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Background: High-Grade Gliomas are the most common primary brain malignancies and despite the multimodal treatment, and the increasing amount of adjuvant treatment options the overall prognosis remains dismal. The present investigation aims to analyze the safety profile of the use of intraoperative ultrasounds (Io-US) in a homogeneous and matched cohort of patients suffering from High-grade gliomas (HGG) operated on with or without the aid of Io-US and Fluorescein in specific relation to the incidence of neurological and functional status sequelae. Methods and materials: A retrospective analysis was performed on 74 patients affected by HGG. 22 patients were treated with Io-US matched with neuronavigational system (Group A); 15 patients were treated both with the use of Io-US and Fluorescein matched with neuronavigational system (Group B); 37 patients were treated with the use of the neuronavigational system only (Group C). Primary endpoints were the extent of resection and functional outcome (measured with Karnofski Performance Status) Results: Significative differences were observed in terms of a higher extent of resection in Group B. In a multivariate analysis, this data appears to be independent of the location (eloquent/non-eloquent) of the lesion and from its histology. Regarding functional outcomes, no differences were detected between the two groups. Conclusions: The present study is the first that analyzes the simultaneous use of Io-US and Fluorescein, and the results demonstrate that these two instruments together could improve the extent of resection in HGG while ensuring good outcomes in terms of functional status.

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.

Introduction: Intraoperative Neurophysiological Monitoring (IOM) is widely used in neurosurgery but specific guidelines are lacking. Therefore, we can assume differences in IOM application between Neurosurgical centers. Research question: The section of Functional Neurosurgery of the Italian Society of Neurosurgery realized a survey aiming to obtain general data on the current practice of IOM in Italy. Materials and methods: A 22-item questionnaire was designed focusing on: volume procedures, indications, awake surgery, experience, organization and equipe. The questionnaire has been sent to Italian Neurosurgery centers. Results: A total of 54 centers completed the survey. The annual volume of surgeries range from 300 to 2000, and IOM is used in 10–20% of the procedures. In 46% of the cases is a neurologist or a neurophysiologist who performs IOM. For supra-tentorial pathology, almost all perform MEPs (94%) SSEPs (89%), direct cortical stimulation (85%). All centers perform IOM in spinal surgery and 95% in posterior fossa surgery. Among the 50% that perform peripheral nerve surgery, all use IOM. Awake surgery is performed by 70% of centers. The neurosurgeon is the only responsible for IOM in 35% of centers. In 83% of cases IOM implementation is adequate to the request. Discussion and conclusions: The Italian Neurosurgical centers perform IOM with high level of specialization, but differences exist in organization, techniques, and expertise. Our survey provides a snapshot of the state of the art in Italy and it could be a starting point to implement a consensus on the practice of IOM.

Introduction: Normal-pressure hydrocephalus (NPH) is a common condition associated with a cognitive deterioration and possibly involving up to 9%-14% of all nursing home residents older than 65 years old. The purpose of the present paper is to introduce an inclusive study protocol aimed at increasing the diagnostic precision and follow-up accuracy., Methods: A total of 28 patients were operated on for NPH in our institution in the period ranging between January 2015 and December 2019. All the patients underwent magnetic resonance imaging of the brain with standard sequences, calculation of the Evans index and corpus callosum angle, and evaluations by means of Montreal Cognitive Assessment (MOCA), Mini-Mental State Examination, and Frontal Assessment Battery (FAB) neuropsychological tests preoperatively and at 1 and 6 months. A preoperative lumbar test infusion (LIT) with fine measurement of the intrathecal pressures at the beginning and at the end of the procedures was performed., Results: MOCA and FAB proved an overall improvement