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Object Preoperative image-based neuronavigation-assisted endoscopy during intracranial procedures is gaining great interest. This study aimed to analyze the precision of navigation-assisted endoscopy according to the navigation setup, the type of optic and its working angulation. Methods A custom-made box with four screws was referenced. The navigation-assisted endoscope was aligned on the screws (targets). The precision on the navigation screen was defined as the virtual distance-to-target between the tip of the endoscope and the center of the screws. Three modifiers were assessed: (1) the distance D between the box and the reference array (CLOSE 13 cm – MIDDLE 30 cm – FAR 53 cm), (2) the distance between the tip of the endoscope and the navigation array on the endoscope (close 5 cm – middle 10 cm – far 20 cm), (3) the working angulation of the endoscope (0°-endoscope and 30°-endoscope angled at 90° and 45° with the box). Results The median precision was 1.3 mm (Q1: 1.1; Q3: 1.7) with the best setting CLOSE/close. The best setting in surgical condition (CLOSE/far) showed a distance-to-target of 2.3 mm (Q1: 1.9; Q3: 2.5). The distance D was correlated to the precision (Spearman rho = 0.82), but not the distance d (Spearman rho = 0.04). The type of optic and its angulation with the box were also correlated to the precision (Spearman rho = − 0.37). The best setting was the use of a 30°-endoscope angled at 45° (1.4 mm (Q1: 1.0; Q3: 1.9)). Conclusion Navigated-assisted endoscopy is feasible and offers a good precision. The navigation setup should be optimized, reducing the risk of inadvertent perifocal damage.

BACKGROUND: Non-vestibular schwannomas are relatively rare, with trigeminal and jugular foramen schwannomas being the most common. This is a heterogenous group which requires detailed investigation and careful consideration to management strategy. The optimal management for these tumours remains unclear, and there are several controversies. The aim of this paper is to provide insight into the main principles defining management and surgical strategy, in order to formulate a series of recommendations. METHODS: A task force was created by the EANS skull base section committee along with its members and other renowned experts in the field to generate recommendations for the surgical management of these tumours on a European perspective. To achieve this, the task force performed an extensive systematic review in this field and had discussions within the group. This article is the third of a three-part series describing non-vestibular schwannomas (IX, X, XI, XII). RESULTS: A summary of literature evidence was proposed after discussion within the EANS skull base section. The constituted task force dealt with the practice patterns that exist with respect to preoperative radiological investigations, ophthalmological assessments, optimal surgical and radiotherapy strategies and follow-up management. CONCLUSION: This article represents the consensually derived opinion of the task force with respect to the treatment of non-vestibular schwannomas. For each of these tumours, the management paradigm is shifting towards the compromise between function preservation and progression free survival.

Objective Surgical clipping has become a relatively rare procedure in comparison to endovascular exclusion of cerebral aneurysms. Consequently, there is a declining number of cases where young neurosurgeons can practice clipping. For this reason, we investigated the application of a new 3-dimensional (3D) simulation and rehearsal device, Surgical Theater, in vascular neurosurgery. Methods We analyzed data of 20 patients who underwent surgical aneurysm clipping. In 10 cases, Surgical Theater was used to perform the preoperative 3D planning (CASCADE group), while traditional imaging was used in the other cases (control group). Preoperative 3D simulation was performed by 4 expert and 3 junior neurosurgeons (1 fellow, 2 residents). During postoperative debriefings, expert surgeons explained the different aspects of the operation to their younger colleagues in an interactive way using the simulator. Questionnaires were given to the surgeons to get qualitative feedback about the simulator, and the junior surgeons' performance at simulator was also analyzed. Results There were no differences in surgery outcomes, complications, and surgical duration (P > 0.05) between the 2 groups. Senior neurosurgeons performed similarly when operating at the simulator as compared with in the operating room, while junior neurosurgeons improved their performance at the simulator after the debriefing session (P Conclusions Surgical Theater proved to be realistic in replicating vascular neurosurgery scenarios for rehearsal and simulation purposes. Moreover, it was shown to be useful for didactic purposes, allowing young neurosurgeons to take full advantage and learn from senior colleagues to become familiar with this demanding neurosurgical subspecialty.

Background We describe the minimally invasive, facet-sparing postero-lateral approach to the thoracic spine for a ventral dural repair in a patient with intracranial hypotension secondary to a spontaneous dural breach. Methods We performed a minimally invasive approach using a short paramedian posterior skin incision followed by a 10 × 10 mm targeted trans-laminar approach, to achieve a microsurgical repair of a symptomatic ventral dural defect causing severe disability. Conclusion The facet-sparing postero-lateral approach is safe and effective in the surgical management of thoracic dural tears, even in the most anterior ones, and avoids the traditional costotransversectomy.

Radiation-induced cavernous malformations (RICMs) are delayed complications of brain irradiation during childhood. Its natural history is largely unknown and its incidence may be underestimated as RCIMS tend to develop several years following radiation. No clear consensus exists regarding the long-term follow-up or treatment. A systematic review of Embase, Cochrane Library, PubMed, Google Scholar, and Web of Science databases, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, was performed. Based on our inclusion/exclusion criteria, 12 articles were included, totaling 113 children with RICMs, 86 were treated conservatively, and 27 with microsurgery. We were unable to precisely define the incidence and natural history from this data. The mean age at radiation treatment was 7.3 years, with a slight male predominance (54%) and an average dose of 50.0 Gy. The mean time to detection of RICM was 9.2 years after radiation. RICM often developed at distance from the primary lesion, more specifically frontal (35%) and temporal lobe (34%). On average, 2.6 RICMs were discovered per child. Sixty-seven percent were asymptomatic. Twenty-one percent presented signs of hemorrhage. Clinical outcome was favorable in all children except in 2. Follow-up data were lacking in most of the studies. RICM is most often asymptomatic but probably an underestimated complication of cerebral irradiation in the pediatric population. Based on the radiological development of RICMs, many authors suggest a follow-up of at least 15 years. Studies suggest observation for asymptomatic lesions, while surgery is reserved for symptomatic growth, hemorrhage, or focal neurological deficits.

