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Introduction: Cesarean section is the most prevalent in obstetrics and its rate is rising worldwide every year. Although this operation is considered safe, it is not free from complications. In the present review the topic of lacerations in the fetus during cesarean section is discussed. The rate of fetal lacerations during cesarean section is 0.79-1.9% of all cesareans. Several risk factors for this complication have been elaborated in the literature and are presented in this review. However, so far there is no proven method or technique that has been proven effective in the prevention of this complication. Fetal lacerations are not always identified in the operating room and are discovered later in the newborns department. Most lacerations occur on the fetal scalp and face, however, they can occur everywhere in the body of the fetus. Treatment is performed with adhesive medications or by surgical stitches. Normally, fetal lacerations are expressed later in life as a cosmetic problem but some may cause functional handicap of the affected organs. Every delivery that ends with this complication is followed by a lawsuit against the physicians involved in the case and almost always, the alleged physicians are found guilty. A possible solution to this problem is discussed in the present review.

Introduction: Planning cranioplasty (CPL) in patients with suspected or proven post-traumatic hydrocephalus (PTH) poses a significant management challenge due to a lack of clear guidance., Research Question: This project aims to create a European document to improve adherence and adapt to local protocols based on available resources and national health systems., Methods: After a thorough non-systematic review, a steering committee (SC) formed a European expert panel (EP) for a two-round questionnaire using the Delphi method. The questionnaire employed a 9-point Likert scale to assess the appropriateness of statements inherent to two sections: "Diagnostic criteria for PTH" and "Surgical strategies for PTH and cranial reconstruction.", Results: The panel reached a consensus on 29 statements. In the "Diagnostic criteria for PTH" section, five statements were deemed "appropriate" (consensus 74.2-90.3 %), two were labeled "inappropriate," and seven were marked as "uncertain."In the "Surgical strategies for PTH and cranial reconstruction" section, four statements were considered "appropriate" (consensus 74.2-90.4 %), six were "inappropriate," and five were "uncertain.", Discussion and Conclusion: Planning a cranioplasty alongside hydrocephalus remains a significant challenge in neurosurgery. Our consensus conference suggests that, in patients with cranial decompression and suspected hydrocephalus, the most suitable diagnostic approach involves a combination of evolving clinical conditions and neuroradiological imaging. The recommended management sequence prioritizes cranial reconstruction, with the option of a ventriculoperitoneal shunt when needed, preferably with a programmable valve. We strongly recommend to adopt local protocols based on expert consensus, such as this, to guide patient care., Competing Interests: No conflict of interest is to be disclosed by Salvatore Chibbaro, Thomas Sauvigny, Ivan Timofeev, Harry Mee, and Ismail Zaed. Corrado Iaccarino received educational grants from 10.13039/100009006Integra Lifescience. Franco Servadei received consultancy and speaker fees from Finceramica, Integra Life Sciences, and Upsurgeon. Silvio Franchetti received education grants producing HA., (© 2024 The Authors.)

