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The classification of adenohypophysial neoplasms as "pituitary neuroendocrine tumors" (PitNETs) was proposed in 2017 to reflect their characteristics as epithelial neuroendocrine neoplasms with a spectrum of clinical behaviors ranging from small indolent lesions to large, locally invasive, unresectable tumors. Tumor growth and hormone hypersecretion cause significant morbidity and mortality in a subset of patients. The proposal was endorsed by a WHO working group that sought to provide a unified approach to neuroendocrine neoplasia in all body sites. We review the features that are characteristic of neuroendocrine cells, the epidemiology and prognosis of these tumors, as well as further refinements in terms used for other pituitary tumors to ensure consistency with the WHO framework. The intense study of PitNETs has provided information about the importance of cellular differentiation in tumor prognosis as a model for neuroendocrine tumors in different locations.

Background: Suffering from Solid Cancer (SC) may adversely impact the Health-related Quality of Life (H-QoL). The aims of this study are to measure the H-QoL in a sample of people suffering from SC and to clarify the role of the co-occurrence of depressive episodes. Results were compared with a healthy control group and with groups of other disorders. Methods: In 151 patients with SC (mean±sd age 63.1±11.5; female 54.3%), H-QoL was assessed by SF-12, depressive episodes were identified by PHQ-9. The attributable burden of SC in impairing H-QoL was calculated as the difference between SF-12 score of a community sex and age ¼ matched healthy control group and that of the study sample. The attributable burden of SC was compared with other chronic diseases using specific diagnostic groups drawn from case-control studies that used the same database for selecting control samples. Results: H-QoL in people with SC was significantly worse than in the healthy control group (p Conclusion: The findings confirm a strong impact of SC but showed that H-QoL in SC was higher than in chronic diseases with better “quoad vitam” outcome. Since depression was a strong determinant, its prevention, early detection and therapy are the main objectives that must be reached in cancer patients.

Background: Restrictions during Covid-19 pandemic lockdown, in which rhythms of life have been compromised, can influence the course of bipolar disorder (BD). This study follows patients with bipolar disorder living in two geographically close cities (Cagliari and Tunis), but with different lockdown conditions: less severe in Tunis.Methods: Two cohorts were evaluated during lockdown (April 2020, t0) and 2 months later with lockdown lifted for a month (t1). Individuals were: over 18 years old without gender exclusion, BD I or II, in care for at least 1 year, received a clinical interview in the month before the start of the lockdown, stable clinically before the lockdown. The assessment was conducted by telephone by a psychiatrist or psychologist with good knowledge of patients. Diagnoses were made according to DSM-5 criteria. Depressive symptoms were collected through the Hamilton Rating Scale for Depression; cut-off 14 indicative of depressive episode. Circadian rhythms were measured using the BRIAN scale.Results: Forty individuals in Cagliari (70%female, age 48.57 ± 11.64) and 30 in Tunis (53.3% Female, age 41.8 ± 13.22) were recruited. In Cagliari at t0 45% had depressive episodes against none in Tunis, a similar difference appeared at t1. At t0 and t1 the Cagliari sample had more dysfunctional scores in the overall BRIAN scale and in the areas of sleep, activities and social rhythms; no differences were found in nutrition, both samples had predominantly nocturnal rhythm. In Cagliari at t0 and t1, the depressive sub-group showed more dysfunctional scores in the BRIAN areas sleep, activity, and nutrition. However, the differences in biological rhythms resulted, through ANCOVA analysis, independent of the co-presence of depressive symptoms.Discussion: A rigid lockdown could expose people with BD to depressive relapse through dysregulation of biological rhythms. The return to more functional rhythms did not appear 1 month after lockdown. The rekindling of the pandemic and the restoration of new restrictive measures will prevent, at least in the short term, the beneficial effect of a return to normality of the two cohorts.This was a limited exploratory study; future studies with larger samples and longer observational time are needed to verify the hypothesis.

Background and aim Spontaneous partial or complete thrombosis of saccular unruptured intracranial aneurysm (UIAs) is a known occurrence in giant aneurysms. However, spontaneous complete thrombosis of non-giant aneurysms is a rare event in the natural history of UIAs. The aim of this paper is to report on the cases from literature of complete spontaneous thrombosis with a view to identify possible factors associated with this phenomenon. Material and methods We performed a systematic review of the current literature on spontaneous complete thrombosis of saccular, non-giant, unruptured UIAs, including a case that we treated at our institution. We analysed the possible risk factors for thrombosis, association with ischemic events, rupture and recanalization. We reviewed the possible management’s strategies for this group of patients described in literature to date. Results We identified 26 patients for a total of 27 thrombosed aneurysms from the literature review (including our case). Thrombosis was prevalent in women, in the anterior circulation and in larger aneurysms. Endovascular events in the parent artery, either spontaneous or iatrogenic, were associated with spontaneous thrombosis in 4 cases. In 47 % of cases an antiplatelet treatment (AP) was introduced. Rupture and recanalization of the aneurysm were observed in 14 % and 33 % respectively. A larger size was the only factor statistically associated with rupture (P = 0041). AP was not statistically associated with recanalization or rupture of the aneurysm. Conclusion Complete spontaneous thrombosis is not a curative event. Its natural history is associated with recanalization, rupture and ischemic stroke. Conservative treatment with a clinical-radiological follow up and treatment with AP is a safe option for small aneurysms. Definitive aneurysmal exclusion should be considered in medium and large aneurysms due to the significant risks associated with untreated aneurysms.

Carotid-cavernous fistula (CCF) is a rare complication after transsphenoidal surgery with only 10 cases published (Ahuja et al., 1992; Cinar et al., 2013; Cossu et al., 2020; Dolenc et al., 1999; Kalia et al., 2009; Karaman et al., 2009; Kocer et al., 2002; Koitschev et al., 2006; Pigott et al., 1989; Takahashi et al., 1969). Intraoperative findings vary from unrecognized events to life-threatening hemorrhages.We provide a description of the management of an acute CCF occurring during sphenoidotomy in a patient with pituitary apoplexy. Osteotomy performed in the rostrum resulted in a fracture, which extended toward the intracavernous carotid artery.Bleeding was managed with mechanical compression. Endovascular treatment allowed closure of the fistula through transarterial coiling and glue. Arterial patency was preserved and the patient had no new neurological deficit.Drilling should be considered over osteotomy for the anterior sphenoidotomy.The video can be found here: https://youtu.be/0Me23xIVeNI.

