Search

The ischemia/reperfusion mechanism is believed to be responsible for parenchymal damage caused by temporary hypoperfusion and worsened by the subsequent attempt of reperfusion. This represents a true challenge for physicians of several fields, including neurosurgeons. A limited number of papers have shed the light on a rare pathologic condition that affects patients experiencing an unexplained neurologic deficit after spine surgery, the so-called "white cord syndrome." This entity is believed to be caused by an "ischemia/reperfusion" injury on the spinal cord, documented by a postoperative intramedullary hyperintensity on T2-weighted magnetic resonance imaging sequences. To date, the cases of white cord syndrome reported in literature mostly refer to cervical spine surgery. However, the analysis of several reviews focusing on spine surgery outcome suggests postoperative neurologic deficits of new onset could be charged to a mechanism of ischemia/reperfusion, even if the physiopathology of this event is seldom explored or at least discussed. The same neuroradiologic finding can suggest mechanical damage due to inappropriate surgical manipulation. On this purpose, we performed a systematic review of the literature with the aim to identify and analyze all the factors potentially contributing to ischemic/reperfusion damage of the spinal cord that may potentially complicate any spinal surgery, without distinction between cervical or thoracic segments. Finally, we believe that postoperative neurologic deficit after spinal surgery constituting the "white cord syndrome" could be under-reported; both neurosurgeons and patients should be fully aware of this rare but potentially devasting complication burdening cervical and thoracic spine surgery.

Spine is a frequent site of bone metastases, with a 8.5 months median survival time after diagnosis. In most cases treatment is only palliative. Several advanced techniques can ensure a better Quality of Life (QoL) and increase life expectancy. Radiofrequency ablation (RFA) uses alternating current to produce local heating and necrosis of the spinal lesion, preserving the healthy bone. RFA is supported by vertebral reinforcement through kyphoplasty and vertebroplasty in order to stabilize the fracture with polymethylmethacrylate (PMMA) injection, restoring vertebral body height and reducing the weakness of healthy bone. The aim of this study is to demonstrate the efficacy and advantages of RFA plus vertebral reinforcement through PMMA vertebroplasty and fixation in patients affected by bone spinal metastases. We retrospectively analyzed 54 patients with thoraco-lumbar metastatic vertebral fractures admitted to our Unit between January 2014 and June 2020. Each patient underwent RFA followed by PMMA vertebroplasty and transpedicle fixation. We evaluated pain relief through the Visual Analogue Scale (VAS) Score and PMMA vertebral filling based on the mean Saliou filling score. Analysis of variance (ANOVA) was used to test pain relief with statistical significance for p

Microvascular Doppler (MicroV) is a new-generation Doppler technique developed by Esaote (Esaote s.p.a., Genova, Italy), which is able to visualize small and low-flow vessels through a suppression of interfering signals. MicroV uses advanced filters that are able to differentiate tissue artifacts from low-speed blood flows; by exploiting the space–time coherence information, these filters can selectively suppress tissue components, preserving the signal coming from the microvascular flow. This technique is clinically applied to the study of the vascularization of parenchymatous lesions, often with better diagnostic accuracy than color/power Doppler techniques. The aim of this paper is to develop a reproducible protocol for the recording and collection of MicroV intraoperative ultrasound images by the use of a capable intraoperative ultrasound machine and post-processing aimed at evaluation of brain-tumor microvascularization through the analysis of radiomic features. The proposed protocol has been internally validated on eight patients and will be firstly applied to patients affected by WHO grade IV astrocytoma (glioblastoma—GBM) candidates for craniotomy and lesion removal. In a further stage, it will be generally applied to patients with primary or metastatic brain tumors. IOUS is performed before durotomy. Tumor microvascularization is evaluated using the MicroV Doppler technique and IOUS images are recorded, stored, and post-processed. IOUS images are remotely stored on the BraTIoUS database, which will promote international cooperation and multicentric analysis. Processed images and texture radiomic features are analyzed post-operatively using ImageJ, a free scientific image-analysis software based on the Sun-Java platform. Post-processing protocol is further described in-depth. The study of tumor microvascularization through advanced IOUS techniques such as MicroV could represent, in the future, a non-invasive and real-time method for intraoperative predictive evaluation of the tumor features. This evaluation could finally result in a deeper knowledge of brain-tumor behavior and in the on-going adaptation of the surgery with the improvement of surgical outcomes.

