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Background and Objectives: Binocular optical microscopy (OM) paved the way for a new era in brain and spine neurosurgery fields with the introduction of microsurgery. Despite its enormous contribution to modern neurosurgery, OM presents some intrinsic limitations that surgeons need to face during procedures such as prolonged non-ergonomic positions and decreased vision quality to the assistant eyepiece. To overcome these limitations, in recent years, new operative tools have been introduced, such as exoscopes. Here, we present our experience with exoscopes in spine surgery. Materials and Methods: In the period between January 2022 and December 2023, we gradually implemented the use of a high-definition 4K-3D exoscope (ORBEYETM, Olympus, Japan) in patients undergoing spinal surgery. Results: A total of 243 patients underwent spine surgery with exoscope magnification (47 intradural tumors, 99 lumbar degenerative cases, 79 cervical degenerative cases, 5 dorsal calcified disk herniations, 4 dural arteriovenous fistulas (dAVFs), and 9 others). We compared this cohort with a similar cohort of patients operated in the same period using OM based on different endpoints: operating time, complication rate, and infection rate. We did not find any statistically significant difference in any of the endpoints between these two groups. Conclusions: In our experience, the exoscope provides a better resolution of spinal anatomy and higher quality real-time images of the surgery for the entire OR team and improves the ergonomic posture of both surgeons, without lengthening the operating time and without increasing the rate of adverse events. Prospective studies with a larger cohort of patients are needed to further validate these findings. [ABSTRACT FROM AUTHOR]

Simple Summary: Central Nervous System (CNS) hemangioblastomas (HBs) are rare and benign tumors that may be sporadic or hereditary, linked mainly to von Hippel–Lindau disease. Considering their slow-growing behavior and the possible risks related to surgical treatment, a careful, tailored approach should be adopted. This work aims to provide a systematic overview of the clinical appearance and neuroradiological characteristics of CNS HBs, along with a report of clinical–radiological data of a mono-institutional retrospective cohort, with particular emphasis on the possible role of intraoperative multimodal imaging to guide surgical strategy. Hemangioblastomas (HBs) are rare, benign tumors often related to von Hippel–Lindau disease. They represent the most frequent primary cerebellar tumors in adults. Neurosurgical procedures aim to obtain a gross-total resection of tumor nodules, avoiding intra-postoperative hemorrhage. The introduction of new intraoperative imaging techniques has considerably changed surgical strategies in neuro-oncology. We present an overview of clinical and radiological data of a mono-institutional retrospective cohort, focusing on the role of intraoperative multimodal imaging in surgical strategy. From 2015 to 2021, we identified 64 (81%) cranial (42 cerebellar, 8 supratentorial, and 14 of the brainstem) HBs and 15 (19%) spinal (4 cervical and 11 dorsal) HBs in 79 patients. Intraoperatively, indocyanine green videoangiography with FLOW800 was used in 62 cases (52 cranial and 10 spinal), intraoperative ultrasound and contrast-enhanced ultrasounds in 22 cases (18 cranial and 4 spinal HBs), and fluorescein in 10 cases (in 6 cranial and 2 spinal cases used as SF-VA). Gross total resection was achieved in 100% of the cases (53 mural nodule removal and 26 complete resections of the solid tumor). No side effects were reported following the combination of these tools. Multimodal intraoperative techniques provide valuable and reliable information to identify the tumor and its vasculature, guiding a more precise and safer resection and reducing the risk of recurrence. [ABSTRACT FROM AUTHOR]