of the neurocognitive conditions at 1 month postoperatively. The mean pressure at the beginning of the LIT, was negatively associated with the neuropsychological outcome variables (Mini-Mental State Examination, FAB, and MOCA) in the 3 different evaluations, with FAB and MOCA at 6 months. We found a strong positive correlation between the Evans index as measured on the first magnetic resonance imaging scan both with the diastolic and systolic pressure at the beginning of the test., Conclusions: Neuropsychological assessment, combined with LIT with intrathecal pressure managements aids the diagnostic process in patients affected by NPH. It allows standardizing in a rigorous fashion the follow-up evaluation of patients undergoing surgery for a ventriculoperitoneal shunt., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Malignant middle cerebral artery infarction (mMCA) is a devastating disease with rates of fatality as high as 80%. Decompressive hemicraniectomy (DHC) reduces mortality, but many survivors inevitably remain severely disabled. This study aimed to analyze patients with mMCA undergoing DHC or best medical treatment (BMT) baseline characteristics and factors linked to therapeutic choice and determinants of prognosis., Methods: We recorded clinical and radiological features of patients undergoing BMT or DHC. The two groups were compared for epidemiology, clinical presentation, neuroimaging, and prognosis. Regression analysis was performed to identify predictors of surgical treatment and outcome., Results: One hundred twenty-five patients were included (age 67.41 ± 1.39 yo; 65 M). Patients undergoing DHC (N = 57) were younger (DHC 55.71 ± 1.48 yo vs. BMT 77.22 ± 1.38) and had midline shift (DHC 96.5% (55/57) vs. BMT 35.3% (24/68), a larger volume of the affected hemisphere and reduced ventricles volume as compared to BMT. The chance of surgery depended on age (Exp(B) = 0.871, p < 0.001), clinical status at onset (NIHSS Exp(B) = 0.824, p = 0.030) and volume of the ventricle of the affected hemisphere (Exp(B) = 0.736, p = 0.006). Death rate during admission was significantly lower for DHC (DHC 15% (6/41) vs BMT 71.7% (38/53), Fisher's test = 30.234, p < 0.001)., Conclusion: Although DHC may cause prolonged hospitalization and long-term disabled patients, it is a lifesaving therapy that should be considered for selected patients with mMCA but perioperative complications and cost-utility should be considered. Patients and families should be correctly counseled about this therapeutic choice and its short- and long-term consequences., Competing Interests: Declaration of Competing Interest The Authors declare that there is no conflict of interest., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: Vertebral body erosion (VBE) is commonly caused by neoplastic, inflammatory, or infectious diseases: it can be rarely associated with aortic wall disorders, such as chronic contained rupture of aortic aneurysm (CCR-AA). CCR-AA is a rare event comprising <5% of all reported cases. This condition is easily undiagnosed, differential diagnosis may be challenging, and there is no consensus or recommendation that dictates guidance on management of spinal surgical treatment., Methods: We performed a systematic review of the literature of all cases of VBE secondary to CCR-AA to identify clinical, radiologic, and surgical outcome characteristics with the aim of providing a basis for future research studies., Results: The search returned 80 patients. All reported patients had a history of hypertension. In almost all patients, the AA size reported was high (mean diameter, 7.056 cm). The treatment of this condition involves various reported treatment strategies: a totally conservative approach, treatment of the aortic aneurysm through a minimally invasive endovascular procedure, or an open surgery and combined approach. Despite the wide variability in therapeutic strategy, the rate of good outcomes was relatively high at 80%., Conclusions: Back pain and pain along the vertebral column are such frequent symptoms that unusual causes or serious and life-threatening complications may be overlooked. In addition to the common traumatic and degenerative causes of back pain, AA must also be considered. A combined approach between vascular and spine surgery could be achieved without any increased risk., (Copyright © 2021 Elsevier Inc. All rights reserved.)