Objective To evaluate the value of an adjuvant cisternostomy (AC) to decompressive craniectomy (DC) for the management of patients with severe traumatic brain injury (sTBI). Methods A single-center retrospective quality control analysis of a consecutive series of sTBI patients surgically treated with AC or DC alone between 2013 and 2018. A subgroup analysis, “primary procedure” and “secondary procedure”, was also performed. We examined the impact of AC vs. DC on clinical outcome, including long-term (6 months) extended Glasgow outcome scale (GOS-E), the duration of postoperative ventilation, and intensive care unit (ICU) stay, mortality, Glasgow coma scale at discharge, and time to cranioplasty. We also evaluated and analyzed the impact of AC vs. DC on post-procedural intracranial pressure (ICP) and brain tissue oxygen (PbO2) values as well as the need for additional osmotherapy and CSF drainage. Results Forty patients were examined, 22 patients in the DC group, and 18 in the AC group. Compared with DC alone, AC was associated with significant shorter duration of mechanical ventilation and ICU stay, as well as better Glasgow coma scale at discharge. Mortality rate was similar. At 6-month, the proportion of patients with favorable outcome (GOS-E ≥ 5) was higher in patients with AC vs. DC [10/18 patients (61%) vs. 7/20 (35%)]. The outcome difference was particularly relevant when AC was performed as primary procedure (61.5% vs. 18.2%; p = 0.04). Patients in the AC group also had significant lower average post-surgical ICP values, higher PbO2 values and required less osmotic treatments as compared with those treated with DC alone. Conclusion Our preliminary single-center retrospective data indicate that AC may be beneficial for the management of severe TBI and is associated with better clinical outcome. These promising results need further confirmation by larger multicenter clinical studies. The potential benefits of cisternostomy should not encourage its universal implementation across trauma care centers by surgeons that do not have the expertise and instrumentation necessary for cisternal microsurgery. Training in skull base and vascular surgery techniques for trauma care surgeons would avoid the potential complications associated with this delicate procedure.

Background: This study aimed to evaluate the respect for users’ rights, job satisfaction, and well-being between mental health workers (MHWs) compared to non-mental health care workers (nMHWs) from the same Italian region. Methods: The sample was recruited from community mental health and non-mental health outpatient centers in Sardinia. Participants fulfilled the WellBeing at work and respect for human-rights questionnaire (WWRR). The sample included 240 MHWs and 154 nMHWs. Results: MHWs were more satisfied with their work and workplace compared to nMHWs. MHWs had stronger beliefs that users were satisfied with the care received, and both workers and users’ human rights were respected in their workplace. MHWs reported to need more rehabilitation therapists and psychologists in their services, while nMHWs needed more nurses and professionals for users’ personal care. Italian MHWs are more satisfied with their work and workplace, and more convinced that users are satisfied with the care received and that users’ and staff human rights are respected in their workplaces, compared to nMHWs. Conclusions: The historic link between the community mental health network and other support networks in Italy and the consequent perception of proximity to the citizens of the care network may be the reason for this optimal situation of Italian MHWs.

The aim of this study was to compare users’ and mental health workers’ (MHW) perception of respect of human rights and job/care satisfaction in mental health services in Italy during the COVID-19 pandemic. A sample of users and MHW of Sardinia, Italy, fulfilled the “Well-Being at work and respect for human rights questionnaire” (WWRR). The study included 240 MHW and 200 users. Users showed a higher level of satisfaction of care than MHW of work, and a higher perception of the satisfaction of users and human rights respected for health workers. Both user and MHW responses were about 85% of the maximum score, except for satisfaction with resources. Responses were higher for users, but users and MHW both showed high levels of satisfaction. In previous surveys, MHW of Sardinia showed higher scores in all items of WWRR, except for satisfaction with resources, compared with workers from other health sectors of the same region, and with MHW from other countries. The low score for satisfaction with resources (in users and staff) is consistent with a progressive impoverishment of resources for mental health care in Italy. The study, although confirming the validity of the Italian model, fully oriented towards community, sets off an alarm bell on the risks resulting from the decrease in resources.

Patients with multiple myeloma (MM) have an extremely heterogeneous prognosis. The International Staging System (ISS) is actually the most reliable staging system and chromosomal abnormalities were integrated in the Revised-ISS. We wanted to evaluate the prognostic value of spinal secondary localization in patients with MM and its impact on the ISS.Epidemiological and biological data, as well as treatment protocols and secondary localization were analyzed for 650 consecutive patients diagnosed with MM from January 2006 to January 2017.The overall survival (OS) was dependent on the WHO performance status, ISS and Salmon and Durie stage at diagnosis. Furthermore, presence of spinal metastases at diagnosis was predictive of a worse outcome (p 0.0001), while presence of peripheral bone metastases was not. Spinal metastases had a significant impact on OS for ISS III patients (p 0.0001). Also, a history of bone marrow graft was associated with a better OS (p 0.0001), while radiotherapy had no significant impact. The multivariate analysis confirmed that the spinal metastases at diagnosis determined a high-risk subgroup for ISS III patients with a very poor OS (p 0.0001).Spinal metastases are a negative prognostic factor for patients with MM, especially for ISS III patients, and are associated with a shorter OS. Spinal metastasis should be systemically searched for and should be included in a modified staging system to better manage these patients.

Background Isolated sphenoid mucoceles are rare, but because of their close proximity to important vasculonervous structures, local extension may result in serious consequences. Case Description A 47-year-old patient presented with headaches, meningismus, and a left homonymous lateral hemianopia. We report the atypical evolution of a posttraumatic sphenoid mucocele invading the sellar region and extending into the subarachnoid space with compression of the right optic tract, and we describe its surgical management. Further, with the aid of cadaveric specimens, we aim to analyze the precise pathway followed by the expanding collection from an anatomic perspective. Conclusions Anatomic knowledge of the sellar and parasellar regions is the key to understand the process of how sphenoid mucoceles may extend intracranially. Early endoscopic drainage with a large sphenoidotomy allows favorable outcomes and prevents serious consequences.