BACKGROUND Intraoperative ultrasound (IOUS) is becoming more and more adopted in neurosurgery, since it has been associated to greater extent of resection (EOR) and to gross total resection (GTR) during brain tumor surgery. IOUS main limitations are spatial resolution, width and orientation of the field of view and scan quality, which are operator-dependent. Furthermore, most neurosurgeons are not confident with this technique, which needs a long learning curve in order to identify and interpret anatomic structures. OBJECTIVE To describe an effective procedure to take advantages of both IOUS and neuronavigation in case of lack of a navigated ultrasound system. METHODS We propose a reliable "indirect-navigated" technique which is based on the optical tracking of un-navigated IOUS probe by the use of a multipurpose passive tracker and a proper configuration of common neuronavigation system. RESULTS Navigated IOUS is not available in all neurosurgical operating rooms but ultrasound systems are common tools in many hospital facilities and neuronavigation systems are common in almost all the neurosurgical operating rooms. The proposed indirect-navigated technique shows some paramount advantages: since almost all the neurosurgical operating rooms are provided with a neuronavigation system, the only tool needed is the ultrasonography. Therefore, this procedure is largely accessible and costless, reliable, and may improve the neurosurgeon's ability in ultrasonographic anatomy. CONCLUSION This technique is based on the coplanar and coupled use of both un-navigated IOUS probe and standard optical neuronavigation, in order to allow the intraoperative navigation of IOUS images when a navigated ultrasound system is not available.

Transcranial MR-guided Focused ultrasound (tcMRgFUS) is a surgical procedure that adopts focused ultrasounds beam towards a specific therapeutic target through the intact skull. The convergence of focused ultrasound beams onto the target produces tissue effects through released energy. Regarding neurosurgical applications, tcMRgFUS has been successfully adopted as a non-invasive procedure for ablative purposes such as thalamotomy, pallidotomy, and subthalamotomy for movement disorders. Several studies confirmed the effectiveness of tcMRgFUS in the treatment of several neurological conditions, ranging from motor disorders to psychiatric disorders. Moreover, using low-frequencies tcMRgFUS systems temporarily disrupts the blood–brain barrier, making this procedure suitable in neuro-oncology and neurodegenerative disease for controlled drug delivery. Nowadays, tcMRgFUS represents one of the most promising and fascinating technologies in neuroscience. Since it is an emerging technology, tcMRgFUS is still the subject of countless disparate studies, even if its effectiveness has been already proven in many experimental and therapeutic fields. Therefore, although many studies have been carried out, many others are still needed to increase the degree of knowledge of the innumerable potentials of tcMRgFUS and thus expand the future fields of application of this technology.

Brain gliomas require a deep knowledge of their effects on brain connectivity. Understanding the complex relationship between tumor and functional brain is the preliminary and fundamental step for the subsequent surgery. The extent of resection (EOR) is an independent variable of surgical effectiveness and it correlates with the overall survival. Until now, great efforts have been made to achieve gross total resection (GTR) as the standard of care of brain tumor patients. However, high and low-grade gliomas have an infiltrative behavior and peritumoral white matter is often infiltrated by tumoral cells. According to these evidences, many efforts have been made to push the boundary of the resection beyond the contrast-enhanced lesion core on T1w MRI, in the so called supratotal resection (SpTR). SpTR is aimed to maximize the extent of resection and thus the overall survival. SpTR of primary brain tumors is a feasible technique and its safety is improved by intraoperative neuromonitoring and advanced neuroimaging. Only transient cognitive impairments have been reported in SpTR patients compared to GTR patients. Moreover, SpTR is related to a longer overall and progression-free survival along with preserving neuro-cognitive functions and quality of life.

Hemostasis represents a fundamental step in every surgical procedure. During neurosurgical procedures, proper and robust hemostasis into confined spaces can significantly reduce the odds of perioperative complications. Over the decades, multiple methods have been applied, and several medical devices have been developed to promote and guarantee proper hemostasis. This study presents a systematic review of the most used intraoperative hemostatic methods and devices in neurosurgery. Insightful research was performed on the PubMed database according to the PRISMA guidelines. This comprehensive review of scientific literature represents a synoptic panel where the most used intraoperative hemostatic methods and devices available today in neurosurgery are classified and described.