Background: Brain edema and/or acute hydrocephalus are common features that limit working space during early surgery of aneurysmal subarachnoid hemorrhage (aSAH). Intraoperative ventriculostomy offers an immediate brain relaxation. However, management and complications related to the routine use of intraoperative external ventricular drainage (iEVD) are not well investigated., Methods: We retrospectively reviewed all patients who were treated with pterional craniotomy and clipping for ruptured anterior circulation aneurysms in our center between 2012 and 2019. We included in this study all patients submitted to iEVD using the Paine's point on the side of craniotomy. Indication for positioning of an iEVD was given in all cases whenever initial cisternal dissection was hampered by the lack of cerebrospinal fluid (CSF) circulation due to SAH and/or hydrocephalus., Results: In the study period, 162 patients with aSAH underwent surgical clipping. In 103 patients, an iEVD was used. The overall rate of iEVD-related complications was 6.7%, including 3 cases of catheter misplacement, one case of catheter obstruction, one case of related hemorrhage, and 2 cases of infection. The rate of shunt-dependent hydrocephalus was 16.5% (17/103 patients)., Conclusion: In our experience, iEVD is a safe technique that facilitates dissection during early surgery for intracranial ruptured aneurysms, without requiring an additional burr hole procedure., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Background: Intramedullary spinal cord tumors are rare lesions of the central nervous system. Anatomical, molecular and radiological features are well defined, but correct management is still matter of debate. Pertinent literature has reported conflicting opinions regarding the use of intraoperative electrophysiological monitoring (IONM) in the surgical treatment of this kind of lesions, recently. We report a retrospective study from two Italian centers, in order to highlight the usefulness of IONM in the management of intramedullary lesions., Methods: We performed a retrospective review of patients with intramedullary spinal tumor who underwent surgical resection from February 2011 to February 2018 in two different institutions. Clinical and radiological data, lesion features, timing of symptom onset and IONM findings were recorded. The IONM included somatosensory-evoked potentials (SSEP), motor-evoked potentials (MEP) and D-Wave whenever possible. We evaluated the outcome according to the Modified McCormick scale. We also evaluated the accuracy and relevance of surgical outcomes for each evoked potential (SSEP, MEP, D-Wave)., Results: A total of 57 patients were included. A gross total removal was achieved in 46 cases. Neurological follow-up was assessment at 3 days, and 3 and 6 months after surgery. Comparing the preoperative status and 6 months follow-up: the modified McCormick scale showed a neurological stability for 30 patients (52.63%), a worsening of neurological status for 7 patients (12.28%) and an improvement for 20 patients (35.08%). IONM presented high accuracy (sensibility of 100% and specificity of 95.65%) and significantly predicted postoperative permanent motor deficits (P<0.0001; AUC=0.978). D-Wave appeared to have significant greater predictive value than MEP and especially SSEP alone (0.967 vs 0.722 vs 0.542; P=0.044 and P<0.001 respectively)., Conclusions: The gold standard in the intramedullary lesion treatment is maximal safe resection with good neurological outcome, as shown in our patients. The use of IONM is helpful in intramedullary tumors resection in order to minimize postoperative neurological deficits and our analysis suggests that the use of D-Wave presents a statistically significant higher accuracy for predicting postoperative deficits than SSEP and MEP alone.

Gastric cancer (GC) is the fifth most commonly diagnosed malignancy and the fourth leading cause of cancer death worldwide. Skin metastases from internal organs are rare; skin metastasis from GC occurs even more rarely than skin metastases originating from other organs, and is associated with systematic disease and poor prognosis. The present study described an interesting and rare case of an extensive skin rash in a 42-year-old man diagnosed with GC, which was mainly affecting his left hemithorax, abdomen and back. The rash masqueraded as erysipelas and was initially treated as such; however, it did not respond to antibiotics, corticosteroids and antihistamines. Due to its persistence and location, the rash was biopsied and GC metastasis was confirmed. Third-line chemotherapy was administered and the rash decreased in size; however, the patient suffered from disease deterioration with lung metastases and respiratory failure. The patient eventually died 4 months after the diagnosis of skin metastasis. In conclusion, cutaneous metastasis should be considered as a late and difficult to treat metastasis of GC, which requires high surveillance from medical oncologists, and a multidisciplinary approach for prompt and accurate diagnosis., Competing Interests: The authors declare that they have no competing interests., (Copyright © 2020, Spandidos Publications.)

Objective: Chronic subdural hematoma (CSDH) is one of the most common pathology in daily neurosurgical practice and incidence increases with age. The aim of this study was to evaluate the prognostic factors and surgical outcome of CSDH in patients aging over 90 years compared with a control group of patients aging under 90 years., Methods: This study reviewed 25 patients with CSDH aged over 90 years of age treated in our department. This group was compared with a younger group of 25 patients aged below their eighties. At admission past medical history was recorded concerning comorbidities (hypertension, dementia, ictus cerebri, diabetes, and heart failure or attack). History of alcohol abuse, anticoagulant and antiplatelet therapy, head trauma and seizures were analyzed. Standard neurological examination and Markwalder score at admission, 48 hours after surgery and 1-6 months follow-up, radiologic data including location and CSDH maximum thickness were also evaluated., Results: Their mean age was 92.8 years and the median was 92.4 years (range, 90-100 years). In older group, the Markwalder evaluation at one month documented the complete recovery of 24 patients out of 25 without statistical difference with the younger group. This data was confirmed at 6-month follow-up. One patient died from cardiovascular failure 20 days after surgery. The presence of comorbidities, risk factors (antiplatelet therapy, anticoagulant therapy, history of alcohol abuse, and head trauma), preoperative symptoms, mono or bilateral CSDH, maximum thickness of hematoma, surgical time and recurrence were similar and statistically not significant in both groups., Conclusion: In this study, we demonstrate that surgery for very old patients above 90 years of age affected by CSDH is safe and allows complete recovery. Comparing two groups of patients above and under 90 years old we found that complication rate and recovery were similar in both groups.