Since ColoRectal Cancer (CRC) remains the third cause of cancer death in the world, a better understanding of the reasons underlying poor adherence to and delay in undergoing CRC screening programs is important. CRC screening decision-making process can be conceptualized as the relationship between intention and behavior and needs to be investigated including the impact on patients' decision of a broad range of psychological factors and personal predisposition as fear of a positive screening test, poor understanding of the procedure, psychological distress, anxiety, anticipation of pain, feelings of embarrassment and vulnerability. Also socioeconomic, ethnic and sociological influences, and organizational barriers have been identified as factors influencing CRC screening adherence. Decision-making process can finally be influenced by the healthcare background in which the intervention is promoted and screening programs are carried out. However, there is still a gap on the scientific knowledge about the influences of diverse elements on screening adherence and this deserves further investigations in order to carry out more focused and effective prevention programs.

Surgical treatment of functional pituitary adenomas is as rule performed by transsphenoidal approach. However, when then lesion invades the parasellar structures and the cavernous sinus, the transsphenoidal removal of these adenomas is usually incomplete. In this video, we present the technical nuances of a transcavernous approach to the anterio-medial triangle for the resection of a residual functional pituitary adenoma. The patient is a 40-year-old male who was diagnosed with growth hormone secreting pituitary macroadenoma. He underwent two transsphenoidal resections in 2013 and 2016 with a small residue in the left cavernous sinus. Subsequently, due to a failure of biochemical remission despite medical management, a transcranial transcavernous surgery was performed. Brain magnetic resonance imaging showed a mass in the roof of the left cavernous sinus, located at the level of the anteromedial triangle, adherent to the clinoidal segment of the internal carotid artery (ICA). The computed tomographic scan showed an osteolysis of the inferior surface of the anterior clinoidal process. After performing an extended pterional craniotomy and an extradural clinoidectomy, the cleavage plane is extended between the temporal dura and the inner layer of the lateral wall of the cavernous sinus. Intraoperative Doppler and stimulation are used to localize the clinoidal segment of the ICA and the third cranial nerve, delimiting the anteromedial triangle. The lesion is progressively dissected and removed. An optic neuropexy with the previously harvested fat is performed in case of a complementary radio surgical treatment. The patient had an uneventful postoperative course and showed a biochemical remission at the 3-month follow-up.The link to the video can be found at: https://youtu.be/oHfugVtU-Nc.

Introduction:It has been proposed that sailing can improve quality of life, personal and social skills of people with severe psychosocial disabilities. This study aimed to assess the efficacy of a psychosocial rehabilitative intervention focused on sailing on quality of life, self-efficacy and sense of coherence in people with severe psychosocial disabilities.Methods:The study was a randomized, with parallel groups, waiting-list controlled trial. Participants were 51 people with severe psychosocial disabilities. The intervention was a structured course to learn sailing in a crew lasting three months. A randomized group began the sailing course immediately after a pre-treatment assessment; the waitlist group began the sailing course after a three months period of treatments as usual. Participants were assessed before and after the sailing course, or the waiting list period, on the General Self-Efficacy scale (GSES), Sense Of Coherence scale (SOC) and Health Survey-short form (SF-12).Results:Self-efficacy significantly increased after the sailing course and decreased after treatment as usual (p=0.015). Sense of coherence and the levels of quality of life tended to improve after the sailing course, albeit below levels of statistical significance.Conclusion:When compared to more traditional psychosocial rehabilitative activities, an intervention focused on sailing in a crew positively impacts the sense of coherence and the levels of quality of life and significantly improves self-efficacy of people with severe psychosocial disabilities. Further longitudinal research is required.

Background and objective: Craniopharyngiomas are locally aggressive neuroepithelial tumors infiltrating nearby critical neurovascular structures. The majority of published surgical series deal with childhood-onset craniopharyngiomas, while the optimal surgical management for adult-onset tumors remains unclear. The aim of this paper is to summarize the main principles defining the surgical strategy for the management of craniopharyngiomas in adult patients through an extensive systematic literature review in order to formulate a series of recommendations. Material and methods: The MEDLINE database was systematically reviewed (January 1970–February 2019) to identify pertinent articles dealing with the surgical management of adult-onset craniopharyngiomas. A summary of literature evidence was proposed after discussion within the EANS skull base section. Results: The EANS task force formulated 13 recommendations and 4 suggestions. Treatment of these patients should be performed in tertiary referral centers. The endonasal approach is presently recommended for midline craniopharyngiomas because of the improved GTR and superior endocrinological and visual outcomes. The rate of CSF leak has strongly diminished with the use of the multilayer reconstruction technique. Transcranial approaches are recommended for tumors presenting lateral extensions or purely intraventricular. Independent of the technique, a maximal but hypothalamic-sparing resection should be performed to limit the occurrence of postoperative hypothalamic syndromes and metabolic complications. Similar principles should also be applied for tumor recurrences. Radiotherapy or intracystic agents are alternative treatments when no further surgery is possible. A multidisciplinary long-term follow-up is necessary.

