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Background Intracranial artery dissection is a rare and generally under-recognized cause of ischaemic stroke or subarachnoid haemorrhage. Objectives The aim of this study was to analyse the efficacy of cone-beam computed tomography angiography (CBCT-A) to detect arterial ultrastructural alterations in intracranial artery dissection. Method This is an observational and retrospective case series. Results Between January 2018 and November 2020, four patients were admitted with an acute ischaemic stroke due to intracranial dissection studied with CBCT-A. In all cases, the CBCT-A documented vascular ultrastructural alterations related with the intracranial dissection. Conclusions CBCT-A is an intraprocedural diagnostic technique that is useful for the diagnosis of intracranial dissections.

Objectives We present a challenging case of a 61-year-old male patient with a double meningioma. The first one was located on the right side of foramen magnum and the second one was located on left anterolateral side of C1–C2. Background Patient referred at our institution for a progressive spastic paraparesis from approximately 1 year with a recent onset of numbness in right hand. Neuroradiological imaging showed an extra-axial enhancing tumor with a dural tail on the right border of foramen magnum and another contralateral extra-axial enhancing lesion at C1–C2 level (Fig. 1). Results We have chosen a park bench position. Neurophysiological monitoring was used during both positioning and surgery. A linear skin incision in the occipital region extended to C7 was performed and a suboccipital craniotomy with the laminectomy of C1–C3 was performed (Fig. 2). Videofluroangiography was performed to the best visualization of the vertebral artery position during microsurgical dissection and exposure of craniovertebral junction region. An Y-shape dural opening was executed and two meningiomas was resected with the classical four D steps (devascularize, detach, debulking, and dissect). All anatomical structures were respected and there were no changes at neuromonitoring. Patient was discharged after 10 days in good neurological condition. Conclusion a single approach for multiple meningiomas of the craniovertebral junction and upper cervical spine region is feasible and effective. Videofluoroangiography as a way to achieve better visualization and control of the vertebral artery, and neurophysiological monitoring are crucial tools to reduce the morbidity of this surgical challenge.The link to the video can be found at: https://youtu.be/4w9HCfQZkgg.

Introduction Glioblastoma treatment requires a multidisciplinary approach involving oncologists, radiotherapists and surgeons. Surgery constitutes the initial step of the therapeutic strategy and its efficacy is dependent on the extent of resection (EOR). Over the last decade, the goal of surgical treatment was the resection of the contrast enhancement on T1 MRI, defined as gross-total resection (GTR). More recently, an increasing number of studies reports a positive impact on survival parameters of a more aggressive surgical strategy aiming to resect all peri-tumoral infiltrated areas. These areas are histologically characterized by the presence of pathological cells infiltrating normal white matter and surround the neoplastic core of glioblastoma identified by gadolinium enhancement in T1-weighted MR. Intuitively, the major risk of the so called supramarginal resection is related to the possibility of resecting functionally eloquent brain tissue. Several strategies have been proposed to maximize the safety of resection and minimize the occurrence of postoperative functional deficits. The aim of this review was to focus on the clinical impact of supramarginal resection of glioblastomas, highlighting the role of image-guided surgery combined with neuromonitoring to increase surgical safety and efficacy. Evidence acquisition The MEDLINE database has been queried for the literature research. Evidence synthesis Ten studies matched the inclusion criteria, reporting a global number of 3221 patients. Conclusions The current evidence suggests a positive correlation between a more extensive resection based on FLAIR abnormal areas and overall survival.

Background There are no current evidence-based recommendations on mechanical thrombectomy (MT) in M2 or other distal occlusions. The objective of this paper was to investigate clinical and radiologic outcomes of MT in distal locations using the new generation of mini-0.017 microcatheter compatible—stent retrievers (SRs) compared with a direct aspiration first pass technique (ADAPT) MT. Methods A systematic search was performed for studies published from January 2016 to March 2019. According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies that reported clinical and radiologic outcomes of patients undergoing MT using new generation of SRs or ADAPT in distal locations. The cumulative prevalence was estimated for each outcome. Heterogeneity of the data was assessed by the Higgins index (I2), and a random-effects model was applied. Results Fifteen studies and 494 patients were included; 7 studies reported on patients treated with a new SR and 8 studies analyzed patients treated with ADAPT. The rate of thrombolysis in cerebral infarction score 2b–3 after MT for distal occlusions was 80.6% (383 of 494; 95% confidence interval [CI], 74.8%–86.3%; I2 = 64.4%). Successful recanalization was comparable after SR use with low-profile devices and ADAPT (176 of 226; 82%; 95% CI, 72.6%–1.5%; I2 = 70.5% vs. 207 of 268; 79.4%; 95% CI, 71.8%–86.9%; I2 = 60.8%, respectively; P = 0.4). The rate of the modified Rankin scale score of 0–2 at 3 months was higher in the ADAPT group (160 of 251; 68.9%; 95% CI, 51.8%–85.9%; I2 = 92.2%) than the SR group (92 of 177; 58.7%; 95% CI, 37.3%–80%; I2 = 58.7%; P = 0.01). The mortality rate was lower among the ADAPT group (20 of 251; 5.4%; 95% CI, 1.4%–9%; I2 = 63%) than the SR group (16 of 108; 13%; 95% CI, 6%–19%; I2 = 13%; P = 0.008). Conclusions MT in distal locations using the new generation of SR yields comparable results compared with ADAPT in terms of recanalization; however, the use of SR is associated with lower functional independence and higher mortality rate.

