Search

Deep brain stimulation (DBS) is currently considered a promising neuromodulation therapy for refractory epilepsy not suitable for resective surgery. Several anatomical targets and different stimulation approaches have been proposed in order to obtain satisfactory seizures reduction. As expected, according with different patterns of neural pathways involvement, the efficacy of each anatomical target stimulation in reducing seizure frequency varies among the different epileptic syndromes.

The intracranial pressure (ICP) show large daily fluctuation, mainly due to postural changes and physical activity (e.g. it goes up to 470 mmH2O under Valsalva manoeuvre1). Consequently, the dural sinus must be sufficiently rigid in order to avoid its collapse during cerebrospinal fluid (CSF) pressure peaks. Hereby, we describe a patient with collapsible dural sinus associated with an intracranial hypertension syndrome without a detectable raised ICP, suggesting that a number of crucial assumptions on idiopathic intracranial hypertension with (IIH) or without papilledema (IIHWOP) might be discussed.

Background Pituitary tumors are a heterogeneous group of lesions that are usually benign. Therefore, a proper understanding of the anatomy, physiology, and pathology is mandatory to achieve favorable outcomes. Accordingly, diagnostic tests and treatment guidelines should be determined and implemented. Thus, we decided to perform a multicenter study among Italian neurosurgical centers performing pituitary surgery to provide an actual depiction from the neurosurgical standpoint. Methods On behalf of the SINch (Societa Italiana di Neurochirurgia), a survey was undertaken with the participants to explore the activities in the field of pituitary surgery within 41 public institutions. Results Of the 41 centers, 37 participated in the present study. The total number of neurosurgical procedures performed in 2016 was 1479. Most of the procedures were performed using the transsphenoidal approach (1320 transsphenoidal [1204 endoscopic, 53 microscopic, 53 endoscope-assisted microscopic] vs. 159 transcranial). A multidisciplinary tumor board is convened regularly in 32 of 37 centers, and a research laboratory is present in 18 centers. Conclusions Diagnosing pituitary/hypothalamus disorders and treating them is the result of teamwork, composed of several diverse experts. Regarding neurosurgery, our findings have confirmed the central role of the transsphenoidal approach, with preference toward the endoscopic technique. Better outcomes can be expected at centers with a multidisciplinary team and a full, or part of a, residency program, with a greater surgical caseload.

Objective The α 2 agonist dexmedetomidine (DEX) is an anesthetic agent that can provide sedation and analgesia without respiratory depression or changes in neuronal activity during microrecordings. The aim of our study was to confirm the efficacy and safety of anesthesia with DEX for unilateral deep brain stimulation of the subthalamic nucleus (STN) in patients with Parkinson disease. Methods In 2013 and 2014, a series of 11 consecutive patients received continuous low-dose DEX infusion during unilateral deep brain stimulation of the STN. Intraoperative microrecordings, stimulation results, and patient reaction times in executing verbal and motor tasks were retrospectively analyzed. Functional outcomes were evaluated by comparing preoperative and 1-year postoperative Unified Parkinson's Disease Rating Scale Part III scores. Results Typical activity of the STN was recorded in all patients, and the delay in the execution of both motor and verbal tasks was ≤2 seconds. No hemorrhagic complications occurred, and no postoperative side effects were observed. The mean percentage of Unified Parkinson's Disease Rating Scale Part III improvement at last follow-up was 39.01% (range, 23.70%–55.60%). The mean percentage of levodopa equivalent dose reduction was 45.86% (range, 21.50%–65.70%). Conclusions The results of our study confirm that the use of DEX in managing patients with Parkinson disease during unilateral deep brain stimulation of the STN is safe and effective and can be considered a promising option for sedation during this type of procedure.

The management of giant and large pituitary adenomas with wide intracranial extension or infrasellar involvement of nasal and paranasal cavities is a big challenge for neurosurgeons and the best surgical approach indications are still controversial. Endoscopic extended endonasal approaches have been proposed as a new surgical technique for the treatment of such selected pituitary adenomas. Surgical series coming from many centers all around the world are flourishing and results in terms of outcomes and complications seem encouraging. This technique could be considered a valid alternative to the transcranial route for the management of giant and large pituitary adenomas.

Background Mucocele is an inflammatory disease caused by the retention of mucoid secretions within a paranasal sinus. Although rare, the presence of a vascular lesion inside the sphenoid sinus could determine ostium obstruction, thus causing mucocele development. Clinical Presentation An 84-year-old woman was referred to our institution due to a lesion abutting into the sphenoid sinus; she was complaining of constrictive frontal headache, progressive worsening of visual acuity in the left eye; later, sudden homolateral ptosis and diplopia occurred. The radiologic evidence was consistent with the diagnosis of thrombosed aneurysm of the right intracavernous carotid artery, surrounded by sphenoidal mucocele. The patient underwent an endoscopic endonasal transsphenoidal approach exclusively for sphenoid mucocele drainage. Conclusion Although rare, the presence of a vascular lesion inside the sphenoid sinus has to be considered among the possible diagnostic hypotheses of masses abutting in this cavity; the association with mucocele is even more rare and, to date, has not been described.