Loess deposits in southern Britain contain a record of dust, climate and landscape dynamics over the last glacial, yet their age and accumulation rate remain poorly known. Furthermore, the environmental controls on the loess-soil stratigraphy shown in the thickest deposits in southeast England are still debated. Here we apply the first high sampling resolution quartz optically stimulated luminescence study of dust accumulation and loess formation in Britain at the Pegwell Bay site in east Kent. We couple this to mineral magnetic, particle size and geochemical analyses to understand climate, environment and post depositional modification of the loess. The luminescence ages and Bayesian age modelling results suggest two phases of greatly enhanced dust accumulation at the site. Loess began to accumulate around c. 25e23.5 ka, coinciding with Heinrich event 2, and after subsequent lower accumulation rates, a second enhanced phase of deposition occurred at around 20e19 ka.We propose a model where the dynamics of the British-Irish and Fennoscandian Ice Sheets, associated glacial lake drainage, and linked reorganisations of atmospheric circulation, all controlled loess accumulation in southern Britain. Accumulation in the first phase was triggered by increased sediment supply from initial retreat of the North Sea ice lobe, and drainage of Dogger Lake. Loess accumulation during this phase was enhanced by easterly winds from Atlantic depressions tracking to the south of Britain, caused by the maximum extent of the Irish Sea Ice Stream at c. 25e24 ka. The subsequent retreat of the western part of the British Irish Ice Sheet then allowed storm tracking further north, which reduced effectiveness of dust transporting winds across southern Britain, while sediment supply and availability was reduced in North Sea source areas. A second retreat of the maximum extent of the North Sea Lobe of ice after c. 21e20 ka would have led to another abrupt input of sediment-rich ice dammed lake and meltwater from eastern England and the North Sea into the exposed southern North Sea area. This would have again dramatically increased sediment availability for transport and deposition as loess in SE England, resulting in the second dust accumulation phase. We also propose that the abrupt stratigraphic change from calcareous to non-calcareous loess up section at Pegwell Bay was driven, not by these changes in dust input, but rather deepening of the permafrost active layer after c. 21 ka. This deepening was associated with warmer and wetter conditions driven by Atlantic storms tracking further north following the regression of the Irish Sea Ice Stream and overall ice sheet retreat. As such, last glacial dust dynamics and loess accumulation in Britain is highly influenced by the interaction of the British Irish Ice Sheet the Fennoscandian Ice sheet, Atlantic storm tracks, and the topography and drainage of the exposed North Sea., Swedish Research Council (VR grant 2017e03888) and the Quaternary Research Association (QRA) Quaternary Research Fund. BB acknowledges the financial support of project BU235P18 (Junta de Castilla y Leon, Spain) and the European Regional Development Fund (ERD).

Introduction: The phenomenon of migration is characterized and influenced by a number of different variables; and the different stages of journey are related to different levels and types of psychological distress. Women, in particular, are exposed to further specific risks during migration. Aim: To determine the factors that affect the psychological health of migrant women during the different stages of the migration journey. Methods: We provide a narrative review of the literature around the experiences of women during migration process, with a geographical focus on women migrating to the Mediterranean area. Results: Little data is currently available on the burden of mental health disorders for female migrants. Most studies about the mental health status of migrants were not gender-disaggregated or focused specifically on migrant women’s experiences of violence. Sexual and Gender-Based Violence (SGBV) was found to be a common risk factor faced by all the women who leave their native country to migrate to other countries. Conclusion: Despite the importance of the issue and the gender-specific variables related to the experience of migrant women, few studies have looked specifically at psychological variables and mental health status in the female migrant population. It is crucial that future studies are conducted around female migration, violence towards women, and women’s mental health, in order to provide an evidence-base for promoting adequate policies and prevention/treatment programs for women.

Background and objective: The optimal management of large vestibular schwannomas continues to be debated. 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 this problem from a European perspective. Material and methods: A systematic review of MEDLINE database, in compliance with the PRISMA guidelines, was performed. A subgroup analysis screening all surgical series published within the last 20 years (January 2000 to March 2020) was performed. Weighted summary rates for tumor resection, oncological control, and facial nerve preservation were determined using meta-analysis models. This data along with contemporary practice patterns were discussed within the task force to generate consensual recommendations regarding preoperative evaluations, optimal surgical strategy, and follow-up management. Results: Tumor classification grades should be systematically used in the perioperative management of patients, with large vestibular schwannomas (VS) defined as > 30 mm in the largest extrameatal diameter. Grading scales for pre- and postoperative hearing (AAO-HNS or GR) and facial nerve function (HB) are to be used for reporting functional outcome. There is a lack of consensus to support the superiority of any surgical strategy with respect to extent of resection and use of adjuvant radiosurgery. Intraoperative neuromonitoring needs to be routinely used to preserve neural function. Recommendations for postoperative clinico-radiological evaluations have been elucidated based on the surgical strategy employed. Conclusion: The main goal of management of large vestibular schwannomas should focus on maintaining/improving quality of life (QoL), making every attempt at facial/cochlear nerve functional preservation while ensuring optimal oncological control, thereby allowing to meet patient expectations. Despite the fact that this analysis yielded only a few Class B evidences and mostly expert opinions, it will guide practitioners to manage these patients and form the basis for future clinical trials., SCOPUS: re.j, info:eu-repo/semantics/published

Climate could influence the COVID-19 pandemic, but while no evidence has been advanced on the influence of colder climates, some studies have provided data to support a possible heat-related protective factor. The objective is to verify whether areas with a Cold Temperate Climate (TC) have a higher Case Fatality Ratio (CFR) for COVID-19 than areas with a Cold Climate (CC) or with a Mediterranean Climate (MC) in the European Union and the Enlarged European Region. Countries or regions were subdivided into 3 groups according to the Köppen climate classification system: TC (Cfa, Cfb and Cfc in the Köppen system); MC (Csa, Csb); CC (D and E in the Köppen system). The total number of cases and the total number of deaths were detected on 13 August 2020 on the COVID-19 Map - Johns Hopkins Coronavirus Resource Center-the CFR was thus calculated by area. Living in TC areas is strongly associated with risk of a high Case Fatality Ratio for COVID-19, OR for MC =0.42, IC 95% 0.41-0.43; OR for CC=0.33, IC 95% 0.33-0.35. The results are confirmed in the EU, OR per MC=0.85, CI 95% 0.84-0.87; OR per CC=0.63, IC 95% 0.61-0.65.The study found that the IC in a humid temperate climate is associated with higher CFR with respect to the coldest and warmest temperate climates in Europe. This does not appear to be the only determinant of the pandemic.

Cervical pathologies are addressed through a variety of anterior and posterior approaches and minimally invasive procedures have been successfully applied during the last decades. Posterior cervical foraminotomy (PCF) should be proposed with isolated foraminal stenosis. We provide a step-by-step description of PCF through the use of tubular retractors. Its advantages and limitations were detailed. PCF performed with tubular retractors represent a safe and efficient alternative to address an isolated level disease with unilateral radiculopathy. The risk of mechanical instability is limited when only the medial third of the facet is drilled. Patients present rapid functional recovery.

