Search

Purpose: Advances in intraoperative imaging and neuronavigation techniques have positively affected glioma surgery. The desire to reduce brain-shift-related problems while achieving the real-time identification of lesions and residual and anatomical relationships has strongly supported the introduction of intraoperative ultrasound (ioUS) in neuro-oncological surgery. This paper presents tips based on our experience with ioUS in neurosurgery., Methods: We retrospectively analyzed 264 patients who underwent high-grade glioma (HGG) resection at the University of Turin and 60 patients who were treated at the University of Rome., Results: The main issues are the correct choice of the probe and how to evaluate the anatomy to understand how the information from the three common US planes (axial, sagittal and coronal plane) can be used in each case. It is also important to correctly identify anatomical structures in ioUS imaging. In a normal brain, the sulci, sickle, tentorium, choroid plexus, ependyma and the walls of the vessels are all hyperechoic. In addition, some structures are hypoechoic with a homogeneous acoustic gradient: ventricles, cysts and everything that contains liquor. Tumors are usually hyperechoic in ioUS because of their higher cellularity. Conversely, acute edema that contains fluid is hypoechoic, while chronic edema is hyperechoic., Conclusions: IoUS is a real-time, accurate and inexpensive imaging method. The difficulties of interpretation can be overcome by experience in US imaging and a better understanding of the interaction between navigation and imaging fusion techniques. Training on a large number of cases is important for the correct assessment of ioUS information to obtain valuable, real-time information during HGG surgery.

Pneumocephalus is an air collection in cranial cavity caused by accidental exposition of intracranial compartment after trauma or surgery. Skull base reconstruction with free flap is a useful surgical tool to avoid cerebral herniation or intracranial infection. The authors describe a patient of pneumocephalus following anterior skull base meningioma resection, unsuccessfully treated with 2 attempts of fascia lata grafts harvested from both thighs. A free-style chimeric anterolateral thigh free flap was performed using middle third of rectus femoris muscle to fill the planum spheno-ethmoidalis defect and adipocutaneous paddle for postoperative monitoring and for favoring a tension free skin closure. Free-style dissection with limited undermining in the previously scarred thigh was performed to avoid donor-site complication. Postoperative course was uneventful with complete resolution of the pneumocephalus.

Background: Vertebral artery (VA) identification within the suboccipital triangle is a key step in craniocervical junction surgery. Often VA exposition at this level is arduous (space-occupying lesions, previous surgery); to identify VA more proximally may prove useful in complex cases. An alternative triangle is present just below the suboccipital one, where VA can be easily controlled; we named it the inferior suboccipital triangle (IST). The aim of the study is to identify IST anatomical relations and VA space orientation and evaluate its practical utility in surgery., Methods: An anatomical study was performed on ten sides of five injected cadaverdic specimens. Relevant anatomical data were databased., Results: The IST is limited superiorly by the inferior oblique muscle, inferolaterally by the posterior intertransversarii muscle and inferomedially by the C2 lamina; VA at this level has a vertical course with a slight medial to lateral direction (mean 10.8°) and minor posterior to anterior inclination (mean 3.4°). VA within the IST has a constant course without significant loops or kinkings; periarterial venous plexus is less represented at this level. The IST measures an average of 1.89 cm 2 , and VA at this level has an average length of 98 mm., Conclusions: IST is a significantly large anatomical space where the VA course is rather regular, and its length is sufficient for vascular proximal control purposes. Periarterial venous plexus is less evident at this level, easing the surgical exposure. VA exposition within the IST can be used as an alternative option when space-occupying lesions, scars and stabilisation devices make arterial dissection hazardous in more cranial V3 segments.

Pterional craniotomy (PT) has long been the standard approach for the treatment of middle cerebral artery (MCA) aneurysms, even though it may cause temporalis muscle atrophy, facial nerve injury, and masticatory difficulties. Minipterional craniotomy (MPT) is an alternative approach that may provide the same surgical corridor, limiting the risk of postoperative esthetic and functional complications. From January 2011 to December 2014 we consecutively performed 68 craniotomies for surgical treatment of unruptured MCA aneuryms: 37 were standard PT and 31 were MPT. There were no significant differences in mean age, sex, and aneurysm topography between the two groups. The mean skin incision length was 14 cm in the PT group and 6 cm in the MPT group. According to the Glasgow Outcome Scale (GOS) and modified Rankin Scale (mRS), there were no significant differences in clinical outcome at discharge or follow-up between the two groups. Also, the rates of complete aneurysm exclusion were comparable. However, the number of patients complaining of masticatory disorders was higher among those treated with PT. Finally, the number of complications observed in the PT group was higher than that in the MPT group, but only the differences in mean hospitalization length and necessity for a dural patch for reconstruction were statistically significant. In conclusion, the MPT approach is a safe and effective alternative to the standard PT for the treatment of unruptured MCA aneurysms.