Background: Dumbbell tumors are typically benign schwannomas, neurofibromas, and meningiomas and only rarely there are malignant variants of these lesions or other malignant histotypes. Here, a 34-year-old male presented with a thoracic spinal dumbbell metastatic neuroendocrine carcinoma of unknown primary origin. Case Description: A 34-year-old male presented with 2 months of thoracic pain and progressive mid thoracic sensory loss. A post contrast thoracic MRI showed a dumbbell tumor localized between the T7 and T9 levels with extension laterally into the T7-T8 and T8-T9 foramina. The patient underwent a laminectomy for tumor resection following which his pain and gait improved. Histopathologically, the tumor demonstrated multiple rounded small cells with a Ki67 level around 30%, suggesting a malignant metastatic neuroendocrine tumor of unknown etiology. Conclusion: We successfully treated a 34-year-old male with a T7-T9 malignant spinal dumbbell neuroendocrine tumor of unknown etiology utilizing a decompressive laminectomy.

Background: Because the neurological presentation of spinal epidural hematomas (SEH) is often not specific, they may be misdiagnosed as acute lumbar disk herniations. Here, we present a case in which a traumatic disc extrusion mimicked an epidural hematoma and reviewed the appropriate literature. Case Description: A 27-year-old male sustained a high-energy fall. The lumbar MRI scan showed a L4-S1 ventral medium/high signal intensity mass on the T1- and high signal intensity lesion on T2-weighted images; the original diagnosis was spinal epidural hematoma. However, at surgery, consisting of a left L4 and L5 hemilaminectomy with L4-L5 and L5-S1 laminotomy, an extruded lumbar disc was encountered at the L4-L5 level and removed; no additional pathology or SEH was found at either level. Conclusion: On MR, SEH may mimic acute lumbar disk herniations. Depending on the clinical symptoms/signs, surgical intervention will both correctly confirm the diagnosis and relieve neural compression.

Background: Therapeutic epidural spinal injections (ESIs) of steroids are one of the most common nonsurgical management modalities employed for alleviating pain due to chronic persistent lumbar spinal disease. However, it is well documented that they have significant risks and complications without any long-term efficacy. ESI may result in epidural empyema which may be difficult to diagnose with delays resulting in significant permanent neurological sequelae. Case Description: A 45-year-old female presented with a lumbar spinal epidural empyema after receiving ESI for low back and right leg pain due to a lumbar disc herniation. Laboratory studies showed elevations of multiple inflammatory markers, and the MR documented a significant lumbar epidural empyema contributing to significant thecal sac compression. Clinically, the patient had an acute cauda equina syndrome warranting emergency surgery consisting of a laminectomy for debridement/decompression followed by long-term antibiotic treatment. Conclusion: Epidural empyema is a major potential complication of lumbar ESI. Multiple markedly elevated inflammatory markers (WBC, ESR, CRP, and procalcitonin) and MRI evidence of an epidural empyema necessitates emergent surgical intervention to limit morbidity, neurological sequelae, and mortality.

Background Surgical decompression of the ulnar nerve (UN) is effective for treating cubital tunnel syndrome (CubTS). Nevertheless, the outcome is not always satisfying. Different surgical, clinical, and imaging findings have been claimed as outcome predictors, but there is no consensus in the literature. We analyzed the outcome-predicting role of ultrasonography (US) of the UN in patients with CubTS and its possible role for diagnosis and follow-up. Methods Patients with CubTS treated by simple UN decompression underwent US and electrodiagnotic (ED) studies of the UN at the elbow before and after surgery. Outcome was evaluated through the Bishop scale. A correlation analysis between pre- and postoperative clinical, US, and ED findings was performed. Results Thirty-six patients were enrolled. Preoperatively, we observed a negative correlation between the motor conduction velocity (MCV) and the transverse (TD) and anteroposterior diameters and cross-sectional area (CSA) of the UN at the precubital (P = 0.001, P = 0.001, P = 0.005) and cubital level (P = 0.02, P = 0.002, P = 0.001). Preoperative precubital TD and CSA were associated with outcome (P = 0.01, P = 0.006) and postoperative MCV (P = 0.004, P = 0.008). The cut-off values TD >6 mm and CSA >23.91 mm2 were predictors of poor outcome. Finally, postoperative cubital TD and CSA values were inversely correlated with outcome (P = 0.0002, P = 0.0007) and postoperative MCV (P = 0.0002, P = 0.0004). Conclusions The US examination of the UN is useful for the management of patients with CubTS as an adjunct to clinical and ED evaluations. US measurements are correlated with pre- and postoperative ED findings and thus are useful for diagnosis and follow-up. Interestingly, specific precubital US measurements are good predictors of outcome.