Pituitary neuroendocrine tumors (PitNETs) : nomenclature evolution, not clinical revolution

OBJECTIVESurgery for frontal lobe epilepsy remains a challenge because of the variable seizure outcomes after surgery. Disconnective procedures are increasingly applied to isolate the epileptogenic focus and avoid complications related to extensive brain resection. Previously, the authors described the anterior quadrant disconnection procedure to treat large frontal lobe lesions extending up to but not involving the primary motor cortex. In this article, they describe a surgical technique for unilateral disconnection of the prefrontal cortex, while providing an accurate description of the surgical and functional anatomy of this disconnective procedure.METHODSThe authors report the surgical treatment of a 5-month-old boy who presented with refractory epilepsy due to extensive cortical dysplasia of the left prefrontal lobe. In addition, with the aim of both describing the subcortical intrinsic anatomy and illustrating the different connections between the prefrontal lobe and the rest of the brain, the authors dissected six human cadaveric brain hemispheres. These dissections were performed from lateral to medial and from medial to lateral to reveal the various tracts sectioned during the three different steps in the surgery, namely the intrafrontal disconnection, anterior callosotomy, and frontobasal disconnection.RESULTSThe first step of the dissection involves cutting the U-fibers. During the anterior intrafrontal disconnection, the superior longitudinal fasciculus in the depth of the middle frontal gyrus, the uncinate fasciculus, and the inferior frontooccipital fasciculus in the depth of the inferior frontal gyrus at the level of the anterior insular point are visualized and sectioned, followed by sectioning of the anterior limb of the internal capsule. Once the frontal horn is reached, the anterior callosotomy can be performed to disconnect the genu and the rostrum of the corpus callosum. The intrafrontal disconnection is deepened toward the falx, and at the medial surface, the cingulum is sectioned. The frontobasal disconnection involves cutting the anterior limb of the anterior commissure.CONCLUSIONSThis technique allows selective isolation of the epileptogenic focus located in the prefrontal lobe to avoid secondary propagation. Understanding the surface and white matter fiber anatomy is essential to safely perform the procedure and obtain a favorable seizure outcome.

OBJECTIVEAnterior quadrant disconnection represents a safe surgical option in well-selected pediatric patients with a large frontal lobe lesion anterior to the motor cortex. The understanding of the anatomy of the white matter tracts connecting the frontal lobe with the rest of the cerebrum forms the basis of a safe and successful disconnective surgery. The authors explored and illustrated the relevant white matter tracts sectioned during each surgical step using fiber dissection techniques.METHODSFive human cadaveric hemispheres were dissected to illustrate the frontal connections in the 3 planes. The dissections were performed from lateral to medial, medial to lateral, and ventral to dorsal to describe the various tracts sectioned during the 4 steps of this surgery, namely the anterior suprainsular window, intrafrontal disconnection, anterior callosotomy, and frontobasal disconnection.RESULTSAt the beginning of each surgical step, the U fibers were cut. During the anterior suprainsular window, the superior longitudinal fasciculus (SLF), the uncinate fasciculus, and the inferior fronto-occipital fasciculus (IFOF) were visualized and sectioned, followed by sectioning of the anterior limb of the internal capsule. During the intrafrontal disconnection, the SLF was cut, along with the corona radiata. At the medial surface the cingulum was sectioned. The anterior callosotomy disconnected the anterior third of the body of the callosum, the genu, and the rostrum. The frontobasal disconnection addressed the last remaining fibers connecting the frontal lobe with the rest of the hemisphere, namely the anterior limb of the anterior commissure.CONCLUSIONSThe anterior peri-insular quadrantotomy aims at effectively treating children with large lesions of the frontal lobe anterior to the motor cortex. A precise understanding of the gyral anatomy of this lobe along with the several white matter connections is crucial to avoid motor complications and to ensure complete disconnection.

The 2017 World Health Organization classification of central nervous system and endocrine tumors have introduced significant changes in the diagnostic criteria for pituitary lesions. The aim of our paper is to describe the epidemiological, clinico-pathological, and radiological features of a single consecutive institutional surgical series of rare pituitary lesions, using these new criteria. Of the 316 endoscopic endonasal trans-sphenoidal approaches performed for pituitary lesions between 2010 and 2018, 15 rare lesions were encountered. These included metastases, pituitary carcinomas, pituicytomas, granular cell tumor, primary pituitary lymphomas, germinoma, mixed gangliocytoma-adenoma, hypophysitis, and pituitary hyperplasia. Their clinical, radiological, and pathological features are herewith presented along with a literature review that enabled us to propose an algorithm to facilitate a diagnosis for rare pituitary lesions.

Introduction: Spinal epidural abscess (SEA) is a very rare condition in pediatric patients. Varicella zoster infection could be a predisposing factor, and SEA should be suspected in patients with signs of secondary bacterial infection and even mild neurological signs. Clinical case: We describe here a case of a 30-month-old girl with a history of remitting varicella infection, diagnosed for a lumbar epidural abscess and sacro-ileitis, secondary to group A Streptococcus (GAS). Discussion: This is the third case of SEA from GAS reported in the literature in a pediatric population with varicella infection. We discuss here the clinical presentation and the diagnostic challenges for SEA in childhood through a review of the literature.