Background: Neurosurgical randomized controlled trials (RCTs) are difficult to carry out due to the low incidence of certain diseases, heterogeneous disease phenotypes, and ethical issues. This results in a weak evidence base in terms of both the number of trials and their robustness. The fragility index (FI) measures the robustness of an RCT and is the minimum number of patients in a trial whose status would have to change from a nonevent to an event to change a statistically significant result to a nonsignificant result. The smaller the FI, the more fragile the trial's outcome. Methods: RCTs that have influenced neurosurgical practice were included in this analysis. Simulations were run to calculate the FI. To determine associations with a high or low FI, multivariable logistic regression was used to calculate adjusted odds ratios and 95% confidence intervals adjusting for baseline confounders. Results: Of 2975 papers screened, 74 were included. The median FI was 4.5 (interquartile range: 1.5–10). RCTs included a median of 165 patients (interquartile range: 75–330), with a maximum of 10,008. A total of 38 trials had lost to follow-up patients that might have impacted the robustness of the results (51%). Conclusion: Results of neurosurgical RCTs on which we base our clinical decision-making and treatment guidelines are often fragile. Improved methodologies, international collaboration, and cooperation between specialties might improve the evidence base in the future.

Neurosurgical 3D visualizers and simulators are innovative devices capable of defining a surgical strategy in advance and possibly making neurosurgery safer by rehearsing the phases of the operation beforehand. The aim of this study is to evaluate Surgical Theater™, a new 3D neurosurgical planning, simulation, and navigation system, and qualitatively assess its use in the operating room.Clinical data were collected from 30 patients harbouring various types of brain tumours; Surgical Theater™ was used for the preoperative planning and intraoperative 3D navigation. Preoperative and postoperative questionnaires were completed by first and second operators to get qualitative feedback on the system's functionality. Furthermore, we measured and compared the impact of this technology on surgery duration.Neurosurgeons were overall satisfied when using this rehearsal and navigation tool and found it efficient and easy to use; interestingly, residents considered this device more useful as compared to their more senior colleagues (with significantly higher scores, p0.05), possibly because of their limited anatomical experience and spatial/surgical rehearsal ability. The length of the surgical procedure was not affected by this technology (p0.05).Surgical Theater™ system was found to be clinically useful in improving anatomical understanding, surgical planning and intraoperative navigation, especially for younger and less experienced neurosurgeons.

The optimal management of petroclival meningiomas (PCMs) continues to be debated along with several controversies that persist. A task force was created by the EANS skull base section along with its members and other renowned experts in the field to generate recommendations for the management of these tumors. To achieve this, the task force reviewed in detail the literature in this field and had formal discussions within the group. The constituted task force dealt with the existing definitions and classifications, pre-operative radiological investigations, management of small and asymptomatic PCMs, radiosurgery, optimal surgical strategies, multimodal treatment, decision-making, and patient’s counselling. This article represents the consensually derived opinion of the task force with respect to the management of PCMs.

Assessment of long-term functional outcomes after meningioma surgery is important. We systematically reviewed the literature on health-related quality of life (HrQoL) and functional disability (FD) of patients after surgery for intracranial meningiomas. Using PRISMA 2015 guidelines, we screened 289 abstracts and 43 titles were retained for full-paper screening. 15 articles did not present enough data to meet the inclusion criteria and 7 articles failed to assess functional assessment and HrQoL. Twenty-two articles were included in our review. HrQol was assessed in N = 18 publications, most frequently using SF-36 (N = 10), followed by EQ5D-5L (N = 4), EORTC-QLQ (N = 4), and the FACT questionnaire (N = 2). The assessment of FD was reported in N = 11 publications, mostly using the KPS (N = 8). The Barthel index was used in N = 2 publications. Follow-up was reported in N = 12 publications, ranging from 6 months to 9 years. Scientific publications assessing long-term postoperative HrQol and FD in patients undergoing meningioma surgery are scarce and the data are heterogeneously reported, using various scales and follow-up protocols. Efforts should be undertaken to uniformly assess long-term post-operative functional outcomes in meningioma patients.

Foramen magnum meningiomas (FMMs) account for 1.8–3.2% of all meningiomas. With this systematic review and meta-analysis, our goal is to detail epidemiology, clinical features, surgical aspects, and outcomes of this rare pathology. Using PRISMA 2015 guidelines, we reviewed case series, mixed series, or retrospective observational cohorts with description of surgical technique, patient and lesion characteristics, and pre- and postoperative clinical status. A meta-analysis was performed to search for correlations between meningioma characteristics and rate of gross total resection (GTR). We considered 33 retrospective studies or case series, including 1053 patients, mostly females (53.8%), with a mean age of 52 years. The mean follow-up was of 51 months (range 0–258 months). 65.6% of meningiomas were anterior, and the mean diameter was of 29 mm, treated with different surgical approaches. Postoperatively, 17.2% suffered complications (both surgery- and non-surgery-related) and 2.5% had a recurrence. The Karnofsky performance score improved in average after surgical treatment (75 vs. 81, p < 0.001). Our meta-analysis shows significant rates of GTR in cohorts with a majority of posterior and laterally located FMM (p = 0.025) and with a mean tumor less than 25 mm (p < 0.05). FMM is a rare and challenging pathology whose treatment should be multidisciplinary, focusing on quality of life. Surgery still remains the gold standard and aim at maximal resection with neurological function preservation. Adjuvant therapies are needed in case of subtotal removal, non-grade I lesions, or recurrence. Specific risk factors for recurrence, other than Simpson grading, need further research.

