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The treatment protocols for glioblastoma multiforme (GBM) involve a combination of surgery, radiotherapy and adjuvant chemotherapy. Despite this multimodal approach, the prognosis of patients with GBM remains poor and there is an urgent need to develop novel strategies to improve quality of life and survival in this population. In an effort to improve outcomes, intra-arterial drug delivery has been used in many recent clinical trials; however, their results have been conflicting. The blood-brain barrier (BBB) is the major obstacle preventing adequate concentrations of chemotherapy agents being reached in tumor tissue, regardless of the method of delivering the drugs. Therapeutic failures have often been attributed to an inability of drugs to cross the BBB. However, during the last decade, a better understanding of BBB physiology along with the development of new technologies has led to innovative methods to circumvent this barrier. This paper focuses on strategies and techniques used to bypass the BBB already tested in clinical trials in humans and also those in their preclinical stage. We also discuss future therapeutic scenarios, including endovascular treatment combined with BBB disruption techniques, for patients with GBM. [ABSTRACT FROM AUTHOR]

Glioblastoma multiforme (GBM) is the most common and aggressive malignant glioma that is treated with first-line therapy, using surgical resection followed by local radiotherapy and concomitant/adjuvant temozolomide (TMZ) treatment. GBM is characterised by a high local recurrence rate and a low response to therapy. Primitive neuroectodermal tumour (PNET) of the brain revealed a low local recurrence rate; however, it also exhibited a high risk of cerebrospinal fluid (CSF) dissemination. PNET is treated with surgery followed by craniospinal irradiation (CSI) and platinum-based chemotherapy in order to prevent CSF dissemination. GBM with PNET-like components (GBM/PNET) is an emerging variant of GBM, characterised by a PNET-like clinical behaviour with an increased risk of CSF dissemination; it also may benefit from platinum-based chemotherapy upfront or following failure of GBM therapy. The results presented regarding the management of GBM/PNET are based on case reports or case series, so a standard therapeutic approach for GBM/PNET is not defined, constituing a challenging diagnostic and therapeutic dilemma. In this report, a case of a recurrent GBM/PNET treated with surgical resection and radiochemotherapy as Stupp protocol, and successive platinum-based chemotherapy due to the development of leptomeningeal dissemintation and an extracranial metastasis, is discussed. A review of the main papers regarding this rare GBM variant and its therapeutic approach are also reported. In conclusion, GBM/PNET should be treated with a multimodal approach including surgery, chemoradiotherapy, and/or the early introduction of CSI and platinum-based chemotherapy upfront or at recurrence.

Background: Single-level cervical radiculopathy may be treated conservatively with cervical tractions. Posterior cervical transfacet fusion with a facetal spacer is a viable option. The aim of the present study is to compare posterior cervical transfacet fusion with conservative physical treatment in single-level cervical radiculopathy., Methods: A total of 80 patients were randomized in 2 groups, a surgical group in which patients were given posterior cervical transfacet fusion and a traction group in which patients were treated conservatively with mechanical cervical tractions. Visual analog scale for arm and neck, Neck Disability Index, and Short Form-36 (SF-36) questionnaires were administered preoperatively and after treatment up to 12 months., Results: After treatment, visual analog scale arm scores were greater in traction group (4.7 vs. 1.5 the day after treatment) and at follow-up controls (traction group vs. surgical group: 5.3 vs. 0.6 at 1 month, 3.6 vs. 0.3 at 6 months, 1.8 vs. 0.2 at 12 months). Neck Disability Index scores were lower in the surgical group (surgical group vs. traction group: 4.4 vs. 20.3 at 1 month, 1.3 vs. 10.5 at 6 months). SF-36 scores were greater in the surgical group (surgical group vs. traction group: 96 vs. 70 at 1 month, 96.5 vs. 82.6 at 6 months). Neck disability index and SF-36 scores were superimposable between the groups at 12-month follow-up. No adjacent-segment arthrosis or late complications were reported at 1-year follow-up in the surgical group., Conclusions: posterior cervical transfacet fusion is a safe and effective procedure to treat single-level cervical radiculopathy., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Study Design: A blinded, randomized, comparative prospective study., Objective: The aim of this study was to compare the use of intrathecal morphine to endovenous morphine on postoperative pain after posterior lumbar surgery., Summary of Background Data: Intrathecal morphine can provide significant safe analgesia for at least 12 hours and up to 24 hours in patients undergoing major surgery. Its dosages have been decreasing in the last 30 years, but currently, the optimal dose remains unknown. As of today, there are no studies comparing the efficacy and the side effects of this technique with intravenous morphine administration after minimally invasive lumbar fusion surgery., Methods: We randomized and compared two groups of 25 patients, who were given either 100 μg intrathecal (ITM group) or 5 ± 2 mg intravenous morphine delivered intravenously for 24 hours at 2 mL/h (IVM group) after minimally invasive posterior lumbar fusion. VAS score at 0, 6, 12, 24 hours, mobilization out of bed at 6 hours, hospitalization duration and complications as lower limbs paresthesia, urinary retention at 6 and 12 hours, nausea, vomit, itch, and constipation were evaluated., Results: Data showed a lower VAS score, a reduction of constipation, lower limbs paresthesia, or urinary retention at 12 hours in ITM rather than in the IVM group. None suffered of vomit, itch, or nausea in both groups. Urinary retention was observed more frequently in ITM group at 6 hours. Patients of ITM group were mobilized out bed earlier than those from IVM group., Conclusion: A low dosage of intrathecal morphine is safe and effective after minimally invasive lumbar fusion surgery. The reduction of pain in the study group permitted a shorter hospitalization and earlier mobilization out of bed, augmenting patients' comfort., Level of Evidence: 2.