Maximal safe resection represents the gold standard for surgery of malignant brain tumors. As regards gross-total resection, accurate localization and precise delineation of the tumor margins are required. Intraoperative diagnostic imaging (Intra-Operative Magnetic Resonance-IOMR, Intra-Operative Computed Tomography-IOCT, Intra-Operative Ultrasound-IOUS) and dyes (fluorescence) have become relevant in brain tumor surgery, allowing for a more radical and safer tumor resection. IOUS guidance for brain tumor surgery is accurate in distinguishing tumor from normal parenchyma, and it allows a real-time intraoperative visualization. We aim to evaluate the role of IOUS in gliomas surgery and to outline specific strategies to maximize its efficacy. We performed a literature research through the Pubmed database by selecting each article which was focused on the use of IOUS in brain tumor surgery, and in particular in glioma surgery, published in the last 15 years (from 2003 to 2018). We selected 39 papers concerning the use of IOUS in brain tumor surgery, including gliomas. IOUS exerts a notable attraction due to its low cost, minimal interruption of the operational flow, and lack of radiation exposure. Our literature review shows that increasing the use of ultrasound in brain tumors allows more radical resections, thus giving rise to increases in survival.

High-grade gliomas (HGGs) are the most frequently diagnosed primary brain tumors. Even though it has been demonstrated that combined surgical therapy, chemotherapy, and radiotherapy improve survival, HGGs still harbor a very poor prognosis and limited overall survival. Differently from other types of primary neoplasm, HGG manifests also as a neurological disease. According to this, palliative care of HGG patients represents a peculiar challenge for healthcare providers and caregivers since it has to be directed to both general and neurological cancer symptoms. In this way, the end-of-life (EOL) phase of HGG patients appears to be like a journey through medical issues, progressive neurological deterioration, and psychological, social, and affective concerns. EOL is intended as the time prior to death when symptoms increase and antitumoral therapy is no longer effective. In this phase, palliative care is intended as an integrated support aimed to reduce the symptoms burden and improve the Quality Of Life (QOL). Palliative care is represented by medical, physical, psychological, spiritual, and social interventions which are primarily aimed to sustain patients’ functions during the disease time, while maintaining an acceptable quality of life and ensuring a dignified death. Since HGGs represent also a family concern, due to the profound emotional and relational issues that the progression of the disease poses, palliative care may also relieve the distress of the caregivers and increase the satisfaction of patients’ relatives. We present the results of a literature review addressed to enlighten and classify the best medical, psychological, rehabilitative, and social interventions that are addressed both to patients and to their caregivers, which are currently adopted as palliative care during the EOL phase of HGG patients in order to orientate the best medical practice in HGG management.

Introduction: Meningiomas are the most common tumors of the CNS, where the incidence is around 25% of all primary brain tumors. The optimal treatment is total resection with removal of the dura mater and bone when infiltrated. The histological grading is the most important prognostic factor. Meningiomas may recur after total surgical resection. WHO grade I meningiomas show a recurrence rate between 7-25%. Atypical meningiomas (WHO grade II) between 29-52%. Anaplastic meningiomas (WHO grade III) between 50-94%. From recent studies the Wnt pathway is emerging as involving in growth and progression of meningioma. However, molecular mechanism driving meningioma invasion are not completely clarified. The gene Dkk-3 (Dickkopf WNT signaling pathway inhibitor 3) encodes one of Dickkopf-related protein family of proteins. The activity of this gene is a tumor-suppressive type. The Dkk-3 protein (Dickkopf-related protein 3) is involved in embryonic development through its interactions with the WNT. The REIC/Dkk-3 expression has been shown to be down-regulated in various cancer cell lines. Aim of our study was to study the role of Dkk-3 expression and claudin-5 in meningiomas of different histotype and histological grade. Material and METHODS: We evaluated how meningiomas modify DKK-3 expression in 20 tumors biopsies assessing both immunohistochemistry and western blotting. The tissue samples were embedded in paraffin for immunohistochemical analysis. The expression strength was analyzed and graded based on the positive ratio and intensity of immunoreactivity. The molecular analyses were performed on frozen sections of tumor tissue, by Western Blot method. Statistical analysis was also performed. Results: The expression of Dkk-3 protein and claudin-5 were significantly reduced in meningioma samples compared to controls. These results were confirmed by immunohistochemistry that reveals a slight expression of Dkk-3 protein in meningioma samples examined. It was also highlighted an irregular positivity of claudin-5 protein, on vascular localization. Claudin-5 levels were inversely regulated in meningiomas proteic extract with decreased levels compared to controls. Conclusions: Overexpression of Dkk-3 has been shown to mediate potent anti-tumor effects including reduced cell proliferation, independent growth, invasion and metastasis, and induced cancer cell specific apoptosis.Our preliminary results can suggest that in meningiomas Dkk-3 and Claudin-5 are downregulated. There is an alteration of the BBB. There is a decreasing of apoptotic susceptibility. The immunoreactivity of vascular neoplastic endothelium can suggest a role in angiogenesis. We suggest that the re-establishment of Dkk-3 expression can represent a new potential therapeutic approach in meningiomas treatment also by modulation of blood-brain barrier permeability.