Brain arteriovenous malformations management remains controversial despite the numerous, available treatment options. Randomized controlled trials (RCTs) theoretically provide the strongest evidence for the assessment of any therapeutic intervention. However, poorly designed RCTs may be associated with biases, inaccuracies, and misleading conclusions. The purpose of our study is to assess reporting transparency and methodological quality of the existing RCTs.A search was performed in the PubMed, Scopus, Embase, clinicaltrials.gov, and Cochrane databases. The search was limited to English literature. We included all published RCTs reporting on the management of unruptured brain arteriovenous malformations. The eligible studies were evaluated by 5 blinded raters with the CONsolidated Standards of Reporting Trials 2010 statement and the risk-of-bias 2 tool. The inter-rater agreement was assessed with the Fleiss' Kappa.A randomized trial of unruptured brain arteriovenous malformations (ARUBA) and treatment of brain arteriovenous malformations (TOBAS) trials were evaluated. ARUBA achieved high CONsolidated standards of reporting trials compliance, while TOBAS showed a moderate one. In ARUBA the introduction, discussion, and other information sections reached the highest compliance rate (80%-86%). The lowest rates were recorded in the results and the methods (62% and 73%, respectively). The inter-rater agreement was moderate to substantial (54.1% to 78.4%). All the examined studies demonstrated a high risk of bias, mainly related to ill-defined intended interventions, missing outcome data, and selection of the reported results.Our study confirmed the high risk of bias mainly attributed to several protocol violations, deviations, minimal external validity and selection, attrition, and allocation biases of the ARUBA trial. Analysis of the TOBAS trial revealed a moderate overall reporting clarity and a high risk of bias.

Risks and survival times of ventriculoperitoneal (VP) shunts implanted due to hydrocephalus after craniotomies for brain tumors are largely unknown. The purpose of this study was to determine the overall timing of VP shunting and its failure after craniotomy for brain tumors in adults. The authors also wished to explore risk factors for early VP shunt failure (within 90 days). A population-based consecutive patient cohort of all craniotomies for intracranial tumors leading to VP shunt dependency in adults (> 18 years) from 2004 to 2013 was studied. Patients with pre-existing VP shunts prior to craniotomy were excluded. The survival time of VP shunts, i.e., the shunt longevity, was calculated from the day of shunt insertion post-craniotomy for a brain tumor until the day of shunt revision requiring replacement or removal of the shunt system. Out of 4774 craniotomies, 85 patients became VP shunt-dependent (1.8% of craniotomies). Median time from craniotomy to VP shunting was 1.9 months. Patients with hydrocephalus prior to tumor resection (N = 39) had significantly shorter time to shunt insertion than those without (N = 46) (p

Introduction: The extent of meningioma resection is the most fundamental risk factor for recurrence, and exact knowledge of extent of resection is necessary for prognostication and for planning of adjuvant treatment. Currently used classifications are the EANO-grading and the Simpson grading. The former comprises radiological imaging with contrast-enhanced MRI and differentiation between “gross total removal” and “subtotal removal,” while the latter comprises a five-tiered differentiation of the surgeon’s impression of the extent of resection. The extent of resection of tumors is usually defined via analyses of resection margins but has until now not been implemented for meningiomas. PET/MRI imaging with 68Ga-DOTATOC allows more sensitive and specific imaging than MRI following surgery of meningiomas. Objective: To develop an objective grading system based on microscopic analyses of resection margins and sensitive radiological analyses to improve management of follow-up, adjuvant therapy, and prognostication of meningiomas. Based on the rationale of resection-margin analyses as gold standard and superior imaging performance of 68Ga DOTATOC PET, we propose “Copenhagen Grading” for meningiomas. Results: Copenhagen Grading was described for six pilot patients with examples of positive and negative findings on histopathology and DOTATOC PET scanning. The grading could be traceably implemented and parameters of grading appeared complementary. Copenhagen Grading is prospectively implemented as a clinical standard at Rigshospitalet, Copenhagen. Conclusion: Copenhagen Grading provided a comprehensive, logical, and reproducible definition of the extent of resection. It offers promise to be the most sensitive and specific imaging modality available for meningiomas. Clinical and cost-efficacy remain to be established during prospective implementation.

Intracranial meningiomas mostly affect patients in their fifth decade and beyond, raising pertinent questions regarding the risk of surgery, particularly in the elderly. Here, we describe the case of a septuagenarian patient with occipital meningioma causing severe visual field cuts that experienced full recovery of the visual function after a Simpson I resection of the lesion. This case illustrates the potential of recovery of the brain, even in the case of severely impaired function in elderly patients. To complete the picture, we review the literature on occipital meningiomas, advocating for systematic reports and increase data collection on post-operative neurological recovery in the elderly.

Background Work-related musculoskeletal disorders (WMSDs) are a growing and probably undervalued concern for neurosurgeons and spine surgeons, as they can impact their quality of life and career length. This systematic review aims to ascertain this association and to search for preventive measures. Methods We conducted a PRISMA-P-based review on ergonomics and WMSDs in neurosurgery over the last 15 years. Twelve original articles were included, of which 6 focused on spine surgery ergonomics, 5 cranio-facial surgery (mainly endoscopic), and one on both domains. Results We found a huge methodological and content diversity among studies with 5 surveys, 3 cross-sectional studies, 2 retrospective cohorts, and 2 technical notes. Spine surgeons have sustained neck flexion and neglect their posture during surgery. In a survey, low back pain was found in 62% of surgeons, 31% of them with a diagnosed lumbar disc herniation, and 23% of surgery rate. Pain in the neck (59%), shoulder (49%), finger (31%), and wrist (25%) are more frequent than in the general population. Carpal tunnel syndrome showed a linear relationship with increasing cumulative hours of spine surgery practice. Among cranial procedures, endoscopy was also significantly related to shoulder pain while pineal region surgery received some attempts to optimize ergonomics. Conclusions Ergonomics in neurosurgery remains underreported and lack attention from surgeons and authorities. Improvements shall target postural ergonomics, equipment design, weekly schedule adaptation, and exercise.