We describe the case of a 33-year-old woman with a history of over 15 years of a slow growing firm osseous-like right retroauricular mass. Surgical resection was easily performed using a sharp technique, because of a clear cleavage plane. The histologic diagnosis was a rare, unexpected, protuberant fibro-osseous lesion named "Bullough lesion." Only few cases of this benign pathologic entity have been described in English literature. Clinical differential diagnosis must be done with osteoma, periosteal chondroma, and other fibro-osseous lesions such as fibrodysplasia and ossifying fibroma. Because of the paucity of data, the natural history of this lesion is unknown and serial clinical and radiological follow-up is advised., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Decompressive craniectomy (DC) is a known risk factor for the development of post-traumatic hydrocephalus. The occurrence of subdural hygroma (SH) was also reported in 23-56% of patients after DC and it seemed to precede hydrocephalus in more than 80% of cases. We analyzed the relationship among DC, SH and hydrocephalus., Methods: From 2007 to 2011, 64 patients underwent DC after head trauma. Variables we analyzed were: intaventricular hemorrhage, age, GCS, distance of craniectomy from the midline, evacuation of a hemorrhagic contusion (HC) and infection. Logistic regression was used to assess the independent contribution of the predictive factors to the development of hydrocephalus., Results: Nineteen patients (29.7%) developed hydrocephalus. Interhemispheric SH was present in 8/19 patients with hydrocephalus and temporally preceded the occurrence of ventricular enlargement. Moreover, most patients who developed a interhemispheric SH had been undergone DC whose superior margin was close to the midline. Logistic regression analysis showed that craniectomy closer than 25 mm to the midline was the only factor independently associated with the development of hydrocephalus., Conclusion: Craniectomy close to the midline can predispose patients to the development of hydrocephalus. SH could be generated with the same mechanism, and these three events could be correlated on a timeline., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Objective: Treatment of glioblastoma recurrence can have a palliative aim, after considering risks and potential benefits. The aim of this study is to verify the impact of surgery and of palliative adjuvant treatments on survival after recurrence., Methods: From January 2002 to June 2008, we treated 76 consecutive patients with recurrent glioblastoma. Treatment was: 1-surgery alone--17 patients; 2-adjuvant-therapy alone--24 patients; 3-surgery and adjuvant therapy--16 patients; no treatment--19 patients. The impact on median overall-survival (OS-time between recurrence and death/last follow-up) of age, Karnofsky performance scale (KPS), resection extent and adjuvant treatment scheme (Temozolomide alone vs low-dose fractionated radiotherapy vs others) was determined. Survival curves were obtained through the Kaplan-Meier method. Cox proportional-hazards was used for multivariate analyses. Significance was set at p<0.05., Results: Median OS was 7 months. At univariate analysis, patients with a KPS≥70 had a longer OS (9 months vs 5 months--p<0.0001). OS was 6 months for patients treated with surgery alone, 5 months for patients that received no treatment, 8 months for patients treated with chemotherapy alone, 14 months for patients treated with surgery and adjuvant therapy--p=0.01. Patients with a KPS<70 were significantly at risk for death - HR 2.8 - p=0.001. Subgroup analysis showed no significant differences between patients receiving gross total or partial tumor resection and among patients receiving different adjuvant therapy schemes. Major surgical morbidity at tumor recurrence occurred in 16 out of 33 patients (48%)., Conclusion: It is fundamental, before deciding to operate patients for recurrence, to carefully consider the impact of surgical morbidity on outcome., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Objective: The management of post-traumatic ventriculomegaly (PTV) is controversial. This is due to the difficulty to determine whether PTV is related to an atrophic process or to a true "active" hydrocephalus. The purpose of this study is to analyze the CSF-dynamics in patients with PTV and, possibly, to identify parameters that correlate with prognosis., Methods: 15 patients with PTV were treated following this protocol: 1-frontal ventriculostomy (with Rickham reservoir); 2-CSF-dynamics evaluation; 3-ventriculo-peritoneal shunt. CSF dynamics evaluation was based on an intraventricular infusion test (performed three to five days after ventriculostomy). Outflow Resistance (R-out) and Intracranial Elastance Index (EI, i.e. the reciprocal of intracranial compliance) were calculated. Patients were classified according to response to shunt into: 1-fast responders: rapid clinical improvement, i.e. within days/one month from surgery; 2-slow responders: patients presenting little clinical improvement occurring after months (despite neurorehabilitation); 3-non responders: no clinical improvement., Results: Seven patients (46.7%) were classified as fast-responders, three patients were classified as slow-responders (20%) and five patients were classified as non-responders (33.3%). Opening