Background and Study Aims:  Spinal schwannomas are benign slow-growing tumors, and gross total resection is the gold standard of treatment. The conventional surgical approach is laminectomy, which provides a wide working area. Today minimally invasive surgery (MIS) is popular because it is associated with shorter hospital stay, less operative blood loss, minimized tissue traumas and relative postoperative pain, and, and spine surgery, avoidance of spinal instability., Material and Methods:  From January 2016 to December 2019, we operated on 40 patients with spinal intradural extramedullary tumor (schwannoma) with laminectomy or hemilaminectomy. Baseline medical data, including patients' sex and age, tumor location, days of postoperative bed rest, operative time, length of hospitalization, and 1-month visual analog scale (VAS) value were collected and analyzed. Data analysis was performed using STATA/IC 13.1 statistical package (StataCorp LP, College Station, Texas, United States)., Results:  Hemilaminectomy was associated with faster operative time ( p  < 0.001), shorter postoperative time spent in bed ( p  < 0.001), and shorter hospitalization ( p  < 0.001). At 1-month follow-up, the mean VAS score was 4.6 (1.7) among the laminectomy patients and 2.5 (1.3) among the hemilaminectomy patients ( p  < 0.001). Postoperative complications occurred in 1 (7.7%) and 7 (25.9%) patients in the hemilaminectomy and laminectomy groups, respectively ( p  = 0.177)., Conclusions:  Unilateral hemilaminectomy has significant advantages compared with laminectomy in spinal schwannoma surgery including shorter operative time, less time spent in bed, shorter hospitalization, and less postoperative pain., Competing Interests: None declared., (Thieme. All rights reserved.)

Thoracic disk herniation (TDH) after traumatic injury is a relatively uncommon disease with few cases reported in the literature. Herniated disks in this location typically may result in progressive myelopathy and refractory pain. In the presence of these symptoms, surgical treatment may be indicated since spontaneous regression in this area is less common than that of disk herniations in the cervical or lumbar spine. Herein, we present the case of giant traumatic TDH that occurred at the T9-T10 level and spontaneously resolved after 5 months.We highlight the fact that regression of a herniated disk at the thoracic level may occur even in the absence of treatment. When considering this phenomenon, conservative management of these cases with clinical and radiological monitoring may be an appropriate first-line management for patients without signs of progressive myelopathy or severe refractory pain., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Atypical meningiomas are characterized by a high rate of recurrence and shorter overall survival (OS) compared with grade I meningioma. Predictive parameters for OS and recurrence-free survival (RFS) are controversial., Methods: Patient age, sex, preoperative symptoms, tumor localization, size, Simpson grade, postoperative complications, extent of resection, number of mitoses, MIB1 proliferation index, brain invasion, postoperative radiotherapy, and clinical outcome (Karnofsky performance scale [KPS] postoperatively and at long-term follow-up) were evaluated. Data regarding recurrence rate, mortality, OS, and RFS at 1-, 3-, and 5-year follow-up were also collected. Median follow-up was 76 months; all patients had at least 3 years of follow-up., Results: Between 2007 and 2017, 73 patients underwent surgery for atypical meningiomas (World Health Organization grade II) at 2 centers. Preoperative KPS score >80 as well as 1-month, 6-month, and 1-year follow-up KPS scores were related to better OS. Postoperative complications did not modify OS and RFS. Gross total removal (Simpson grade I, II) was achieved in 80.8% of patients. RFS was statistically influenced by extent of resection (P = 0.002). MIB1 proliferation index >8 was a negative predictive factor for recurrence at univariate and multivariate analysis (P = 0.001 and P = 0.021). Radiotherapy was statistically related to a worse outcome. The incidence of recurrence was 38%. RFS was 98.6% at 1-year follow-up, 81.1% at 3 years, and 57.5% at 5 years. All patients were alive at 1-year follow-up. OS was 90.5% at 3-year follow-up and 78.8% at 5-year follow-up., Conclusions: Despite some limitations, our study demonstrates that aggressive surgical treatment achieving a gross total removal is a positive predictive parameter for RFS as well as a good clinical outcome (KPS score >80) and is related to a longer OS., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: The repositioning of an autologous bone flap after decompressive craniectomy (DC) for traumatic intracranial hypertension remains the first-line treatment for cranial reconstruction. Aseptic autologous bone flap resorption (BFR) is the most frequent complication. The identification of possible predictive parameters for BFR would help to improve the management of these patients., Patients and Methods: Three hundred and nine patients undergoing autologous bone flap repositioning after previous DC for TBI between September 2003 and September 2017 were included in the study., Results: BFR was identified in 76 (24,59 %) of the 309 patients undergoing autologous CP. Age of ≤ 45 years and CP bone fragmentation were seen to be significant independent risk factors for BFR (p =  0.001 and p =  0.018, respectively) using multivariate logistic regression analysis. Of the radiologic predictors, CP size and the gap between CP and the skull defect were independently associated with BFR (p =  0.034 and p =  0.0003, respectively). The Youden index and ROC curve analysis were used to estimate the cut-off values for the continuous parameters and determine the sensitivity and specificity of the radiologic risk factors. The cut-off value for these two factors was found to be 114,98 cm2 and ≥ 578,5 mm2, respectively. The area under the ROC curve was 0.627 for bone flap size and 0.758 for the DC-CP gap. The DC-CP gap had greater sensitivity and specificity as a predictor of BFR, compared to bone flap size (p = 0.079 and p = ≤ 0.001, respectively)., Conclusions: In this large cohort of patients with autologous cranioplasty, younger age, fragmented autologous bone flap and a wide gap between CP and cranial defect were predictive of bone flap resorption., (Copyright © 2020 Elsevier B.V. All rights reserved.)