To perform a systematic review of extracranial-to-intracranial (EC-IC) bypass surgery with parent vessel trapping for blood blister–like aneurysms (BBAs) of the internal carotid artery (ICA) according to PRISMA guidelines. Search of PubMed using “bypass” [all fields] and “ICA” [all fields] or “internal carotid artery” [all fields] and (“blood blister–like aneurysm” [MeSH terms]. Thirty-four original articles were identified, of which 21 were excluded (treatment not including bypass or insufficient details on complications or clinical outcomes). Thirteen articles published between 2008 and 2019 were included, totaling 98 patients, with a median of 7.5 patients per article (range 1–17). Mean age was 53.3 years (range 23–80). The main techniques were external carotid artery to middle cerebral artery (ECA-MCA) in 81% and superficial temporal artery to MCA (STA-MCA) in 19%. The most common grafts were radial artery (74%) and STA (19%). The risk of intraoperative rupture varied from 0 to 75%, with a mean of 12%. With respect to clinical outcomes, the modified Rankin Scale (mRS) was not stated in 30% of the cases. When stated, mRS was ≤ 2 in 79%, mRS was 3–5 in 10%, and 4% had mRS 6 (death). We identified only 13 articles, with no prospective studies. Outcomes were better than generally reported for ruptured aneurysms, both with respect to poor outcome (mRS > 2) and in-hospital mortality, perhaps reflecting a selection bias. In general, the data reporting quality was low, precluding any firm conclusions, but EC-IC bypass with ICA trapping may be a valid treatment option for ruptured ICA BBAs.

Meningiomas are the most common intracranial extra-axial tumor. While the literature is abundant on the therapeutic management of meningioma recurrence after the initial surgery, the natural history of repeated recurrences is poorly described, as well as and their respective management. A partly retrospective, partly prospective review was conducted in a Norwegian cohort of 1469 consecutive cases of meningioma surgically treated, totaling 11 414 patient-years of follow-up. 114 recurrences (7.7%) were treated surgically with a risk a surgical retreatment of 1% per patient-year of follow-up. 36 patients were operated on 3 times or more. The time-to-retreatment (TTR) decreased significantly and steadily between surgeries, from 4.3 ± 4 years after the first surgery to 2.4 ± 2.9 years after the third surgery. The primary driver for recurrence was the WHO grade (OR 7.13 [4.40;11.55], p

BACKGROUND: The optimal management of tuberculum sellae (TS) meningiomas, especially the surgical strategy, continues to be debated along with several controversies that persist. METHODS: A task force was created by the EANS skull base section committee along with its members and other renowned experts in the field to generate recommendations for the surgical management of these tumors on a European perspective. To achieve this, the task force also reviewed in detail the literature in this field and had formal discussions within the group. RESULTS: The constituted task force dealt with the practice patterns that exist with respect to pre-operative radiological investigations, ophthalmological and endocrinological assessments, optimal surgical strategies, and follow-up management. CONCLUSION: This article represents the consensually derived opinion of the task force with respect to the surgical treatment of tuberculum sellae meningiomas. Areas of uncertainty where further clinical research is required were identified.

To perform a systematic review of the techniques for transient circulatory arrest during intracerebral aneurysm surgery according to the PRISMA guidelines. Search of PubMed and Google Scholar using the following: ("heart arrest" OR "cardiac standstill"[All Fields]) AND ("intracranial aneurysm" OR "intracranial"[All Fields] AND "aneurysm"[All Fields]). A total of 41 original articles were retrieved, of which 17 were excluded (review articles, editorials and single-case reports). A total of 24 separate articles published between 1984 and 2018 were included in the final analysis, where the majority of patients harbored anterior circulation giant or large aneurysms. Adenosine-induced cardiac arrest gave a short, temporary asystole. The method had benefits in aneurysm with a broad neck, a thin wall, in specific localizations with narrow surgical corridors or in case of intraoperative rupture. Rapid ventricular pacing (RVP) allows a longer and more easily controlled hypotension. Its use is largely limited to elective cases. Deep hypothermic circulatory arrest required a complex infrastructure, and fatal procedure complications lead to a 11.5-30% 30-day mortality rate, limiting its application to giant or complex aneurysm of the basilar artery or to residual posterior circulation aneurysm after endovascular treatment. Adenosine and RVP are both effective options to facilitate clipping of complex aneurysms. However, their use in patient with ischemic heart disease and cardiac arrhythmias should be avoided, and their safety in the context of subarachnoid hemorrhage is yet to be determined. Today, deep hypothermic circulatory arrest is almost obsolete due to endovascular alternatives.

Background The optimal management of clinoidal meningiomas (CMs) continues to be debated. Methods We constituted a task force comprising the members of the EANS skull base committee along with international experts to derive recommendations for the management of these tumors. The data from the literature along with contemporary practice patterns were discussed within the task force to generate consensual recommendations. Results and conclusion This article represents the consensus opinion of the task force regarding pre-operative evaluations, patient’s counselling, surgical classification, and optimal surgical strategy. Although this analysis yielded only Class B evidence and expert opinions, it should guide practitioners in the management of patients with clinoidal meningiomas and might form the basis for future clinical trials.

Background: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has placed tremendous strain on the national health care systems throughout Europe. As a result, there has been a significant influence on residents' education. We surveyed European neurosurgery residents to estimate the magnitude of the pandemic's impact on neurosurgical training. Methods: An anonymous, voluntary, 44-question, web-based survey was administered to European neurosurgical residents from November 2, 2020, to January 15, 2021, by e-mail invitation. Close-ended, multiple-choice questions were used to examine the perspectives of neurosurgical trainees of different training programs in Europe regarding the pandemic's impact on education, as well as to evaluate the online webinars as a sufficient alternative educational tool, and their future role. Results: The total number of participants was 134 from 22 European countries. Nearly 88.8 % of respondents reported that the pandemic had a negative influence on their education. A statically significant decrease in surgical exposure, outpatient clinic involvement, and working hours was observed (P < 0.05). Webinars, although widely disseminated, were not considered as a sufficient training alternative. Conclusions: The SARS-CoV-2 pandemic had a significant impact on neurosurgical training. During the last year, with the outbreak of the pandemic, formal training education was heavily compromised. Online webinars do not seem to be a sufficient alternative, and some trainees estimate that a whole year of training has been compromised. Our current data have to be cautiously considered for possibly reorganizing the whole training experience. The pandemic may well function as a stimulus for optimizing neurosurgical training.