A variety of pathological conditions may affect the clivus and the craniovertebral junction (CVJ). These include congenital disorders, chronic inflammation, neoplasms, infections, and posttraumatic conditions that could all result in CVJ compression and myelopathy Endoscopic-assisted procedures have been further developed for CVJ decompression and they have now become conventional approaches. The aims of the present study were:(1) to compare "radiological" and "surgical" nasoaxial lines (NAxLs); (2) to introduce an analogous radiological line as a predictor of the superior extension of the transoral approach (palatine inferior dental arch line (PIA); (3) to compare the "radiological" nasopalatine line (NPL) with the "surgical" NPL (SNPL) and surgical PIA (SPIA); (4) to compare "our" SNPL with the NAxL; and (5) to find possible radiological reference points to predict, preoperatively, the maximal extent of superior dissection for the transoral approach (SPIA).

Chronic diseases of consciousness (CDC) can still be considered a challenging frontier for modern medicine, probably because of their not completely understood physiopathological mechanisms. Following encouraging evidence on cerebral hemodynamics, some authors have hypothesized a role for neuromodulation in the treatment of CDC patients. In the past 40 years, spinal cord stimulation (SCS) and deep brain stimulation (DBS) have been used experimentally for the treatment of patients in a severe altered state of consciousness, with some interesting but not conclusive results. The present review summarizes the data currently available in the literature on this particular and debated topic. On these grounds, further clinical studies are needed to better understand the altered dynamics of neuronal network circuits in CDC patients as a step towards novel therapeutic strategies.

Giant aneurysms of the basilar artery are rare and are frequently associated with obstructive hydrocephalus and brainstem compression. Treatment still remains a challenge both for neurosurgeons and for interventional neuroradiologists. Cases reported in the literature are anecdotal and, overall, their outcomes are poor. We present the case of a patient with a giant aneurysm of the basilar artery tip, involving the origin of both the posterior cerebral and superior cerebellar arteries, who underwent coiling and ventriculoperitoneal shunting for associated obstructive hydrocephalus. A pCONus ® stent (Phenox; Bochum, Germany) was detached with its petals opened over the ostia of the parent vessels, with the aim being to reconstruct the neck of the aneurysm and to preserve the flow in the parent vessel. Moreover, the presence of the stent was useful to maintain the coils within the dome of the aneurysm. The pCONus is a new neurovascular device that is also useful for treating cases of complex basilar artery aneurysms when the ostia of the parent vessel origin is at the level of the aneurysm neck.

Background: Endoscopy represents both an alternative and useful complement to the standard microsurgical approach to the anterior craniovertebral junction (CVJ). Nevertheless, few studies provide an experimental comparison between transnasal and transoral endoscopic control on CVJ. We compared the surgical exposition angle and the working channel volume of both the transnasal and transoral approaches in the cadaver., Methods: Eleven fresh non-perfused cadavers were studied. Transnasal and transoral linear and angled exposure of the CVJ were evaluated by means of X-ray and CT scan both in sagittal and lateral planes., Results: The transoral endoscopic surgical exposition was wider compared with the transnasal in anterior and lateral projections:(1)in the sagittal plane, both in vertical exposition (transnasal inferior to transoral from 5.89 % to 76.48 %, average 35.89 %) and in vertical surgical angle (from 22 % to 77.42 %, average 56.53 %); (2)in the coronal plane, both in coronal exposition (transnasal inferior to transoral from 50.77 % to 83.88 %, average 70.34 %) and in coronal surgical angle (from 65.58 % to 86.71 %, average 76.70 %). The sagittal surgical domain was found to spanning from the inferior third of the clivus to C3 with the transoral and from the middle third of the clivus to the nasopalatal line (NPL) with the transnasal approach. The overlapping surgical domain area was found to be the inferior third of the clivus., Conclusions: The endoscope assisted transoral approach allows a better surgical control of the CVJ. It provides a better CVJ exposure, in sagittal and transverse planes, providing a larger working channel and an easier manoeuvrability. The transnasal approach is limited in caudal direction down to the NPL, otherwise the transoral approach is limited in the rostral direction with a maximum to the foramen magnum in normal specimen. In every individual case, pros and cons of the appropriate approach have to be taken into account as well as the choice of a combined transnasal and transoral approaches strategy.

Anaplastic large cell lymphoma (ALCL) is characterized by large anaplastic cells of T-cell or null-cell phenotype expressing CD30 (Ki-1 antigen). In most cases this neoplasm expresses the anaplastic lymphoma kinase (ALK), a chimeric protein resulting from the t(2;5)(p23;q35) translocation. ALK-positive anaplastic large cell lymphoma is most frequent in the first three decades of life and shows a male predominance, involving both nodal and extranodal sites, but rarely the CNS. We report a 21-year-old patient with a previous history of nodal ALK-positive ALCL, lymphohistiocytic subtype, who was admitted for recent occurrence of left-sided anesthesia with pain and progressive motor weakness of both legs. An MRI of the spine documented an intradural extramedullary mass dislocating the thoracic cord, suggesting a meningioma and the patient underwent surgical decompression. Histological examination revealed a lymphoproliferative neoplasm with morphology and immunophenotype of ALK-positive anaplastic large cell lymphoma. After surgery, all preoperative symptoms disappeared. To our knowledge, no cases of ALCL presenting as secondary localization with an intradural extramedullary spinal mass have been reported in the literature., (© 2012 Japanese Society of Neuropathology.)

In this paper we present the architecture of a framework for building Science Gateways supporting official standards both for user authentication and authorization and for middleware-independent job and data management. Two use cases of the customization of the Science Gateway framework for Semantic-Web-based life science applications are also described.