The use of intraoperative neurophysiological monitoring (IOM) has been proposed to prevent new neurological deficit during aneurysm clipping. The purpose of this meta-analysis was to evaluate if IOM can prevent neurological injury during clipping of intracranial aneurysm. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for systematic reviews and meta-analysis, we reviewed clinical comparative studies who evaluate the rate of new neurological deficit in patients who had a surgical clipping with and without IOM. Of the 268 citations screened, four studies (including 873 patients) met the inclusion criteria and were included in the meta-analysis. Patients who received surgery with IOM had less new neurological deficit than those who underwent surgery without it (p = 0,04). This finding was more significant in the subgroup analysis of two studies focused on middle cerebral artery (MCA) aneurysm (p = 0,02). However, a specific analysis of the three studies reporting the results of IOM to prevent permanent deficit revealed that there is only a trend for less neurological events in monitored patients without statistically significance (p = 0,05). The use of IOM during clipping of intracranial aneurysm was associated with less new neurological deficit with the obtained evidence of the included studies. However, at long-term follow-up the use of IOM did not correlate with a significant improvement in neurological outcome., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Stereotactic gamma knife radiosurgery (GKS) may induce a transient enlargement of vestibular schwannomas (VS). This phenomenon, known as pseudoprogression or swelling, starts at about 3 months following GKS, peaks at about 6 months, and typically subsides thereafter, usually without significant neurological deterioration. We describe a 34-year-old female who developed an aggressive enlargement of a VS 1 month after GKS. The patient was treated with an immediate external ventricular drainage and surgical resection via retrosigmoid approach for an acute neurological deterioration due to hydrocephalus and brainstem compression. Histopathological examination revealed a VS with abundant intratumoral thrombosis and necrosis, suggesting that its rapid expansion could be related to massive radiation-induced tumor necrosis. The present case indicated that rapid life-threating enlargement of a VS may occur as an early complication following GKS.

Post-traumatic supra and infratentorial acute extradural hematomas (SIEDHs) are an uncommon type of extradural hematoma with only few small series published. In this scenario, the purposes of the present study are to present our experience in the management of 8 patients with acute SIEDH and to perform a systematic literature review. The clinical and radiological data of 8 patients operated for SIEDH at our department were analyzed retrospectively. Using the PRISMA guidelines, we reviewed the articles published from January 1990 to January 2018 reporting data about SIEDH. A total of 3 articles fulfilled the inclusion criteria and were analyzed. The incidence of SIEDHs is very rare constituting < 2% of all traumatic extradural hematomas (EDH). SIEDHs are associated with non-specific symptoms. Only 20% of patients were in coma (GCS < 8) at admission. A "lucid interval" was not reported. The source of bleeding of SIEDH was venous in all cases due to the following: bone fracture with diploe bleeding (50%), transverse/sigmoid sinus injury (22%), oozing meningeal venous vessel (8%), detachment of transverse sinus without wall injury (6%), and unknown in the other cases. Due to the venous nature of the source of hemorrhage, the clinical manifestation of a SIEDH may develop in a slow way, but once a critical volume of hematoma is reached, the deterioration can become rapid and fatal for acute brain stem compression. Surgery is the mainstay of SIEDHs treatment: among 42 cases with SIEDH included in this review, 40 (95.23%) patients were treated with surgery while only two were managed conservatively. Also in our series, all patients underwent surgery. A combined supratentorial craniotomy and suboccipital craniotomy leaving in a bone bridge over the transverse sinus for dural tenting sutures resulted the most used and safe surgical approach. SIEDH is a rare type of EDH. Early diagnosis of SIEDH and prompt surgical evacuation with a combined supratentorial and suboccipital approach provide excellent recovery.