Dear Editor, We would like to report a well-documented case of diagnostic dyspraxia as a consequence of a ruptured distal anterior cerebral artery (DACA) aneurysm. Radiological findings on tractography permit a better understanding of the physiopathology and anatomo-clinical correlations between diagnostic dyspraxia and intracranial hemorrhage secondary to a DACA aneurysm rupture. A right-handed patient presented with brutal onset of left temporal headache. Clinical examination revealed a Glasgow Coma Scale of 14 with a right crural hemiparesis. The cerebral CT scan showed a subarachnoid hemorrhage Fisher grade IV (Fig. 1a), with the majority of the blood in the pericallosal cistern. The angio-CT demonstrated a right A2 aneurysm at the pericallosal—callosomarginal junction; this was treated immediately by urgent endovascular coiling with no periprocedural complications. On day 1, the patient complained about the feeling of oppositional behavior from his non-dominant hand against his dominant hand. The left hand-dissociative movements were triggered by voluntary activities of his right hand: when we asked the patient to take an object with his right hand, his left hand seized the object before the right hand had time to reach it. The patient never doubted that the left hand was part of his own body, and he had no left/right hand confusion, but he felt that his left hand had its own will. No frontal release signs such as grasping or perseverance were observed. Neuropsychological testing showed language difficulties and clinical signs of callosal disconnection (bilateral taping disturbance, interdigital transfer difficulties, left tactile extinction) associated with executive dysfunction. In the subacute phase, T2and DWI-weightedMRI images showed involvement of the body and splenium of the corpus callosum with residual blood in the pericallosal cistern (Fig. 1b). The tractographic analysis confirmed the interhemispheric disconnection at the posterior third of the corpus callosum with a complete interruption of the commissural fibers (Fig. 1c, d). The patient underwent a specialized rehabilitation and had a good recovery with a complete return to autonomous daily life activities. DACA aneurysms account for about 3 to 7 % of intracranial aneurysms, most of which commonly arise at the bifurcation of the pericallosal and calloso-marginal arteries [3]. Ruptured DACA aneurysms are smaller than in other sites and are associated with more frequent intracerebral hematomas [4]. The Alien Hand Syndrome (AHS) was first described by Goldstein as a variety of clinical conditions whose common characteristic is the uncontrolled behavior or the feeling of strangeness of one extremity, most frequently involving the left hand [1, 2]. The common classification distinguishes between the posterior, or sensory form, of AHS and the anterior, or motor form, of this condition. To explain inconsistencies such as the phenomenon of diagonistic dyspraxia, Aboitiz (2003) proposed the distinction of five classes of AHS with peculiar clinical manifestations and specific anatomical substrates [1]. G. Cossu (*) :M. Messerer : R. T. Daniel Departement des Neurosciences Cliniques, Service de Neurochirurgie, Centre Hospitalier Universitaire Vaudois, Universite de Medecine et Biologie de Lausanne, Rue du Bugnon 44, 1011 Lausanne, Switzerland e-mail: giulia.cossu@chuv.ch

Different approaches have to be considered for lesions of the diencephalic-mesencephalic junction based on the localization, extension of the lesion, and relationship to the ventricular system. We present the case of a young lady who presented with a cavernoma of the junction of midbrain and diencephalon after an episode of hemorrhage. The microsurgical anatomy of the trans-callosal trans-choroidal approach for this lesion is described along with its advantages and limitations. The trans-choroidal approach allows adequate access to lesions of the diencephalic-mesencephalic junction that project into the third ventricle.

Background/objective Spinal arachnoid cysts (SAC) are intradural lesions, which may provoke a compression of the spinal cord and roots. Endoscopic techniques are increasingly used to minimize the surgical access and the postoperative scar tissue. Shunts may also represent an option. The aim of this paper is to illustrate the technique of endoscopic-assisted fenestration and positioning of a cysto-peritoneal diversion in a thoracic SAC using a flexible endoscope and to perform a systematic literature review on this subject. Material and methods We reported our case and we performed a review of the literature, searching for all the adult cases of Type III SACs in English language treated through endoscopic procedures. Results We found 5 articles matching our search criteria and we included 9 adult patients in our analysis. Six patients were females and the most common localization was the thoracic spine. Six patients underwent selective laminectomies followed by endoscopic fenestration without cyst wall resection. Three patients had a percutaneous endoscopic inspection of the cyst and in two cases a cysto-subarachnoid shunt space was performed. Improvement of pre-operative neurological deficit was reported in six patients, no patients experienced clinical deterioration. The mean follow-up was 22 months and no progression or recurrence was reported. Conclusion The implementation of endoscopy allows a minimally invasive treatments with good visualization of cyst anatomy and precise shunt positioning under real-time guidance. Endoscopy is technically demanding but it can offer similar clinical outcomes when compared to microscopic procedures with a limited rate of post-operative complications. The long-term risk of recurrence should be established by prospective studies., Spinal arachnoid cyst, Endoscopy, Outcome, Shunt, Surgery.

Gangliocytoma of the sellar region are extremely rare and often coexist with pituitary adenoma. Aim of this review is to collect all the cases reported in literature and to summarize the most recent literature evidences on the subject. A systematic review was performed through PubMed searching for articles describing gangliocytoma of the sellar region in the adult population, up to September 2015. An analysis of epidemiological data, clinical presentation, histochemical and radiological features and follow-up data was performed. A total of 55 articles were included in our analysis, reporting 129 cases of gangliocytoma of the sellar region. One case identified in our institution was also included. 85% of cases presented in association with pituitary adenomas. A female prevalence was evident. Patients presented most frequently with symptoms of hyperprolactinemia (44%) or visual disturbances (47%) when the sellar gangliocytoma was isolated, or with acromegalic manifestations (67%) when the gangliocytoma was associated with a pituitary adenoma. Immunohistochemistry showed a higher prevalence of mixed GH-PRL adenomas in association with sellar gangliocytomas, followed by GH adenomas. A purely intrasellar localization was found in about 25% of cases and a suprasellar extension in 30% of cases. A more extensive infiltration was present in about 40% of cases. A complete resection was obtained in 56% of collision lesions. The follow-up period was variable but endocrine remission was reported in 81% of cases of associated gangliocytoma and pituitary adenoma. Sellar gangliocytomas are rare lesions and an association with pituitary adenomas should always be searched. Mixed GH PRL adenomas are most frequently isolated. Collision lesions seem to have a behavior similar to isolated adenoma but a more important aggressiveness should be excluded at a molecular level. Further studies will allow advancements in clarifying the pathogenesis of this association.

PurposeTSH-secreting pituitary adenomas are rare pituitary tumors. An efficient treatment is essential to limit the mortality and morbidity in untreated patients. The aim of this study is to summarize the evidence about the postoperative outcomes and management of this rare pathology.MethodsA systematic search and meta-analysis of surgical series was performed.ResultsOur analysis included 23 articles (536 patients). No sex difference was observed and mean age at diagnosis was 45years. Hyperthyroidism was reportedly clinical in 67% and biochemical in 90% of patients. Co-secretion of other pituitary hormones was present in 42% of cases. Macroadenomas were found in 79% of patients, showing in 44% and 30% of cases respectively extrasellar extension and cavernous sinus invasion. The pooled rate of postoperative biochemical remission was 69.7% and a gross total resection (GTR) was observed in 54% of patients. The extent of resection was significantly increased in microadenomas (p

Refugees from war zones and asylum seekers are exposed to a wide range of traumas, including persecution, humiliation, gender-based violence, human rights violations, and significant family losses. This results in a statistically higher risk of trauma-related mental disorders. However, refugees and asylum seekers are a heterogeneous population, as far as their gender, age, ethnic, cultural, educational and socio-economic background are concerned. There is no certainty that the Western-centred therapies will be effective in the treatment of the trauma-related mental disorders of refugees and asylum seekers. This chapter summarizes the currently available evidence on the mental health of refugees from war zones and asylum seekers, focusing in particular on the results of randomized controlled trials of psychosocial and other non-conventional interventions applied to refugees and asylum seekers. Culturally sensitive approaches, which activate same-cultural community network support, are more likely to contribute to the effectiveness of the care process.