Background: Among traumatic brain injuries, acute subdural hematoma (aSDH) is considered one of the most devastating still retaining poor surgical outcomes in a considerable percentage of affected patients. However, according to results drawn from published samples of aSDH patients, overall mortality and functional recovery have been progressively ameliorating during the last decades., Methods: We present a retrospective analysis of 316 consecutive cases of post-traumatic aSDH operated on between 2003 and 2011 at our institution., Results: Mortality was 67% (n = 212); a useful recovery was achieved in 16.4% cases (n = 52). Age >65 years, a preoperative Glasgow coma scale (GCS) ≤ 8, specific pre-existing medical comorbidities (hypertension, heart diseases) were found to be strong indicators of unfavorable outcomes and death during hospitalization., Conclusion: Our results, compared with those of the inherent literature, led the authors to question both the "aggressiveness" of neurosurgical care indications in certain subpopulations of patients being known to fare worse or even die regardless of the treatment administered and the relevance of the results concerning mortality and functional recovery reported by third authors.

Background: There is uncertainty about the optimal method for measuring the decompressive craniectomy (DC) surface area and how large the DC should be., Methods: A radiological technique for measuring the surface area of removed bone flaps in a series of 73 DCs was developed. Preoperative and early postoperative computed tomography scans of each patient were evaluated. Midline shift (MLS) was considered the key factor for successful DC and was assigned to either normal (0-4 mm) or pathological (≥5 mm) ranges. The association between postoperative MLS and patient survival at 12 months was assessed., Results: Measurements of all removed bone flaps yielded a mean surface area of 7759 mm 2 . The surface area of the removed bone flap did not influence survival (surviving 7643 mm 2 vs. deceased 7372 mm 2 ). The only factor associated with survival was reduced postoperative MLS (P < 0.034). Risk of death was 14.4 (3.0-70.1)-fold greater in patients with postoperative shift ≥5 mm (P < 0.001)., Conclusion: The ideal surface area for "large" square bone flaps should result in an MLS of <5 mm. Enlargement of the craniectomy edges should be considered for patients in whom MLS ≥5 mm persists according to early postoperative computed tomography scans., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To describe the history of vascular and endovascular neurosurgery., Methods: A literature research was conducted including historical events from 2000 bc to the twenty-first century ad, and a timetable was filled with information regarding the most representative historical landmarks regarding vascular and endovascular neurosurgery., Results: Starting from approaches limited to the cervical carotid artery, vascular neurosurgery gained its way through the intracranial and finally endovascular space thanks to the introduction of both innovative and progressively less invasive procedures. With the invention of cerebral angiography in 1927, Egas Moniz paved the way for modern endovascular neurosurgery., Conclusions: Numerous pioneers have been described through this historical reconstruction. Their genius, effort, dedication, and passion brought a massive contribution to vascular and endovascular neurosurgery as we know it today., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction . According to the 2016 World Health Organization classification of Tumors of the Central Nervous System, the term Primitive Neuroectodermal Tumor has been replaced by the term Embryonal Tumor (ET). We present a case of disseminated cerebrospinal ET presenting in an adult patient. Illustrative Case . A 49-year-old male presenting with low back pain, dysuria, and hypoesthesia of the lower extremities referred to our emergency department. Brain and whole spine contrast-enhanced MRI documented a diffusively disseminated heterogeneous neoplasm with intradural extra- and intramedullary involvement of the cervicothoracic tract and cauda equina. A primary biopsy of the lumbosacral localization was performed through L5 bilateral laminectomy. Histologic diagnosis was Embryonal Tumor Not Otherwise Specified. The patient underwent chemotherapy with postoperative adjuvant alternating Vincristine-Doxorubicin-Ifosfamide (VAI) and Ifosfamide-Etoposide (IE). Discussion . Spinal ETs are exceedingly rare especially when presenting in the adult patient. Neurosurgical and oncologic management is still unclear. When feasible, surgical removal should always be performed to obtain a histologic diagnosis. Postoperative adjuvant therapy might entail both chemo- and radiotherapy; however a consensus on this matter is still lacking.