Background:Melanocytomas are rare pigmented tumors of the central nervous system (CNS). They are more frequent in females in their fifties and are typically benign, but locally aggressive lesions that very are rarely found in the spine. They can occur in all the age groups.Case Description:A 62-year-old male presented with acute paraplegia a attributed to a C7-T1 intradural extramedullary melanocytoma. Urgent surgery, consisting of subtotal removal of the lesion, resulted in subtotal recovery of motor function with full resolution of his sensory deficit. Histologically, the lesion proved to be a melanocytoma.Conclusion:Rarely, patients with intradural extramedullary melanocytomas of the spine may present with acute paralytic deficits warranting emergent surgical intervention.

Among many factors leading to a worse functional prognosis in spinal meningioma (SM) surgery, in a previous study, we recognized anterior/anterolateral axial topography, sphincter involvement at first evaluation, surgery performed on a recurrence, and worse preoperative functional status. The purpose of this paper is to evaluate the cumulative weight of these factors on prognosis through a multinomial logistic regression model performed on an original evaluation scale designed by the authors on the ground of the experience of the neurosurgical departments of our University. The original SM database composed of 173 cases was classified in regard to sex, age, symptoms, axial and sagittal location, Simpson grade resection, and functional pre/postoperative status. Fine presurgical and follow-up reevaluations were available. The authors propose a scale (Spinal Meningiomas Prognostic Evaluation Score (SPES)) of preoperative evaluation to assess the surgery-related risk of neurological worsening experienced by the patients included in the present cohort. The authors describe a strong statistical association between the SPES and the follow-up Frankel and McCormick scores (r = - 460 and .441, p .001, both). Through a univariate ANOVA analysis, we disclosed that patients presenting scores 2 and 3 had a significantly higher association to lesser Frankel and McCormick postoperative scores, in respect to patients presenting SPES scores 0-1 (univariate ANOVA, p .008 and .011). Anterior or anterolateral axial location, operating on a recurrence of SM, sphincter involvement, and worse functional grade at onset present, along with the SPES scores are fairly predictive and reliable in respect to the long-term results of patients suffering from SM.

Objectives: To assess the delayed (15 days) histological and ultrastructural changes occurring following endovascular treatment with a direct aspiration first pass technique (ADAPT) or stent retrievers (SRs) and to compare the findings in order to determine which is the least harmful technique and what changes occur. Materials and Methods: Damage to the wall of swine extracranial arteries was evaluated after ADAPT with the Penumbra system or thrombectomy with various SRs. The procedures were performed using two pigs as animal models; extracranial cervical arteries were selected based on their diameters in order to reproduce the procedures as in human intracranial arteries, and endovascular thrombectomies were done after the injection of autologous thrombi. Two weeks later, the animals were euthanized, and 60 arterial samples were obtained for analysis by optical and electron microscopy. Results: Optical and electron microscopy revealed that both techniques cause, in different way, alterations to the structure of the vessel wall. Conclusions: Both techniques caused damage to the vessel wall. The main damages were localized at the level of the tunica media and adventitia, instead of the tunica intima as in the acute phase. Further investigation is required to better understand whether these alterations could have chronic consequences.

Objective Craniovertebral junction (CVJ) meningiomas are one of the most surgically complex conditions in neuro-oncologic surgery. The aim of this work is to correlate our data with clinical outcome to outline factors leading to a worse functional prognosis. Methods We analyzed sex, age, clinical presentation, topography, surgical approach, Simpson grade resection, postoperative lower cranial nerve deficits, consistency, histology, site of origin, presence of a capsule, and radiologic and clinical follow-up at 1, 6, and 12 months of 61 patients affected by CVJ meningiomas, operated on in our institution from 1992 to 2014. Results 78.7% of patients were women (mean age, 52.85 years); the onset symptom was pain in 65.5% of cases. The mean preoperative Nurick grade of the sample was 3.78; the most frequent histologic type was endotheliomatous (42.8%). We treated 22 patients with a posterior median approach (5 with lateral and 17 with posterolateral axial topography); in 39 cases (30 anterolateral and 9 anterior) we performed a posterolateral approach. Gross total removal was achieved in 85.2% of cases. We recorded a final follow-up step overall neurologic improvement in the cohort (average preoperative Nurick grade, 3.81, and at 12 months, 2.13). Twenty-nine patients presented with lower cranial nerve deficit (permanent or transient) and no statistically significant association was found between surgical approach and temporary or permanent postoperative complications. Conclusions We selected, in our experience, some predictors of worse outcome: preoperative sphincter impairment, absence of a capsule, cranial site of origin, a poor preoperative functional status, and firm consistency of the tumor.

