas (DAVFs) represent a possible source of intracranial hemorrhage, but these malformations can also manifest with neurologic disorders secondary to ischemic penumbra from vascular steal. In the latter case, the clinical manifestations are less obvious and characteristic, and may include a varied clinical spectrum ranging from focal deficits to generalized malfunction of the brain parenchyma resulting in dementia. Dementias secondary to CVMs constitute a probably underestimated subpopulation of patients of great interest because they present with devastating but potentially reversible cognitive impairment. We examined the pertinent literature regarding the clinical manifestations of CVMs characterized by cognitive impairment and describe the distinctive clinical features. Our results confirm that cognitive impairment is one of the clinical manifestations of CVMs and is a frequently misrecognized and often late-diagnosed cause of reversible dementia.

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.

Dear editor, Being neurosurgeons on duty at a university hospital where Covid-19 patients are referred, we happened to be involved in urgent interventions in patients positive for Sars-cov2. Before...

Aim To report our results about minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) with bilateral pedicle screw fixation, in patients with degenerative lumbosacral spine disease. To describe the indications, surgical technique and results of a consecutive series of 40 patients who had undergone MI-TLIF. Despite the limited number of clinical studies, published data suggest tremendous potential advantages of this technique. Material and methods Forty patients with radiological findings of degenerative lumbosacral spine disease had undergone MI-TLIF between July 2012 and January 2015. Clinical outcomes were assessed by means of Oswestry Disability Index (ODI) and Health Survey Scoring (SF36) before surgery and at first year follow-up. Furthermore, the following parameters were retrospectively reviewed: age, sex, working activity, body mass index (BMI), type of degenerative disease, number of levels of fusion, operative time, blood loss, length of hospital stay. Results Average operative time was 230 minutes, mean estimated blood loss 170 mL, average length of hospital stay 5 days. The ODI improved from a score of 59, preoperatively, to post-operative score of 20 at first year follow-up. Average SF36 score increased from 36 to 54 (Physical Health) and from 29 to 50 (Mental Health) at first year outcome evaluation. Conclusion MI-TLIF with bilateral pedicle screw fixation is an excellent choice for selected patients suffering from symptomatic degenerative lumbosacral spine disease, especially secondary to recurrent disc herniations.

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.

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.

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. Background There are several non-neoplastic lesions which mimick intramedullary spinal cord neoplasm. 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

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).