Background Diffuse idiopathic skeletal hyperostosis (DISH), also known as Forestier's disease, is a rheumatologic condition characterized by ossification of the spinal ligaments and tendons. Large anterior osteophytes are typically present in the lower cervical levels, while upper cervical ossification resulting in dysphagia is very rare. Methods Here, we presented a patient with Forestier's disease involving massive ossification of the anterior longitudinal ligament extending from C3 to C4 downward contributing to severe dysphagia. Results A 65-year-old male presented with cervical pain and dysphagia. The computed tomography of the cervical spine demonstrated massive anterior longitudinal ligament ossification (DISH) extending from C3 to C7. There was an additional large osteophyte at the C3-C4 level, and also a high-grade intracanalicular C6-C7 cervical stenosis due to ossification of the posterior longitudinal ligament. The patient was offered surgical intervention (e.g., resection of the C3-C7 anterior DISH and anterior cervical discectomy/fusion at the C6-C7 level), but he declined. Conclusions When conservative management fails to resolve severe dysphagia for cervical DISH/Forestier's disease, anterior surgical resection is typically performed. In this case, the patient refused surgery and opted for conservative management strategies.

Abscess formation within brain tumor is uncommon. Intrasellar or parasellar tumors are among the most common neoplasms that developed such complications as the results of direct extension of microbial flora from contiguous infected sinuses. Cerebral gliomas with abscess are extremely rare. The major challenge is detection of a correct diagnosis. The diagnosis of brain tumor associated with abscess is particularly difficult by conventional neuroradiological studies. Often, computed tomography (ct) and magnetic resonance imaging (mri) can reveal a sudden increase in size of the mass and significant perilesional edema. However, these studies did not consent a correct early diagnosis and only surgical treatment with histological examination allow the exact diagnosis. 99mtc-labeled sulesomab (leukoscan®) can be useful in the diagnosis of brain tumors with intratumoral abscess. 99mtc-labeled sulesomab (leukoscan®) consists of monoclonal murine igg antibody fab' fragment, bound with technetium-99m with affinity for a 42 kda glycoprotein present on the surface of activated granulocytes (nca-90 surface antigen). It is used in different clinical settings as a potential diagnostic tool for the infections of various tissues. We presented three rare cases of cerebral glioma showing intratumoral abscess formation. All patients had been submitted to 99mtc-leukoscan study. Labeled leukocytes scintigraphy seems to be able to differentiate infectious from non-infectious brain lesions. In our patients mri and magnetic resonance spectroscopy (mrs) were unconvincing while the results of the leukocyte scintigraphy, were successively confirmed by histopathological examination, which also showed the presence of a brain abscess. Thus in our cases the sensitivity and the positive predictive value (ppv) of the granulocyte scintigraphy were both 100%. To the best of our knowledge no data have been reported in the literature on the role of nuclear medicine investigation for the recognition of brain abscesses so far. To date this represents the first description of the role of leukoscan in cerebral gliomas with abscess formation.