Background: Do alterations of cerebrospinal fluid dynamics secondary to decompressive craniectomy (DC) lead to hydrocephalus, and can this effect be mitigated by early cranioplasty (CP)? In this meta-analysis, we evaluated whether the timing of CP decreased the incidence of postoperative hydrocephalus., Methods: We performed a systematic search of PubMed/MEDLINE, Scopus, and the Cochrane databases using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for English language articles (1990-2020). We included case series, case-control, and cohort studies, and clinical trials assessing the incidence of hydrocephalus in adult patients undergoing early CP (within 3 months) versus late CP (after 3 months) after DC., Results: Eleven studies matched the inclusion criteria. The rate of postoperative hydrocephalus was not significantly different between the early (=96/1063; 9.03%) and late CP (=65/966; 6.72%) group ( P = 0.09). Only in the three studies specifically reporting on the rate of hydrocephalus after DC performed to address traumatic brain injury (TBI) alone was there a significantly lower incidence of hydrocephalus with early CP ( P = 0.01)., Conclusion: Early CP (within 90 days) after DC performed in TBI patients alone was associated with a lower incidence of hydrocephalus. However, this finding was not corroborated in the remaining eight studies involving CP for pathology exclusive of TBI., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Surgical Neurology International.)

Background: Cervical spondylotic myelopathy (CSM) is one of the most common diseases in the geriatric population. Decompressive laminectomy or laminoplasty is the predominant surgical procedure of choice, but there remains debate as to which procedure is optimal for managing CSM., Methods: Here, we retrospectively analyzed 64 patients with CSM undergoing laminectomy (39 patients) versus laminoplasty (25 patients). The data were collected included respective Japanese orthopedic association (JOA) scores, Nurick grades, and Visual analog scale (VAS) values preoperatively versus 12 months postoperatively., Results: The JOA score after 1 month improved in both groups utilizing laminectomy or laminoplasty. However, at 12 postoperative months, the JOA scores and Nurick grades showed greater improvement following laminoplasty, despite no differences in postoperative pain and complication rates., Conclusion: Patients with cervical spondylotic myelopathy undergoing laminoplasty (25 patients) showed better 12-month postoperative outcomes (JOA scores and Nurick grades) versus those having laminectomies (39 patients)., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Surgical Neurology International.)

Background: Our hypothesis was that by identifying certain preoperative predictive factors, we could favorably impact clinical outcomes in patients undergoing decompressive surgery for lumbar spinal stenosis (LSS)., Methods: In this retrospective study, there were 65 patients (2016-2018) with symptomatic LSS who underwent decompressive laminectomy without fusion. Their clinical outcomes were assessed utilizing the Oswestry Disability Index (ODI). Multiple preoperative variables were studied to determine which ones would help predict improved outcomes: gender, age, body mass index (BMI), general/neurological examination, smoking, and drug therapies (anxiolytics and/or antidepressants)., Results: All patients demonstrated statistically significant improvement on the ODI. Multivariate analysis revealed that those with higher preoperative BMI had significantly lower ODI on 1-year follow-up examinations, reflecting poorer outcomes. Postoperatively, 44 patients (67%) exhibited lower utilization of anxiolytic medications, 52 patients (80%) showed reduced use of antidepressant drugs, and pain medications utilization was reduced in 33 patients (50%)., Conclusion: Decompressive laminectomy without fusion effectively managed LSS. It reduced patients' use of pain, anxiety, and antidepressant medications. In addition, we found that increased preoperative BMIs contributed to poorer postoperative outcomes (e.g., ODI values)., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Surgical Neurology International.)