Long-term risks and survival times of ventriculoperitoneal (VP) shunts implanted due to hydrocephalus (HC) after craniotomy for brain tumors are largely unknown. The aim of this study was to establish the overall VP shunt survival rates during a decade after shunt insertion and to determine risks of shunt failure after brain tumor surgery in the long-term period. In this population-based cohort from a well-defined geographical region, all adult patients (> 18 years) from 2004 to 2013 who underwent craniotomies for intracranial tumors leading to VP shunt dependency were included. Our brain tumor database was cross-linked to procedure codes for shunt surgery (codes AAF) to extract brain tumor patients who became VP shunt dependent after craniotomy. The VP shunt survival time, i.e. the shunt longevity, was calculated from the day of shunt insertion after brain tumor surgery until the day of its failure. A total of 4174 patients underwent craniotomies, of whom 85 became VP shunt dependent (2%) afterwards. Twenty-eight patients (33%) had one or more shunt failures during their long-term follow-up, yielding 1-, 5-, and 10-year shunt success rates of 77%, 71%, and 67%, respectively. Patient age, sex, tumor location, primary/repeat craniotomy, placement of external ventricular drainage (EVD), ventricular entry, post-craniotomy hemorrhage, post-shunting meningitis/infection, and multiple shunt revisions were not statistically significant risk factors for shunt failure. Median shunt longevity was 457.5 days and 21.5 days for those with and without pre-craniotomy HC, respectively (p

Spinal pial arteriovenous fistulae are rare intradural superficial vascular lesion consisting in a direct shunt between spinal pial arteries and veins. The presentation of pial arteriovenous fistula is caused by venous congestion with spinal cord ischemia, mass effect, or hemorrhage. The treatment is surgery or endovascular procedure. We illustrate the case of thoracic pial arteriovenous fistula in a 66-year-old female operated with posterior midline approach and B-mode US. Posterior midline approach with targeted laminotomy using high-speed drill affords an ideal surgical exposure. B-mode US is helpful to detect the fistula and study their relationship with the surrounding structures.

Introduction: Predictors of survival and progression of disease in atypical meningiomas are less well documented in the literature compared to benign meningiomas. Higher grade meningiomas tend to recur often and one of the most critical aspects is how to best deal with relapses. Methods: A total of 77 consecutive patients who underwent craniotomy for atypical meningioma between 1990–2010 at Oslo University Hospital (OUH) were reviewed. Results: Median age at surgery was 62.21 [interquartile range (IQR): 22.87] years. Fifty-one patients (66.2%) had neurological deficits at presentation. Fifty-four patients (70.1%) underwent gross total resection (GTR). Thirty-nine patients (50.7%) had improved/stable neurological outcomes at 6–12 months. Twenty-two patients (28.6%) underwent retreatment, of whom 20 (26.0%) were subjected to resection followed by adjuvant radiotherapy. Overall survival (OS) was significantly longer in patients &lt, 65 years (p &lt, 0.001), with preoperative Karnofsky performance scale (KPS) score of ≥ 70 (p = 0.006), and who required no retreatment (p = 0.033). GTR significantly prolonged the retreatment-free survival rate (p &lt, 0.001). STR carried almost a six-fold greater risk of neurological outcome deterioration (p = 0.044). Conclusions: GTR significantly prolonged retreatment-free survival but had no significant impact on OS. STR was a significant risk factor for deteriorated neurological outcome. Age, preoperative KPS, and retreatment were all strong predictors of OS. Median time-to-retreatment (TTR) did not shorten significantly throughout repeated surgeries.

Background A pial arteriovenous fistula (PAVF) is a rare neurovascular pathology consisting of a direct connection between one or more arterial feeders and a single venous channel. A PAVF was previously considered a subtype of an arteriovenous malformation (AVM). In the current literature these are distinguished as two independent entities with different clinical, physiopathologic, and structural characteristics. We report a case of a surgically treated 37-year-old woman with an extremely rare combination of an unruptured PAVF and AVM. Patient The AVM was mainly supplied by feeders of the middle cerebral artery and drained into the sigmoid sinus via an abnormally dilated and tortuous vein. Following its resection, intraoperative digital subtraction angiography (DSA) in the hybrid operating room revealed the presence of a PAVF that had not been noted during the preoperative planning. Hence the PAVF was completely disconnected as confirmed by DSA again. Conclusion This is the second reported case of an AVM-associated PAVF. Without the intraoperative DSA in the hybrid operating room, this unusual complex cerebrovascular entity would likely have been missed.

To study improvements in outcomes after surgery for intracranial meningiomas.We performed a longitudinal observational study comparing 1469 patients operated on for intracranial meningioma in 4 consecutive time frames (1990-1994, 1995-1999, 2000-2004, and 2005-2010).Median age at surgery was 58.3 years. Median follow-up was 7 years. Patients in later periods were older than in the earlier ones (odds ratio [OR], 1.19 [1.09-1.32]; P0.0005), indicating a trend toward operating on more elderly patients. Before 2000, 42%, 32%, 6%, 19%, and 0.3% achieved Simpson grade (SG) I, II, III, IV, and V, respectively, whereas the SG rates were 35%, 37%, 4%, 23%, and 0.9% after 2000 (OR, 1.18 [1.06-1.30]; P0.005). The perioperative mortality (OR, 0.65 [0.46-0.91]; P0.05) and worsened neurologic outcome rate (OR, 0.70 [0.60-0.83]; P0.0001) were significantly lower in later decades, but the 4 surgical periods were similar regarding postoperative infections and hematomas. Retreatment-free survival (RFS) and overall survival (OS) increased significantly over the 4 time frames (P0.05 and P0.0001, respectively). Multivariate analysis confirmed the improvement of surgical radicality, neurologic outcome, perioperative mortality, OS, and RFS.Meningioma surgery as well as patient population changed over the 2 decades considered in this study. We observed higher rates of gross total resection in the later period and the perioperative outcomes improved or were unchanged, which signifies better long-term outcomes, RFS, and OS.