CSF pressure was less than 15 mmHg for all patients. R-out (cut-off >10 mmHg/ml/min) had 100% sensitivity, 50% specificity, 100% negative predictive value and 63.6% positive predictive value. EI (cut-off value >0.3) had 100% specificity, 42.4% sensitivity, 100% positive predictive value and 66.7% negative predictive value., Conclusions: Based on these considerations, we can suggest that, for patients with normal pressure PTV, analysis of CSF dynamics could be of help in selecting patients for CSF-shunt. A combination of Intracranial Elastance and of R-out could help predicting shunt responsiveness., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Objectives: Glioblastoma recurs within 2 cm from the primary tumor's margins in 90-95% of cases. Natural history of recurrence is not well defined. The aim of this study was to verify if pattern of recurrence can be influenced by the extent of surgery., Patients and Methods: 131 patients with glioblastoma underwent tumor removal, followed by standard adjuvant radio-chemotherapy. Depending on the amount of apparently normal white matter measured around the tumor in the surgical specimen, the extent of surgery was classified into: "border resection" (BR, resection margins at the level of tumor border) or "extended resection" (ER, resection margins 1-2 cm far from tumor border). 88 patients had no residual tumor at post-operative MRI. Among these, 60 patients had a local recurrence (LR) - within 2 cm from the primary tumor's margins, 15 patients had a distant recurrence (DR), 13 patients had no recurrence. Survival curves were obtained through the Kaplan-Meier method. Dichotomous data were compared with the chi-square test., Results: Patients who underwent ER presented a LR in 67% of cases. Patients who underwent BR presented a LR in 87.5% of cases (p=0.03). Survival for 60 patients with LR was 16 months vs 35 months for 15 patients with DR (p=0.06). PFS for patients with LR was 9 months vs 21 months for patients with DR (p=0.05)., Conclusions: If tumor grows far from eloquent areas, ER may increase the probability to obtain a gross total resection, a greater number of patients with DR and, therefore, a longer survival., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Objectives: Post-traumatic hydrocephalus (PTH) is commonly considered as a relative contraindication for endoscopic third-ventriculostomy (ETV). However, few studies are available on this topic., Methods: An analysis of the papers published in the last ten years has been performed, in order to assess the level of evidence on which the current indication for ETV for PTH is based. References were identified by PubMed searches of clinical articles relating to both PTH and ETV. Laboratory investigations were excluded., Results: Only 5 articles were selected, for a total of 15 patients with PTH treated with ETV. All these patients were described by the authors to have a communicating hydrocephalus. No complications of surgery were reported. Outcome data were not available for one patient. Thirteen out of the remaining 14 patients had a clinical improvement after the surgical procedure (93%). Direct or indirect information on pre-operative ICP was available for 11 cases. Eight of them had an elevated ICP and presented a clinical improvement after ETV., Conclusions: There is no current evidence to support that PTH is a contraindication for ETV. Our data suggest that we could reconsider ETV for the treatment of PTH, especially for patients with elevated ICP. Prospective clinical trials (involving several centers, due to the difficulty of recruiting patients with PTH) are needed., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Background: Despite advances in the treatment of acute lymphoblastic leukemia (ALL), overt meningeal leukemia remains a dire condition. The role of intraventricular chemotherapy (IVC) in its treatment is still a matter for debate. Data suggesting benefit from it have been countered by statements of concern regarding the potential complications associated with its use. This report details our results from using IVC., Patients and Methods: We compared two groups of adult patients with ALL at their first meningeal involvement. Twelve of them were submitted to ILC and 9 to IVC., Results: Our data showed that IVC yielded a higher rate of complete response (88% vs. 33%) and a lower incidence of second CNS relapse than did ILC (none vs. 50%). Even though there were more long-term disease-free survivors (33% vs. 8%) among the IVC patients, the difference in median event-free survival was not significant (120 vs. 80 weeks; p = 0.66). IVC was associated with a longer overall survival (p = 0.005) and CNS remission time (p = 0.046). Two cases refractory to ILC were later fully responsive to IVC. There were 22% device-related and 11% drug-related complications., Conclusions: The results are promising, but the small series does not allow for any definite conclusion. In our opinion, the hazards inherent in the placement and operation of the device do not outweight the benefits of IVC for the treatment of overt meningeal leukemia and should not preclude its use. Accurate neurosurgical technique, meticulous care in drug administration and experience with this form of therapy can all contribute to minimizing complications so that full advantage can be taken of IVC's potential.