Introduction: The full endoscopic interlaminar approach (FEILA) is a minimally invasive procedure to treat intracanal lumbar disc herniation not approachable by endoscopic transforaminal access. Disc prolapses have been classified into three categories according to their position and passing nerve root displacement: (i) type A, in which the nerve root is displaced medially; (ii) type B, in which the nerve root is displaced laterally; and (iii) type C, in which the nerve root is ventrally displaced. We focused on the FEILA technique because it was likely to involve few complications and that provided the advantages of the endoscopic approach., Methods: We prospectively evaluated 100 consecutive cases of L5-S1 disc herniations operated on with FEILA, including 85 type A cases, 13 type B, and 2 type C. Patients were evaluated at discharge, 3 months, 6 months and 2 years., Results: The operating time varied from 15 to 40 min. The use of drills and burrs was necessary to treat type B disc herniations; thus, it was preferable that these cases were operated on later in the learning curve. After surgery, 90% of neurological deficits improved. The Oswestry Disability Index and visual analog scale leg at last follow-up were 15 and 9, respectively. There were no major complications. There were five cases of recurrence; four of which were treated with same technique and with good results., Conclusion: FEILA is a safe procedure for the removal of intracanal L5-S1 disc herniations. The late follow-up confirms the stability of the results. We suggest treating type A prolapse at the beginning of the learning curve and type B herniations after sufficient experience in the use of the burrs has been achieved., (© 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.)

Lumbar puncture is a safe and commonly performed procedure, with an overall complication rate of 0.1% to 0.5%. Well-known contraindications to lumbar puncture are an intracranial tumor, noncommunicating hydrocephalus, coagulopathy, and ruptured aneurysm with subarachnoid hemorrhage. We report a case of a young man with epilepsy who, after a lumbar puncture performed for research purposes, presented with an intracerebral hematoma and neurological deficits. To the best of our knowledge, post-tap intraparenchymal hematoma is extremely rare and only 1 case has been reported previously. In consideration, all patients undergoing a lumbar puncture should be informed about this possible rare complication, even in the absence of documented hemorrhagic risk factors.

Piezosurgery is an alternative surgical technique, now widely tested, that uses ultrasounds for bone cutting. This device uses ultrasounds to section hard tissues without harming surrounding soft tissues. The authors analyzed their experience in craniomaxillofacial procedures with piezosurgery. A comparison between operation timing and complication rates between piezosurgery and traditional cutting instruments has been performed. A total of 27 patients were examined (15 females and 12 males; average age, of 5.5 months) affected by craniosynostosis. The aim of this study was to analyze the advantages and disadvantages of piezosurgery in pediatric craniofacial procedures. Piezoelectric device in this study has shown being a valid instrument for bone cutting in accurate procedures, because it allows performing a more precise and safer cutting, without the risk of harming surrounding tissues.

Objective: The purpose of this study was to assess the feasibility of the use of the 2μ-thulium laser in harvesting nasal septal flaps., Background Data: Nasal septal flaps are routinely performed in almost every trans-sphenoidal surgery. The preservation of the arterial vasculature is a mainstay of the procedure. However, the margins of the flap should be sufficiently healthy to regenerate faster, reducing the risk of possible complications., Materials and Methods: Eight patients underwent trans-sphenoidal surgery and removal of pituitary adenomas. Reparation of the defect was performed with the positioning of a rotational vascularized nasal-septal flap. The flaps were harvested with the aid of the 2μ-thulium laser. Every patient was then monitored for 6 months through seriated endoscopic endonasal controls., Results: There were no complications related to the use of the laser, either intraoperatively, or postoperatively. The operative timing did not significantly differ from that of traditional techniques., Conclusions: The use of the 2μ-thulium laser for the harvesting of nasal septal vascularized flaps can be considered safe and feasible. The limited number of treated patients could be considered as the only restriction to the study. A larger study might have uncovered possible instrumentation-related complications, which were not observed in the present study.