Background Pituitary surgery is a continuous evolving specialty of the neurosurgeons' armamentarium, which requires precise anatomic knowledge, technical skills, and integrated culture of the pituitary pathophysiology. Actually it cannot be considered only from a technical standpoint, but rather a procedure resulting from the close cooperation among different specialists (e.g., ophthalmologists, neuroradiologists, endocrinologists, neurosurgeons, otorhinolaryngologists, anesthesiologists, neurophysiologists, pathologists, instrument manufacturers). Methods The “pure” endoscopic endonsal surgery is a procedure performed through the nose, with the endoscope alone throughout the whole approach and without any transsphenoidal retractor. The procedure consists of three main aspects: exposure of the lesion, removal of the relevant pathology, and reconstruction, going through three different steps, the nasal, the sphenoid, and the sellar phases. Conclusions The endoscopic approach offers some advantages due to the endoscope itself: a superior close-up view of the relevant anatomy and an enlarged working angle are provided with an increased panoramic vision inside the surgical area. Concerning results in terms of mass removal, relief of clinical symptoms, cure of the underlying disease, and complication rate, these are, at least, similar to those reported in the major microsurgical series, but patient compliance is by far better. Besides the advantages to the patients, the surgeons—because of the wider and closer view of the surgical target area and the increase of the scientific activity as from the peer-reviewed literature on the topic in the past 10 years, the smoothing of interdisciplinary cooperation—, and the institutions (shorter postoperative hospital stay and increase of the case load)— the adoption of endoscopy in transsphenoidal surgery has gained a strong foothold.

ow back pain is a problem that affects an ever-greater number of patients, and the volume of spinal fusion surL geries performed each year is constantly increasing. Although in most patients the surgery achieves a satisfactory outcome, there is a subpopulation that does not achieve a complete recovery. The causes of such failure can be easily identified in most of cases (e.g., pseudarthrosis); however, there are some patients who continue to complain of low back pain without a reasonable explanation. In those patients who experience a suboptimal outcome after spinal fusion surgery, several parameters may be considered, and serum Vitamin D concentration could be an important marker to investigate because of its importance in maintaining musculoskeletal health. This consideration can be crucial when a spinal fusion surgery is planned, especially in those patients with risk factors for hypovitaminosis D.

Summary The midline skull base is an anatomical area, which extends from the anterior limit of the anterior cranial fossa down to the anterior border of the foramen magnum. For many lesions of this area, a variety of skull base approaches including anterior, antero-lateral, and postero-lateral routes, have been proposed over the last decades, either alone or in combination, often requiring extensive neurovascular manipulation. Recently the endoscopic endonasal approach to the skull base has been introduced to access the midline skull base. The major potential advantage of the endoscopic endonasal technique is to provide a direct anatomical route to the lesion since it does not traverse any major neurovascular structures, thereby obviating brain retraction. The potential disadvantages include the relatively restricted exposure and the higher risk of CSF leak. In the present study we report the endoscopic endonasal anatomy of different areas of the midline skull base from the olfactory groove to the cranio-vertebral junction and accordingly describe the main features of the surgical approaches to each of these regions.

Object In addition to difficulties with anesthetic and medical management, transsphenoidal operations in patients with longstanding acromegaly are associated with inherent intraoperative challenges because of anatomical variations that occur frequently in these patients. The object of this study was to review the overall safety profile and anatomical/technical challenges associated with transsphenoidal surgery in patients with acromegaly. Methods The authors performed a retrospective analysis of 169 patients who underwent endoscopic transsphenoidal operations for growth hormone–secreting adenomas to assess the incidence of surgical complications. A review of frequently occurring anatomical challenges and operative strategies employed during each phase of the operation to address these particular issues was performed. Results Of 169 cases reviewed, there was no perioperative mortality. Internal carotid artery injury occurred in 1 patient (0.6%) with complex sinus anatomy, who remained neurologically intact following endovascular unilateral carotid artery occlusion. Other complications included: significant postoperative epistaxis (5 patients [3%]), transient diabetes insipidus (5 patients [3%]), delayed symptomatic hyponatremia (4 patients [2%]), CSF leak (2 patients [1%]), and pancreatitis (1 patient [0.6%]). Preoperative considerations in patients with acromegaly should include a cardiopulmonary evaluation and planning regarding intubation and other aspects of the anesthetic technique. During the nasal phase of the transsphenoidal operation, primary challenges include maintaining adequate visualization and hemostasis, which is frequently compromised by redundant, edematous nasal mucosa and bony hypertrophy of the septum and the nasal turbinates. During the sphenoid phase, adequate bony removal, optimization of working space, and correlation of imaging studies to intraoperative anatomy are major priorities. The sellar phase is frequently challenged by increased sellar floor thickness, distinct patterns of tumor extension and bony invasion, and anatomical variations in the caliber and course of the internal carotid artery. Specific operative techniques for addressing each of these intraoperative challenges are discussed. Conclusions Transsphenoidal surgery in patients with longstanding acromegaly frequently poses greater challenges than operations for other types of sellar lesions, yet these challenges may be safely and effectively overcome with the anticipation of specific issues and implementation of various intraoperative techniques.