Cerebral metastases are the most frequent brain tumors in adults and they are found in 15-30% of patients with a primary tumor. They develop mainly in the brain or cerebellum and less frequently in the meninges. Dural metastases are rare entities and are found in 9% of patients with terminal systemic cancer and in about 5% they represent the only intra-cranial manifestation. However their real incidence is unknown because of the lack of significant numerical series. Clinical presentation with dural-based metastasis mimicking meningioma is very rare and described mostly as case reports from diverse primary locations. The most common primary sites in surgically resected dural metastases have been found to be breast and prostate, but may also be from a primary melanoma, sarcoma, or lymphoma. These often presented as single, cranial and subdural lesions. They can present dural tail sign and often are dural-based or intra-parenchymal. The determination of extra-axial origin of a tumor has a considerable clinical implication. The location of the lesion affects treatment planning and it is predictive for prognosis. Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) can show a well defined, lobulated, extra-axial, contrast enhancing lesion. Previously, dural tail sign was reported to be specific for meningiomas, but may be associated with other dural-based lesions. Furthermore, their macroscopic appearance during surgery may even be taken for a meningioma. Because of the prognostic relevance in discriminating both tumors, the definitive diagnosis relies on the histopathological findings. Nowadays MR spectroscopy (MRs) can aid in the differential diagnosis. We report ten cases of dural metastasis from different neoplasms, which on both preoperative CT and MRI and at surgery had the typical appearance of a meningioma. Aim of our study was to investigate the neuroradiological findings and neuropathological aspects of these lesions in order to facilitate the differential diagnosis between meningiomas and other neoplasms. The neuroradiological data were compared with intra-operative characteristics and histological and specific immunohistochemical markers. In our patients the neuroradiological diagnosis of meningiomas was not confirmed by histology. MRs provided interesting complementary data, able to increase the specificity of the neuroradiological diagnosis but in many cases was unconvincing. It is certainly mandatory to resect these lesions, often they have a clear interfaces, much like a meningioma, which allows what appears to be a gross total excision. We still plan to obtain an intra-operative pathologic confirmation for suspected lesions that involve the dura. We also would like to emphasize the precise role of pre-operative diagnosis, which in many cases may be a challenge, to avoid the delay in surgery, with consequent deleterious impact on patient care.

Glial tumors, within neuroepitelial-derived lesions, are the most common intra-assial neo‐ plastic histotypes. Gliomas account for about 45% of all primary central nervous system (CNS) tumors and 77% of all malignant primary CNS tumors. Gliomas can originate from neural stem cells, progenitor cells, or from de-differentiated mature neural cells transformed into cancer stem cells. Although brain tumors constitute only a small proportion of overall human malignancies, they carry high rates of morbidity and mortality. Mortality is still close to 100% and the average survival of patients with glioblastoma multiforme (GBM) is less than 1 year when classical treatment is used. Recent progresses in multimodal treatment has led to only a slight increase in average survival up to 15-18 months [1]. The effectiveness of the actual chemotherapeutic approach and multimodal targeted therapies remains modest in gliomas.

Background Trigeminal schwannomas are uncommon intracranial tumors. Extracranial trigeminal schwannomas in the infratemporal fossa are rare. Methods We present a case with a clinical history of facial pain. MRI and CT scans showed a mass arising from the infratemporal fossa extending into the intracranial space. Results We performed a combined neurosurgical and maxillofacial approach with preoperative endovascular embolization. Complete removal of the parasellar component was achieved with a minimal extracranial neoplastic residual. High microvessel density, reflecting intense neoangiogenesis, was detected through the immunohistochemical staining with endoglin. Conclusions Due to the unique development pattern of trigeminal schwannoma involving multiple intracranial fossae and extracranial compartment, we chose a combined neurosurgical and maxillofacial approach with preoperative embolization of the tumor. Immunohistochemical findings suggest that the extensive growth observed may be related to an intense neoangiogenesis, opening the perspective to novel therapeutic options based on the inhibition of neoangiogenesis. © 2012 Wiley Periodicals, Inc. Head Neck, 2013

Despite innovative therapeutic strategies, the expectative of life in patients affected by cerebral gliomas remain dismal. Malignant gliomas represent a class of infiltrative and aggressive neoplasms that are generally resistant to multimodal approach. The efficacy of classical anti-cancer strategies is seriously limited by lack of specific therapies against malignant cells.Glial tumors seem to be able to create a favorable environment for the invasion of glioma cells in cerebral parenchyma when they combine with the extracellular matrix via cell surface receptors. Recent advances in molecular and tumor biology have lead to a new class of modern antitumoral agents. Antisense oligonucleotides are synthetic stretches of DNA which hybridize with specific mRNA strands. The specificity of hybridization makes antisense method an interesting strategy to selectively modulate the expression of genes involved in tumorigenesis. In this review, molecular targets, clinical and experimental studies about the use of antisense oligonucleotides in cerebral gliomas treatment are reported.

