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Tuberculum sellae meningiomas (TSM) are challenging tumors due to their proximity to vital neurovascular structures. We propose a new classification system based on anatomical and radiological parameters. All patients treated for TSM, between January 2003 and December 2016, have been retrospectively reviewed. A systematic research was performed in PubMed database to review all studies comparing the performance of transcranial (TCA) and transphenoidal (ETSA) approaches. Overall, 65 patients were included in the surgical series. Gross total removal (GTR) was achieved in 55 patients (85%) and near total resection in 10 (15%). 54 patients (83%) showed a stability or an improvement of visual functions and 11 (17%) worsened. Postoperative complications were observed in seven patients (11%): CSF leak in one patient (1.5%); diabetes insipidus in two (3%); hypopituitarism in two (3%) third cranial nerve paresis and subdural empyema in one (1.5%). For the literature review, data about 10,833 patients (TCA N.=9159; ETSA N.=1674) were recorded; GTR was achieved in 84.1% (range 68-92%) of TCA and in 79.1% (range 60-92%) of ETSA; visual improvement (VI) occurred in 59.3% of TCA (range 25-84%) and in 79.3% of ETSA (range 46-100%); visual deterioration (VD) was registered in 12.7% of TCA (0-24%) and in 4.1% of ETSA (range 0-17%); a CSF-leak was observed in 3.8% of TCA (range 0-8%) while in ETSA in 18.6% of patients (range 0-62%); vascular injuries was reported in 4% (range 0-15%) of TCA and in 1.5% (range 0-5%) of ETSA. In conclusion, TSMs represent a unique category of midline tumors. The proposed classification system provides an intuitive and reproducible method in the choice of the most suitable approach.

Introduction: Neurosurgery is one of the fields in which intraoperative imaging is paramount. One of these main imaging tools that have been acquiring the interest of the neurosurgical community is Ultrasound elastography (USE), which is an imaging technology sensitive to tissue stiffness. Here we present a systematic review of the use of USE in neurosurgery., Evidence Acquisition: A systematic review of the literature has been performed, according to the PRISMA guideline, for the last 30 years on 3 different databases (MEDLINE, Scopus, and Cochrane), to gather all the studies on the use of ultrasound elastography for neurosurgical pathologies, including both clinical and laboratory studies., Evidence Synthesis: A total of 15 articles met the inclusion criteria. USE has widely and safely been used especially for oncological lesions (meningiomas and gliomas) and focal cortical dysplasia. However, there are also encouraging laboratory studies about its application for the management of traumatic brain injury, and ischemic stroke., Conclusions: This systematic review showed that, despite the lack of strong evidence, USE is a valid intraoperative tool, especially in oncological neurosurgery.

Introduction: Adjacent segment degeneration is among the most recognized long-term complications of lumbar surgery for degenerative spine pathologies with a relevant impact in spine surgical and clinical practice. It is reported a incidence of clinical adjacent segment disease between 5-30% of patients undergoing spinal fusion. We aimed to evaluate the main clinical and surgical risk factors for developing adjacent segment disease., Evidence Acquisition: A systematic review and meta-analysis of the pertinent literature was performed, according to PRISMA and PICO guidelines, focusing on clinical and radiological adjacent segment disease. We exclusively included studies reporting demographic and clinical data, and surgical details published from 30 September 2015 to 30 September 2020. The effect of considered risk factors on the presence of adjacent segment disease was explored with a random-effects model., Evidence Synthesis: A total of 15 scientific publications, corresponding to 6253 patients, met the inclusion criteria for the qualitative and quantitative analysis. 720 of the patients developed a clinical and/or radiological adjacent syndrome disease, and 473 have been surgically managed. Ten articles qualified for the comparative geographical analysis. Advanced age and obesity are relevant risk factors for developing lumbar adjacent segment degeneration. Our data also reported a higher prevalence of adjacent segment degeneration in Western populations than in Eastern populations. The interbody fusion has a protective role toward lumbar adjacent segment degeneration., Conclusions: This study highlighted multifactorial issues regarding adjacent segment disease: clinical, anatomical, biomechanical, and radiological features. In view of increasing life expectancy and spinal surgery procedures, extensive multicenter studies will be needed to define the correct management of the adjacent segment disease.

Introduction: The recent emphasis on simulation-based training in neurosurgery has led to the development of many simulation models and training courses. We aimed to identify the currently available simulators and training courses for neurovascular surgery and endovascular interventions to assess their validity and determine their effectiveness to suggest widespread applicability in educational curricula., Evidence Acquisition: Literature research was performed on academic databases for English language articles that validate simulation or virtual reality intracranial aneurysm models. Studies for neurosurgery and interventional neuroradiology published between January 2011 and January 2021 were included. Each study was assessed according to the Medical Education Research Quality Instrument., Evidence Synthesis: Between January 2011 and January 2021, 44 articles were screened and 12 were identified to be included in our research. The study involved 177 trainers. Participant trainers' characteristics reveal sensible homogeneity between studies. All studies reported a significant improvement in technical outcomes after simulator or virtual reality training. The Medical Education Research Quality Instrument average rate from 12 studies was M=11.7 (range: 8.5-14.5)., Conclusions: Nowadays, the training of a medical doctor in the neurovascular field benefits from modern methods like simulators and virtual reality. With the advent of increasing neurosurgery simulators and training instruments, there is a need for more validity studies. More training tools incorporating full-immersion simulation are recommended to develop a standardized learning curve in neurovascular procedures.

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.

Blood blister-like aneurysms (BBA) consist of focal wall defects covered with thin fibrous tissue correlated with the marked fragility of their wall; this concept is very important for deciding the right treatment of the latter. Until 2008, it was thought that this type of aneurysm almost exclusively affected the internal carotid artery, and in particular, of its dorsal portion. Subsequently, it was discovered that the BBA may also be present on the anterior communicating artery and on the posterior cranial fossa vessels. In this article, we present a case of anterior communicating artery (AComA) BBA and discuss the unique diagnostic and therapeutic aspects of this vascular lesion. Treatment requires an experienced team of vascular and endovascular neurosurgeons to treat this hazardous group of aneurysms; endovascular stenting techniques avoid maneuvres on the aneurysm itself and should therefore be judged as the lowest risk and first-choice procedures available. We found no reports in the English-language literature of BBA that arose from the AComA treated by a Flow-diverter stent (FDS) in the acute phase. BBA constitute technically challenging lesions that may occur at the AComA. Endovascular treatment offers a lower morbidity-mortality compared with surgical approaches; FDS appear to be a promising strategy.