Aim: Acromegaly is caused by a GH-secreting pituitary adenoma, associated with many comorbidities and increased risk of mortality. Surgery is the first-line therapy. Success of therapy is measured by symptomatic improvement, preservation of pituitary function and biochemical control. Trans-sphenoidal surgery (TSS), endoscopic or microscopic, is the preferred treatment. To evaluate surgery effectiveness and individuate the technique associated with a higher remission rate, patients undergoing TSS were retrospectively selected., Methods: Thirty-seven consecutive patients underwent surgery between 1996 and 2006. Tumors were classified into macroadenomas or microadenomas and into intrasellar, extrasellar and extrasellar with cavernous sinus invasion. Surgery was performed in 22 patients with endoscopic technique, in 15 patients with microsurgical approach. The hormonal assays were performed 6 months and yearly after surgery for an average of 5 years., Results: Ten patients were affected by microadenoma, 27 by macroadenoma. In microadenomas remission rate was independent of the used technique. Within macroadenomas, remission percentage in endoscopic approach (68.75%) was significantly higher than in microscopic approach (18.18%) (P=0.018). Postsurgical biochemical remission was calculated combining the surgical technique and tumor extension: the endoscopic approach was associated with a significantly higher remission rate in extrasellar than both in intrasellar and extrasellar with cavernous sinus invasion. In the latter group, any technique had not reached biochemical remission., Conclusion: TSS is able to induce a long-term remission of acromegaly, with low risk of recurrence and complications. Endoscopic approach is more suitable than microscopic technique in macroadenomas and adenomas with suprasellar extension.

Endoscopic disc surgery (EDS) for lumbar spine disc herniation is a well-known but developing field, which is increasingly spreading in the last few years. Rate of recurrence/residual, complications, and outcomes, in comparison with standard microdiscectomy (MD), is still debated and need further data. We performed an extensive review based on the last 6 years of surgical series, systematic reviews, and meta-analyses reported in international, English-written literature. Articles regarding patients treated through endoscopic transforaminal or interlaminar approaches for microdiscectomy (MD) were included in the present review. Papers focused on endoscopic surgery for other spinal diseases were not included. From July 2009 to July 2015, we identified 51 surgical series, 5 systematic reviews, and one meta-analysis reported. In lumbar EDS, rate of complications, length of hospital staying, return to daily activities, and overall patients' satisfaction seem comparable to standard MD. Rate of recurrence/residual seems higher in EDS, although data are nonhomogeneous among different series. Surgical indication and experience of the performing surgeon are crucial factors affecting the outcome. There is growing but still weak evidence that lumbar EDS is a valid and safe alternative to standard open microdiscectomy. Statistically reliable data obtained from randomized controlled trials (better if multicentric) are desirable to further confirm these results.

Epidural hematoma (EH) is a neurosurgical emergency that requires early surgical treatment. It is rarely extended bilaterally causing a detachment of the dural sinus or sinuses. The authors present two rare cases of EH with dural sinus detachment and describe how they suspend them. In these cases it is crucial to firmly suspend the dura mater and the dural sinus to the inner skull surface to prevent postoperative rebleeding.

Rhabdomyosarcoma (RMS) is a rare and aggressive neoplasm characterised by rapid growth and metastatic invasion. The most frequent localisation is the skeletal musculature of the limbs. The head and the neck are rarely involved. A 50-year-old woman presented to our attention because of a progressively increasing headache, ataxia and vomiting. MRI showed a lesion at the right cerebellopontine angle. Thereafter, the patient was submitted to a piece-meal removal of the neoplasm. Despite the postoperative MRI showed no signs of remnant, 7 months after the surgery, the disease recurred with multiple localisations, and the patient died a few days later. This report is the first description in the literature of a pleomorphic RMS of the cerebellopontine angle. This particular tumour carries a bad prognosis because of the vicinity of nervous structures and of the impossibility of achieving a one-piece resection. More than ever, the adjunctive treatments had to be effective against a potential remnant and in controlling recurrences.

Chordoid meningioma is a rare variant of meningioma characterized by a more aggressive behavior. The present study documents the histological, radiological and clinical features of seven cases treated at the Policlinico Umberto I of Rome from 1999 to 2010. There were five males and two females. Most of the cases were located in the supratentorial space, especially the convexity. Surgical gross total resection was achieved in four cases. Of the remaining three cases, two relapsed and underwent further surgeries and adjuvant treatment. The MIB-1 index had a mean value of 7.5 (range 0.3-25.8). Tumors were composed of epithelioid cells or plump to spindle cells, forming cords, cribriforms or nests, in a mucoid matrix. All tumors showed diffuse positive immunoreactivity to vimentin and epithelial membrane antigen. Surgery is the first line of treatment for this kind of lesion. Gross total resection guaranteed a survival free from recurrences in our series. On the other hand, radiation therapy must be considered in patients submitted to a subtotal resection.

In the present work we analysed the possible recognition of professional disease in a subject exposed to ionizing radiation. Haematic parameters were evaluated during the working activity and after the risk's avoidance. Normal haematic values after the pathogenic noxa's avoidance exclude a chronic damage, which in an indispensable datum for professional disease recognition.