In the next few years, the global burden of disease due to mental illness is likely to overtake that of cancer and heart disease. There is research evidence to suggest that nearly half of psychiatric disorders in adulthood start below the age of 15 and nearly three quarters do so before 24 years indicating specific periods of vulnerability. It is evident that mental health and physical health are strongly inter-connected and yet often the focus of public health is on physical health. Promotion of good mental health and education about prevention of mental illness can take many forms. From teaching parenting skills to learning about managing stress from an early age to early intervention can help reduce the burden of mental illness. Public mental health has come into its own as a speciality of psychiatry and thus of medicine only in the last two decades and that too only in some parts of the world. In spite of the evidence for prevention of mental illness and promotion of mental health is getting stronger by the day there appears to be some reluctance among clinicians to take on the role of educators and advocates for public mental health. A common reason is lack of training in the subject at both undergraduate and postgraduate levels as focus is on treatment rather than prevention. Positive mental health can lead to better outcomes at a number of levels. This book brings together evidence on various aspects of public mental health which can be used for advocacy and education.

The groove of the vertebral artery on the posterior arch of the atlas (sulcus arteriae vertebralis) may become a complete or partial osseous foramen: the arcuate foramen. The presence of a complete or partial arcuate foramen is a rare anatomical variant described in a minority of patients and it seems to be associated with vertigo, vertebro-basilar insufficiency, posterior circulation strokes, and musculoskeletal pain. As the number and morphology of cervical vertebrae is highly preserved, we questioned about its significance from an evolutionary point of view. We thus investigated through an extensive literature review if the arcuate foramen is a pure anatomical variation shape or if it might represent an adaptation legacy. We observed five atlas of an extinct species, the Late Pleistocene Mammoths (M. primigenius), and we compared them with five atlas of a closely related existent species, the African elephant (L. africana). All the mammoths’ atlas had an arcuate foramen through which the vertebral artery passed before turning anteriorly and becoming intradural. This foramen was not present in elephants’ atlas, where only a groove was observed, such as in the majority of patients. We would like to raise the hypothesis that this peculiar morphology of mammoths’ atlas might have contributed, in association with other factors, to their precocious extinction and that the arcuate foramen might represent a disadvantage in the evolutionary process, with a low prevalence in humans being the result of a natural selection.

Introduction: It has been proposed that sailing can improve quality of life, personal and social skills of people with severe psychosocial disabilities. This study aimed to assess the efficacy of a psychosocial rehabilitative intervention focused on sailing on quality of life, self-efficacy and sense of coherence in people with severe psychosocial disabilities. Methods: The study was a randomized, with parallel groups, waiting-list controlled trial. Participants were 51 people with severe psychosocial disabilities. The intervention was a structured course to learn sailing in a crew lasting three months. A randomized group began the sailing course immediately after a pre-treatment assessment; the waitlist group began the sailing course after a three months period of treatments as usual. Participants were assessed before and after the sailing course, or the waiting list period, on the General Self-Efficacy scale (GSES), Sense Of Coherence scale (SOC) and Health Survey-short form (SF-12). Results: Self-efficacy significantly increased after the sailing course and decreased after treatment as usual (p=0.015). Sense of coherence and the levels of quality of life tended to improve after the sailing course, albeit below levels of statistical significance. Conclusion: When compared to more traditional psychosocial rehabilitative activities, an intervention focused on sailing in a crew positively impacts the sense of coherence and the levels of quality of life and significantly improves self-efficacy of people with severe psychosocial disabilities. Further longitudinal research is required.

Introduction:Physical activity helps to improve several clinical outcomes of people with severe psychosocial disabilities. The aims of this study were; 1) to assess the efficacy of a psychosocial rehabilitative intervention focused on sailing in a crew on: a) social functioning; b) severity of the psychosocial disability; c) general functioning; d) dysregulation of biorhythms of people with severe psychosocial disabilities, and 2) to evaluate the attenders’ satisfaction about the project.Methods:A randomized waitlist controlled trial with parallel groups was carried out involving 51 people with severe psychosocial disabilities. The intervention was a 3 months-lasting course to learn sailing in a crew. Just after the randomization, a group began the sailing course and the other group (wait list) attended the sailing course after 3 months of treatments as usual. Before and after the sailing course, as well as the waiting list period, all attenders were assessed by HoNOS, GAF, CGI-S and BRIAN. At the end of the sailing course, they completed also a self-report satisfaction questionnaire.Results:Social functioning significantly improved after the sailing course (HoNOS total score “time X group”: p=0.011), mainly because of the improvement of psychopathological symptoms (HoNOS symptoms score “time X group”: p=0.003). Furthermore, participants greatly appreciated the rehabilitative program based on sailing in a crew.Conclusions:When compared to more traditional rehabilitative activities that are usually carried out in mental health services, a psychosocial rehabilitative intervention based on sailing in a crew significantly improve the social functioning of people with severe psychosocial disabilities.