Given the established direct correlation that exists among extent of resection and postoperative survival in brain tumors, obtaining complete resections is of primary importance. Apart from the various technological advancements that have been introduced in current clinical practice, histopathological study still remains the gold-standard for definitive diagnosis. Frozen section analysis still represents the most rapid and used intraoperative histopathological method that allows for an intraoperative differential diagnosis. Nevertheless, such technique owes some intrinsic limitations that limit its overall potential in obtaining real-time diagnosis during surgery. In this context, confocal laser technology has been suggested as a promising method to have near real-time intraoperative histological images in neurosurgery, thanks to the results of various studies performed in other non-neurosurgical fields. Still far to be routinely implemented in current neurosurgical practice, pertinent literature is growing quickly, and various reports have recently demonstrated the utility of this technology in both preclinical and clinical settings in identifying brain tumors, microvasculature, and tumor margins, when coupled to the intravenous administration of sodium fluorescein. Specifically in neurosurgery, among different available devices, the ZEISS CONVIVO system probably boasts the most recent and largest number of experimental studies assessing its usefulness, which has been confirmed for identifying brain tumors, offering a diagnosis and distinguishing between healthy and pathologic tissue, and studying brain vessels. The main objective of this systematic review is to present a state-of-the-art summary on sodium fluorescein-based preclinical and clinical applications of the ZEISS CONVIVO in neurosurgery. [ABSTRACT FROM AUTHOR]

Achievement of complete resections is of utmost importance in brain tumor surgery, due to the established correlation among extent of resection and postoperative survival. Various tools have recently been included in current clinical practice aiming to more complete resections, such as neuronavigation and fluorescent-aided techniques, histopathological analysis still remains the gold-standard for diagnosis, with frozen section as the most used, rapid and precise intraoperative histopathological method that permits an intraoperative differential diagnosis. Unfortunately, due to the various limitations linked to this technique, it is still unsatisfactorily for obtaining real-time intraoperative diagnosis. Confocal laser technology has been recently suggested as a promising method to obtain near real-time intraoperative histological data in neurosurgery, due to its established use in other non-neurosurgical fields. Still far to be widely implemented in current neurosurgical clinical practice, this technology was initially studied in preclinical experiences confirming its utility in identifying brain tumors, microvasculature and tumor margins. Hence, ex vivo and in vivo clinical studies evaluated the possibility with this technology of identifying and classifying brain neoplasms, discerning between normal and pathologic tissue, showing very promising results. This systematic review has the main objective of presenting a state-of-the-art summary on actual clinical applications of confocal laser imaging in neurosurgical practice. [ABSTRACT FROM AUTHOR]

Objective Idiopathic normal pressure hydrocephalus (iNPH) may present, besides the classic triad of symptoms, with extrapyramidal parkinsonianlike movement disorders. We present a randomized prospective study comparing adjustable ventriculoperitoneal (VP) shunt insertion plus dopamine oral therapy (group A) versus VP shunt alone (group B) in patients affected by iNPH associated with parkinsonism. Methods A detailed screening process included neurologic, neurosurgical, and neuropsychological evaluations, followed by a cerebrospinal fluid tap test and resistance outflow measurement. Outcome was evaluated through the Japanese NPH Grading Scale-Revised (JNPHGSR) and the motor (third) section of the Unified Parkinson's Disease Rating Scale, Motor Section (UPDRS-m). Friedman analysis of variance with a Wilcoxon post hoc test was used to evaluate the difference in JNPHGSR and UPDRS-m scores between pretreatment and follow-up (12 months) in the 2 groups, and a Kruskal-Wallis statistic and post hoc Mann-Whitney test were used to compare the change in JNPHGSR and UPDRS-m scores between the 2 groups. Results Thirty-two of 54 (59%) patients (mean age, 73.2 years) screened in 36 months met the inclusion criteria, but only 30 were enrolled (2 refused surgery) (15 in each group). Preoperative 123 I-ioflupane-cerebral single-photon emission computed tomography (DaTSCAN) revealed striatal dopaminergic deficit in 14/30 patients (46.5%). At the final 12 months follow-up, both groups improved JNPHGSR and UPRDS-m scores. The UPDRS-m score improvement was significant in both groups, but greater in group A ( P = 0.003); JNPHGSR score improvement was similar in the 2 groups. Conclusions iNPH associated with parkinsonism may be a frequent finding. In these cases, patients may benefit from VP shunt plus dopamine oral therapy. [ABSTRACT FROM AUTHOR]