Diffuse and high-grade astrocytomas are invasive neoplasms which grow diffusely into the brain parenchyma. Microglia has been termed the brain's immune system, although its specific role remains uncertain. Objective of this study was to assess in a series of astrocytic neoplasms, the expression of a macrophage marker CD 68 and Major Histocompatibility Complex Class II CR3/43. We examined 10 pilocytic astrocytomas, 13 diffuse astrocytomas and 17 anaplastic astrocytomas. For macrophages we used the CD68 monoclonal mouse antibody. For assessing the presence of MHC Class II complexes we used the specific monoclonal antibody CR3/43. CD68-positive mononuclear cells were observed in perivascular and hypoxic areas, within neoplastic tissue, inside and contiguous to vessel wall. CR3/43 positive complexes were detected in mononuclear elongated elements with amoeboid extensions strictly attached to endothelial cells, or contiguous to perinecrotic areas within neoplastic tissue. We suggest an active involvement of macrophage/microglia infiltrates in neovascularization and malignancy in astrocytomas. Macrophage infiltration and major histocompatibility complex class II complexes reactivity in gliomas could also suggest the occurrence of immune surveillance with a preliminary host's immune response. In addition, macrophages could promote angiogenesis mechanisms and induction of tumor growth.

Introduction Metastases are the most frequent malignant lesions of the spine. Around 5 to 10% of the patients with a systemic tumor have got spinal metastases. More than 95% of spinal metastases are extradural lesions. The residual cases are intradural extramedullary lesions and only 0.5% are intramedullary lesions. Prostate, lung, breast, clear cell kidney tumors, lymphoma, myeloma, and gastric carcinoma are the most frequent primitive neoplasms to cause secondary lesions to the spine. The cervical spine is involved in 10% of the cases. In 80% of the cases, metastases are found to be in the lower cervical tract. Life expectancy in patients with lung carcinoma metastasis is approximately 6 months, 1.5/2 years in patients affected by breast, kidney, and prostate cancers. We reviewed our series of patients with spinal metastases operated between 1997 and 2013 with the aim to analyze the efficacy of the surgical treatment to recover the function and biomechanics of the vertebral column. We evaluated the prognosis in terms of duration and quality of residual life. Materials and Methods We included 36 patients (mean age 65 years). The patients were evaluated according to neurological status, Karnofsky score for the quality of life, and Denis score for pain. Indications for surgery were: pain resistant to pharmacological therapy, medullary compression, neurological deficits, and vertebral instability. Patients underwent CT and MR scan examinations of the cervical spine. In all patients, a total body CT scan was performed. All surgical procedures were performed with microsurgical techniques. In 25 cases, the surgical treatment contemplated an anterior approach: single corpectomy in 16 cases and double in 11 cases. In these cases, the vertebral body was replaced by an expandable titanium cage with PMMA filling and plating. In 6 cases, the treatment consisted of a 360-degree reconstruction. In the residual 5 cases, where the lesion was located in the superior cervical tract of the spine, we performed an occipital–cervical fusion through a posterior approach. Postoperative follow-up controls were run at 1, 3, 6, and 12 months. A cervical orthosis was worn by the patient for 40 days. Results During the follow-up time, 18 patients died because of the progression of the primitive tumor. In 36 patients treated with surgery, the histological examination documented a primitive lesion of the breast in 12 cases, of the lung in 10 cases, of the prostate in 5, of the kidney in 4, of the thyroid in 2, and of the testicle in 2. One patient affected by plasmacytoma was also observed. No intra- and perioperative complications arose. The neurological status was preserved intact in all cases with a sensible improvement in those patients affected by severe tetraparesis. We noticed a rise in the Karnofsky score, on an average from 70 to 85. Postoperative neuroimaging controls documented that the instrumentation was in the correct place. Conclusion Surgical treatment of spine metastases allows pain control, management of neurological conditions, and an overall improvement in the quality of residual life.