Background: The physical activity has been indicated as an experience that can help achieve positive, self-oriented own body awareness. This awareness is an aspect that tends to get worse with age. Objective: Our study aims to verify the internal consistency of a questionnaire on physical awareness in a sample of Italian elders; a secondary objective is to measure if there is a relationship between physical awareness and perceived level of physical activity. Methods: Cross sectional study on a consecutive sample of elderly people was administered the “Physical Body Experiences Questionnaire simplified for active aging (PBE-QAG)”, inspired by the “Physical Body Experiences Questionnaire”, modified, simplified and adapted to be used in the elderly over 65. To elderly people the International Physical Activity Questionnaire. Cronbach’s alpha was also used to assess internal reliability of the total PBE-QAG. The factor structure was evaluated through Confirmatory Factor Analyses (CFAs). Results: The Cronbach’s alpha was 0.8 for the “body-mind relationship” scale, 0.81 for the “accepting your body” scale, 0.83 for the “awareness of physical skills” scale, and 0.65 for the “awareness of physical limits” scale. Cronbach’s alpha for the total PBE-QAG was 0.89. The CFA indicated a model with the 4 factors (CFI = 0.989, TLI = 0.984, RMSEA = 0.076). People who conducted physical activity assiduously or regularly and over 10 minutes showed a better score to the PBE-QAG than those who declared a sporadic activity and for “less than 10 minute”, respectively. Conclusion: Our study revealed that the PBE-QAG shows an excellent total internal consistency. In the Italian sample of elderly people the questionnaire shows the model with the 4 factors described in literature.

Endoscopic endonasal trans-sphenoidal surgery has become the gold standard for the surgical treatment of pituitary adenomas and many other pituitary lesions. Refinements in surgical techniques, technological advancements, and incorporation of neuronavigation have rendered this surgery minimally invasive. The complication rates of this surgery are very low while excellent results are consistently obtained through this approach. This paper focuses on the step-by-step surgical approach to pituitary adenomas, which is based on personal experience, and details the results obtained with this minimally invasive surgery.

Objectives. We performed a systematic literature review to analyze the clinical application and the safety of mifepristone, a prominent antiprogesterone agent, in meningioma patients.Materials and Methods. A systematic search was performed through Medline, Cochrane, and clinicaltrials.gov databases from 1960 to 2014.Study Selection. Studies were selected through a PICO approach. Population was meningioma patients, meningioma cells cultures, and animal models. Intervention was mifepristone administration. Control was placebo administration or any other drug tested. Outcomes were clinical and radiological responsiveness, safety profile, and cell growth inhibition.Results. A total of 7 preclinical and 6 clinical studies and one abstract were included. Encouraging results were found in preclinical studies. Concerning clinical studies, the response rate to mifepristone in terms of radiological regression and symptomatic improvement/stability in patients with inoperable meningioma was low. In meningiomatosis, favorable preliminary results were recorded. The safety profile was good. Limitations were as follows. The tumoral expression of progesterone receptors was not analyzed systematically in every study considered.Conclusions. No clear evidence exists to recommend mifepristone in inoperable meningiomas. Preliminary encouraging results were found in diffuse meningiomatosis. Mifepristone is a well-tolerated treatment. Patients’ selection and hormonal profile analysis in meningiomas are fundamental for a better understanding of its benefit. Multicenter placebo-controlled trials are required.

Refractory frontal lobe epilepsy has been traditionally treated through a frontal lobectomy. A disconnective technique may allow similar seizure outcomes while avoiding the complications associated with large brain resections. The aim of this study was to describe a new technique of selective disconnection of the frontal lobe that can be performed in cases of refractory epilepsy due to epileptogenic foci involving 1 frontal lobe (anterior to the motor cortex), with preservation of motor function. In addition to the description of the technique, an illustrative case is also presented.This disconnective procedure is divided into 4 steps: the suprainsular window, the anterior callosotomy, the intrafrontal disconnection, and the frontobasal disconnection. The functional neuroanatomy is analyzed in detail for each step of the surgery. It is important to perform cortical and subcortical electrophysiological mapping to guide this disconnective procedure and identify eloquent cortices and intact neural pathways.The authors describe the case of a 9-year-old boy who presented with refractory epilepsy due to epileptogenic foci localized to the right frontal lobe. MRI confirmed the presence of a focal cortical dysplasia of the right frontal lobe. A periinsular anterior quadrant disconnection (quadrantotomy) was performed. The postoperative period was uneventful, and the patient was in Engel seizure outcome Class I at the 3-year follow-up. A significant cognitive gain was observed during follow-up.Periinsular anterior quadrantotomy may thus represent a safe technique to efficiently treat refractory epilepsy when epileptogenic foci are localized to 1 frontal lobe while preserving residual motor functions.

Coeliac Disease (CD) is an autoimmune disease in which an environmental factor, gluten, triggers a pathological reaction. It results in intra- and entra-intestinal manifestations of disease, including, most frequently, diarrhoea, weight loss, and anaemia. CD occurs in ∼1% of the western population, being one of the most common autoimmune lifelong disorders, and may present with a variety of psychiatric comorbidities. Psychiatric comorbidity in CD often complicates the diagnosis, reduces the quality-of-life, and worsens the prognosis of affected patients. This review summarizes the epidemiological studies that underline this connection, and focuses on the potential mechanisms related to this comorbility, such as nutritional deficiencies, immune responses, interference in brain processes, and dysfunctions in the gut-brain axis. Factors that play a central role on patients' quality of life, psychological well-being and adherence are presented. Finally, evidence of regression in psychiatric symptoms following the introduction of a gluten-free diet is underlined as well.

Delayed post-traumatic mucoceles are rare. We describe the surgical treatment of a post-traumatic ethmoidal mucocele with intra-orbital extension.A uninostril endoscopic endonasal approach (EEA) was performed. The access was contralateral to the lesion to provide a wider lateral view. After a large sphenoid and ethmoid sinuses opening, the collection was drained and the optic nerve precociously identified. The orbital roof was eroded and the frontal dura mater directly visible.The uninostril contralateral approach allows a good exposure of the lateral fields and is conservative towards the nasal mucosa. A favorable skull base anatomy is the prerequisite for its efficacy.

The management of women with brain tumors in the early post-partum period may be demanding as the patho-physiological changes that occur during pregnancy may also manifest in the early post-partum period. The aim of our paper is to report a case of late-onset post-partum pre-eclampsia after brain tumor surgery, complicated by posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS). Hemicraniectomy and intensive care management were necessary to obtain a favorable neurological outcome. The inherent literature on the subject is also analyzed through a systematic research. This is the first case of supratentorial decompressive hemicraniectomy in post-partum PRES, while there has been only one other case of posterior fossa decompression described in this cohort of patients. PRES and RCVS can complicate the neurosurgical management of women in the postpartum period. A careful evaluation of the clinical presentation is necessary as in some particular cases an aggressive medical and surgical treatment is required to obtain a favorable outcome.