Hemangioblastomas (HB) are benign tumors of the central nervous system (CNS) that can appear sporadic or as part of von Hippel-Lindau (VHL) disease. It is often curable with surgical resection, but upon relapse, the disease exhibits a treatment-refractory course. A patient treated for sporadic cerebellar HB relapsed 12 years post-surgery. She developed disseminated disease throughout the CNS, including leptomeningeal manifestations. Repeat surgery and craniospinal radiation therapy were unsuccessful. This case is in line with previous publications on disseminated non-VHL HB. Available treatment options are inefficient, emphasizing the need for improved understanding of HB biology to identify therapeutic targets.

Aki Laakso tutkimusryhmän jäsenenä. Currently available simulators are supposed to allow young neurosurgeons to hone their technical skills in a safe environment, without causing any unnecessary harm to their patients caused by their inexperience. For this training method to be largely accepted in neurosurgery, it is necessary to prove simulation efficacy by means of large-scale clinical validation studies. We correlated and analysed the performance at a simulator and the actual operative skills of different neurosurgeons (construct validity). We conducted a study involving 92 residents and attending neurosurgeons from different European Centres; each participant had to perform a virtual task, namely the placement of an external ventricular drain (EVD) at a neurosurgical simulator (ImmersiveTouch). The number of attempts needed to reach the ventricles and the accuracy in positioning the catheter were assessed. Data suggests a positive correlation between subjects who placed more EVDs in the previous year and those who get better scores at the simulator (p = .008) (fewer attempts and better surgical accuracy). The number of attempts to reach the ventricle was also analysed; senior residents needed fewer attempts (mean = 2.26; SD = 1.11) than junior residents (mean = 3.12; SD = 1.05) (p = .007) and staff neurosurgeons (mean = 2.89, SD = 1.23). Scoring results were compared by using the Fisher's test, for the analysis of the variances, and the Student's T test. Surprisingly, having a wider surgical experience overall does not correlate with the best performance at the simulator. The performance of an EVD placement on a simulator correlates with the density of the neurosurgical experience for that specific task performed in the OR, suggesting that simulators are able to differentiate neurosurgeons according to their surgical ability. Namely this suggests that the simulation performance reflects the surgeons' consistency in placing EVDs in the last year.

International audience; [No abstract available]

Introduction: Incidence of Chronic Subdural Hematoma (cSDH) is rising worldwide, partly due to an aging population, but also due to increased use of antithrombotic medication. Many recent studies have emerged to address current cSDH management strategies. Research question: What is the state of the art of cSDH management. Material and methods: Review. Results: Head trauma, antithrombotic use and craniocerebral disproportion increase the risk of cSDH development. Most patients present with disorientation, GCS 13–15, and symptoms arising from cortical irritation and increased intracranial pressure. cSDH occurs bilaterally in 9–22%. CT allows assessment of cerebral compression (herniation, hematoma thickness, ventricle collapse, midline shift), hematoma age and presence of membranes, factors that ultimately determine treatment urgency and surgical approach. Recurrence remains the principle complication (9–33%), occurring more commonly with older age and bilateral cSDHs. Discussion and conclusion: While incompletely understood, it is generally believed that injury in the dural cell layer results in bleeding from bridging veins, resulting in a hematoma formation, with or without a preceding hygroma, in a potential space approximating the junction between the dura and arachnoid. Neovascularization and leaking from the outer membrane are thought to propagate this process. Evidence that MMA embolization may reduce recurrence rates is a potentially exciting new treatment option, but also supports the theory that the MMA is implicated in the cSDH pathophysiology. The use of steroids remains a controversial topic without clear treatment guidelines. cSDH represents a common neurosurgical problem with burr-hole treatment remaining the gold standard, often in conjunction with subgaleal drains. MMA embolization to stop recurrence may represent an important evolution in understanding the pathophysiology of cSDH and improving treatment.

Purely intraorbital cavernomas remain rare, but still are the most common benign orbital tumors.1 These expansive lesions are now rapidly detected and adequately treated. Surgical resection is the gold standard and a definitive solution. The choice of approach varies between different possibilities, including orbitotomies, trans-sinusal routes, and transconjunctival accesses.2-4 Because the last technique is less known to the neurosurgeon, we describe here a step-by-step guide to perform it. The technique is illustrated with the case of a 62-yr-old male with a voluminous right retroocular cavernoma. He presented a progressive right exophthalmia without visual acuity or campimetric deterioration. Because the cavernoma was purely medial from the optic nerve in the intraconal space, no osteotomy was deemed necessary to extirpate the lesion. The video shows the conjunctival dissection, followed by the medial rectus muscle being dissected, allowing us to attain the retrobulbar space in the orbit. The cavernoma is then dissected from the surroundings and reduced in volume by coagulation so its removal does not apply hyperpressure on the adjacent fragile structures. We then pursue with the closure by stitching the medial rectus muscle to the eyeball. Finally, the conjunctiva is sutured. Postoperatively, there was no complication. A transient mydriasis due to ciliary nerve manipulation spontaneously resolved. Extirpation of the lesion was total. The patient's exophthalmia normalized over the next months. No visual or campimetric deterioration was noted at follow-up. A slight horizontal diplopia was noted after surgery, which normalized at 1 yr. The patient's consent was obtained for the procedure.