Brain abscess is a serious life threatening condition. Leading causes include open head injury, history of neurosurgical procedure, dissemination from distant abscessual foci, sepsis, continuity spreading. Most common pathogens involved in genesis of brain abscesses are Streptococcus and Staphylococcus spp. depending on the pathogenetic mechanism. The aim of this study is to report a brain abscess sustained by Bacillus Simplex, a microorganism thought to be responsible of food-borne diseases, whose marginal role is recognized in human pathology, but in this case, for the first time in literature, described as suspected as cause of brain abscess.

Background Spinal meningiomas are common spinal tumors, in most cases benign and with a good surgical prognosis. However, specific location, infiltration of spinal cord, vascular encasement, or spinal root involvement can bring a less favorable prognosis. Objective To correlate these data with clinical/functional outcome. Methods Two hundred twenty-four consecutive patients with spinal meningiomas treated from 1976 to 2013 in our institution were analyzed; among these, 51 were excluded for incomplete clinical data or follow-up. The remaining 173 cases were classified in regards to sex, age, symptoms, axial location, Simpson grade resection, and functional pre-/postoperative status. Results Most recurring onset symptoms were pain (32.9%) and motor deficit (31.8%); thoracic spine was the most severely affected (69.8%). Functional improvement on the follow-up was observed in 86.7% of cases; 6.4% of patients resulted stable and 6.9% worsened. A low functional grade before surgery was connected to a lesser improvement after. Anterolateral meningiomas were the most represented (42.2%); a gross total resection (Simpson grades I and II) was conducted in 98.8%, and a macroscopically complete removal without dural resection or coagulation (Simpson grade III) was performed in 1.2%. Of the meningiomas, 98.3% were classified as WHO grade I. Recurrence rate was 2.3%, and 7 cases presented complications (4 of 7 required surgical procedure). Conclusion We can affirm that negative prognostic factors in our study were anterior or anterolateral axial location, prolonged presentation before diagnosis, WHO grade >I, Simpson grade resections II and III, sphincter involvement, and worse functional grade at onset.

We report a case of brain abscess following the percutaneous treatment for trigeminal neuralgia. This procedure envisages the access with a needle into the middle cranial fossa through the oral cavity. Thus, in this case, the bacterial infection can be more likely ascribed to the possible contamination of the needle inside the oral cavity rather than to other frequent and more controllable causes of infection like an imperfect sterilization of surgical instruments or an inadequate antiseptic preparation of both operator’s hands and patient’s skin. The subsequent brain abscess was treated with antibiotic therapy (Vancomycin 2 gr a day and Meropenem 8 g a day for 22 days before the surgical procedure and 30 days after, until complete normalization of laboratory parameters, clinical parameters, and neurological symptoms) and surgical drainage, although the culture of the abscess capsule and the purulent material resulted sterile. In conclusion, the percutaneous therapy for trigeminal neuralgia can be objectively related to risks, even if performed by expert hands. Therefore, it is important that the patient should be advised regarding risks/benefits and/or septic complications of such procedures, even if they occur very seldom. An association of surgery and antibiotic therapy results as effective treatment for this pathologic condition.

IntroductionSpinal meningiomas are common spinal tumors in most cases benign and with a good surgical prognosis. However, specific location, infiltration of spinal cord, vascular encasement or spinal root involvement can bring to a less favorable prognosis. Aim of this work is to systematically the influence of this factors in the neurological outcomes of our patients.Matherial and Methods224 consecutive patients with spinal meningiomas treated from 1976 to 2013 in our institution were analyzed; among these 51 were excluded for incomplete clinical data or follow up. The remaining 173 cases were classified regarding to: sex, age, symptoms, axial location, Simpson Grade resection, Functional pre/postoperative status.ResultsMost recurring onset symptoms were pain (32,9%) and motor deficit (31,8%); Thoracic spine was the most severely affected (69,8%). The functional improvement on the follow up was observed in 86,7% of cases, 6,4% of patients resulted stable and 6,9% worsened; a low functional grade before s...