Background Work-related musculoskeletal disorders (WMSDs) affect a significant percentage of the neurosurgical workforce. The aim of the current questionnaire-based study was to examine the prevalence of WMSDs amongst neurosurgeons, identify risk factors, and study the views of neurosurgeons regarding ergonomics. Methods From June to August 2020, members of the “European Association of Neurosurgical Societies,” the “Neurosurgery Research Listserv,” and the “Latin American Federation of Neurosurgical Societies” were asked to complete an electronic questionnaire on the topics of WMSDs and ergonomics. Results A total of 409 neurosurgeons responded to the survey, with a 4.7 male to female ratio. Most of the surgeons worked in Europe (76.9%) in academic public hospitals. The vast majority of the participants (87.9%) had experienced WMSDs, mainly affecting the shoulder, neck, and back muscles. The most common operations performed by the participants were “Craniotomy for convexity/intrinsic tumors” (24.1%) and “Open lumbar basic spine” (24.1%). Neurosurgeons agreed that ergonomics is an underexposed area in the neurosurgical field (84.8%) and that more resources should be spend (87.3%) and training curricula changes should be made (78.3%) in order to alleviate the burden of WMSDs on neurosurgeons. Univariate analysis did not reveal any associations between the development of WMSDs and age, gender, tenure, average duration of operation, operating time per week, type of operation, and surgical approach. Conclusions The problem of WMSDs ought to be more closely addressed and managed by the neurosurgical community. More studies ought to be designed to investigate specific ergonomic parameters in order to formulate practice recommendations.

Background Lesions infiltrating the petrous temporal bone are some of the most complex to treat surgically. Many approaches have been developed in order to address these lesions, including endoscopic endonasal, anterior petrosectomy, posterior petrosectomy, and retrosigmoid. Method We describe in a stepwise fashion the surgical steps of the retrosigmoid intradural inframeatal petrosectomy. Conclusion The retrosigmoid intradural inframeatal petrosectomy may afford satisfactory exposure with limited drilling and minimal disruption of perilesional anatomical structures. It can provide excellent surgical results, especially for soft tumors, while minimizing surgical morbidity.

Background Skull base meningiomas represent a challenge for neurosurgeons, and the procedures are typically performed by experienced neurosurgeons, thus limiting resident training. A new simulation and rehearsal device can be used as an aid for senior surgeons during these operations and serve as a training tool for junior surgeons. Methods Forty patients harboring an anterior/middle fossa meningioma were recruited. Surgical Theater, a rehearsal/simulation platform, was used for preoperative planning and intraoperative 3D navigation on 20 patients (CT-MADE group), while the remaining (control group) underwent a traditional navigation. Qualitative comparisons between the 2 groups were made with regard to surgical procedure and patient outcome. Satisfaction questionnaires were completed by expert neurosurgeons and residents to assess the overall usefulness of the platform. Furthermore, the surface of the simulated craniotomy performed during the planning was compared with the one actually performed during surgery in order to evaluate the reliability of the planning. Results No differences between the 2 groups were found (surgery duration: P = 0.4; visual impairment: P = 0.56). Both residents and senior neurosurgeons enjoyed using the platform for intraoperative navigation and planning; simulated craniotomies were significantly smaller as compared with the real ones (P = 0.009), probably because it was not intuitive to depict the exact margins of the operculum with the platform. Conclusion Surgical Theater helped residents to improve their anatomic and procedural comprehension and was deemed as a useful aid to safely perform some demanding neurosurgical procedures, by both senior and junior surgeons.

Simple Summary Olfactory groove meningiomas account for 9% of all meningiomas, present with unique molecular characteristics and are standardly treated by surgical removal. Due to their location (in direct contact with cortical structures exerting key-role functions in cognition), olfactory groove meningiomas might negatively impact cognitive abilities. However, little is known about the effects of both their presence and surgical removal on patients’ neuropsychological functions. In this retrospective study, we analyze the evolution of neuropsychological abilities in 17 patients benefitting from surgical removal of an olfactory groove meningioma. We observed that those patients already presented with preoperative deficits in pre-frontal cortex cognitive functions, more pronounced in the domain of cognitive flexibility, followed by attention. After an initial postoperative worsening, patients tended to improve in the majority of cognitive aspects, with attention and flexibility remaining impaired at one-year follow-up. Abstract Background: In recent years, several studies have reported abnormal pre- and postoperative neuropsychological functioning in patients with meningiomas located in the prefrontal cortex (notably the ventromedial region). In the case of olfactory groove meningiomas, the tumor is in direct contact with the inferior aspect of the prefrontal cortex, a cortical region with crucial roles in decision-making, cognition and memory functions, potentially negatively impacting neuropsychological functions. Materials and Methods: We retrospectively compared pre- and post-operative neuropsychological testing of 17 patients undergoing surgical removal of olfactory groove meningiomas in our institution between January 2013 and December 2018. Neuropsychological results were obtained from the patients’ medical history and normalized as z-scores of their respective cognitive functions. Results: Assessment of cognitive follow-up showed an important heterogeneity among patients. Pre-operative cognitive impairment was observed in most patients, particularly in cognitive flexibility (mean z-score: −1.35). Immediate post-operative cognitive status showed an overall impairment in all domains of cognition, significant for the domains of attention (p = 0.0273) and flexibility (p = 0.0234) and almost significant for the domain of language (p = 0.0547). The late follow-up at one year showed a trend towards general improvement, although attention and flexibility remained impaired. Discussion: Olfactory groove meningiomas impact pre-frontal cortex cognitive functions, particularly in the domain of cognitive flexibility. After an initial postoperative worsening, patients tended to improve in most aspects after one year, aside from cognitive flexibility and attention.

Background Intracranial artery dissection is an uncommon cause of acute ischemic stroke. Although acute stenting of the dissected arterial segment is a therapeutic option, the associated antiplatelet regimen remains a matter of debate. Objectives To evaluate the efficacy and safety of acute intracranial stenting together with concomitant intravenous administration of tirofiban and to perform a systematic review of the literature. Materials and methods A single-center, retrospective study of the clinical and radiological records of all patients treated at our center by intracranial stenting in the setting of acute ischemic stroke between January 2010 and December 2020. A systematic review of the literature was conducted according to the PRISMA-P guidelines for relevant publications from January 1976 to December 2020 on intracranial artery dissection treated by stent. Results Seven patients with intracranial artery dissections underwent acute stenting with concomitant tirofiban during the study period. Mid-term follow-up showed parent artery patency in 6/7 cases (85.7%). The modified Rankin Score was ≤ 0-2 at 3 months in 5/7 cases (71.4%). The literature review identified 22 patients with intracranial artery dissection treated with acute stenting in association with different antithrombotic therapies. Complete revascularization was obtained in 86.3% of cases with a modified Rankin Score of ≤ 0-2 in 68% of patients at 3-month follow-up. Conclusions Acute intracranial stenting together with intravenous tirofiban administration could be a therapeutic option in patients with intracranial artery dissection and a small ischemic core.

Background A 54-year-old female was referred to our clinic with a lesion of the lower fourth ventricle extending to the median aperture. Here, we report the use a minimally invasive sub-occipital approach (MISA) as a safe and effective surgical management. Method We performed a MISA using a short midline incision and a 1-cm sub-occipital craniectomy. Dissection of the lesion was performed, and “en bloc” resection could be achieved. The lesion was confirmed to be a grade I sub-ependymoma. Conclusion MISA can be safely used when confronted to a lesion of the lower fourth ventricle.

Introduction Augmented reality (AR) is as a useful and reliable tool in cranial surgery. We report the case of a left fronto-temporal meningioma in contact with the left Sylvian bifurcation, managed surgically with the aid of AR. We complete the picture with a systematic review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Evidence acquisition Preoperatively, a careful segmentation of the tumor and the neighboring vessels was performed using our AR navigation software. A left fronto-temporal craniotomy was performed. Using the augmented optics technology, AR images injected into the microscope binocular during the surgery, allowed easy identification of the MCA branches and bifurcation. A systematic review of the literature was performed according to the PRISMA-P guidelines. Evidence synthesis A Simpson I resection was obtained, with no new neurological deficit and an uneventful recovery after surgery. The literature review identified eight separate articles published between 1998-2019, totaling 20 meningiomas surgically managed with the use of AR. Different AR systems are described in neurosurgery, with their respective advantages and disadvantages. Augmented optics allow the surgeon to focus on the procedure. No systematic data on postoperative radiological and clinical outcome were reported. Conclusions The use of AR in meningioma surgery might help surgeons when confronted to lesions surrounded by complex structures. However, little data is available so far to support its routine use.

The use of simulation in surgical training is ever growing. Evidence suggests such training may have beneficial clinically relevant effects. The objective of this research is to investigate the effects of surgical simulation training on clinically relevant patient outcomes by evaluating randomized controlled trials (RCT). PubMed was searched using PRISMA guidelines: “surgery” [All Fields] AND “simulation” [All Fields] AND “patient outcome” [All Fields]. Of 119 papers identified, 100 were excluded for various reasons. Meta-analyses were conducted using the inverse-variance random-effects method. Nineteen papers were reviewed using the CASP RCT Checklist. Sixteen studies looked at surgical training, two studies assessed patient-specific simulator practice, and one paper focused on warming-up on a simulator before performing surgery. Median study population size was 22 (range 3–73). Most articles reported outcome measures such as post-intervention Global Rating Scale (GRS) score and/or operative time. On average, the intervention group scored 0.42 (95% confidence interval 0.12 to 0.71, P = 0.005) points higher on a standardized GRS scale of 1–10. On average, the intervention group was 44% (1% to 87%, P = 0.04) faster than the control group. Four papers assessed the impact of simulation training on patient outcomes, with only one finding a significant effect. We found a significant effect of simulation training on operative performance as assessed by GRS, albeit a small one, as well as a significant reduction to operative time. However, there is to date scant evidence from RCTs to suggest a significant effect of surgical simulation training on patient outcomes. Electronic supplementary material The online version of this article (10.1007/s10143-020-01314-2) contains supplementary material, which is available to authorized users.

The informed consent is a defining moment that should allow patients to understand their condition, what procedure they are undergoing, and what consequences may follow. This process should foster trust and promote confidence, without increasing patients’ anxiety. New immersive 3D imaging technologies may serve as a tool to facilitate this endeavor. In a prospective, single-center, randomized controlled clinical trial (SPLICE Study: Surgical Planning and Informed Consent Study; ClinicalTrials.gov NCT03503487), 40 patients undergoing surgery for intracranial tumors were enrolled. After undergoing a traditional surgical informed consent acquisition, 33 patients were randomized 1:1:1 to 3 groups: in 2 experimental groups, patients underwent a 3D, immersive informed consent with two different surgical planners (group 1 and group 2); in the control group, patients underwent an informed consent supported by traditional 2D radiological images. Patients in the experimental groups appreciated this communication experience, while their objective comprehension was higher ((score mean (SD)): group 1 82.65 (6.83); group 2 77.76 (10.19)), as compared with the control group (57.70 (12.49); P

Background The optimal management of posterior fossa arteriovenous malformations (pfAVMs) is a matter of debate. To advance this discussion, we present our clinical series and the results of a systematic literature review according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Methods Fourteen consecutive patients with pfAVMs were admitted between 2007 and 2018. Preoperative status, radiologic parameters, and outcome were assessed. A systematic literature review was performed according to the PRISMA-P guidelines. Results Ten patients presented with rupture (71%), of whom three had associated aneurysms (AAs). The treatments were microsurgery (n = 4), endovascular (n = 3), radiosurgery (n = 2), a combination of two or three treatment modalities (n = 3), or conservative (n = 2). At discharge, all four patients (100%) with unruptured pfAVMs had a good outcome (modified Rankin Scale [mRS]: 0–2). In contrast, in ruptured pfAVM cases, mRS was 0 to 2 in four patients (40%), mRS 3 to 4 in two (20%), mRS 5 in three (30%), and one patient (10%) died within 30 days after gamma knife treatment due to pancreatitis secondary to chronic alcohol abuse. At discharge, four patients (29%) had persistent preinterventional cranial nerve and/or focal neurologic deficits. The literature review identified 63 articles with 1,753 pfAVM patients. Overall, 66% of pfAVMs presented with rupture, and AAs were found in 20% of the cases, which is higher than in supratentorial AVMs (stAVMs). Conclusions Because pfAVMs are associated with higher rates of hemorrhagic presentation, higher rates of morbidity and mortality when ruptured, and have a higher incidence of AAs compared with stAVMs, early curative treatment is recommended as soon as the diagnosis is established, regardless of rupture status.