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Background and Study Aims Spinal schwannomas are benign slow-growing tumors, and gross total resection is the gold standard of treatment. The conventional surgical approach is laminectomy, which provides a wide working area. Today minimally invasive surgery (MIS) is popular because it is associated with shorter hospital stay, less operative blood loss, minimized tissue traumas and relative postoperative pain, and, and spine surgery, avoidance of spinal instability. Material and Methods From January 2016 to December 2019, we operated on 40 patients with spinal intradural extramedullary tumor (schwannoma) with laminectomy or hemilaminectomy. Baseline medical data, including patients' sex and age, tumor location, days of postoperative bed rest, operative time, length of hospitalization, and 1-month visual analog scale (VAS) value were collected and analyzed. Data analysis was performed using STATA/IC 13.1 statistical package (StataCorp LP, College Station, Texas, United States). Results Hemilaminectomy was associated with faster operative time (p Conclusions Unilateral hemilaminectomy has significant advantages compared with laminectomy in spinal schwannoma surgery including shorter operative time, less time spent in bed, shorter hospitalization, and less postoperative pain.

Ventricular walls penetration frequently occurs in periventricular gliomas surgery. Even when aimed at maximal tumor resection, it can lead to several complications, including CSF leak, delayed wound healing and, potentially, distant tumor dissemination, with a negative impact on overall survival. Several authors have claimed damaged ventricular walls always need repair, especially when the additional use of intrathecal chemotherapy is scheduled. Fibrin sponge has been consistently used in the past to address small ventricular walls defects but more recently attention has been focused on TachoSilTM, that seems to be a valid alternative to close up to 1.5 cm gaps. After an accurate review of literature, we were unable to find any report describing the use of autologous pericranium to the same aim. We report the case of a 54 years-old patient who presented with symptoms of intracranial hypotension four weeks after his last surgery (performed at another Institution) for a relapsing right frontal grade III astrocytoma,. Pre-operative MRI showed a huge gap in the roof of the right frontal ventricular horn, associated to a large subdural hygroma and a massive subcutaneous CSF collection. The gap was repaired using a layer of autologous pericranium, sutured by pial stitches to the surrounding brain and reinforced by fibrin glue. Full and permanent leak sealing was obtained within the next 2 weeks, but patient immediately and fully recovered from his symptoms. Although limited by the single case experience, we believe that pericranium might be considered as an alternative to artificial materials in cases of large ventricular walls openings, being easily intraoperatively retrievable, granting maximal biocompatibility, not significantly impacting on surgery duration and overall costs.

Background: The present article aims to introduce the endolymphatic duct and sac decompression technique (DASD) and to give a spotlight on its benefits in Ménière’s disease (MD) treatment. Methods: Eighty-two patients with intractable MD which met the inclusion criteria were recruited and underwent DASD. This technique allows a meningeal decompression of the duct and the sac from the posterior cranial fossa to the labyrinthine block. The authors considered as main outcomes, the change of the dizziness handicap inventory (DHI) results, with the evaluations of the three sub-scales (Functional scale, Physical scale, and Emotional scale); ear fullness and tinnitus change on the perceptions of the patient; and hearing stage with four-Pure Tone Average (500 hz-1000 hz-2000 hz-4000 hz). The differences between the preoperative and the postoperative score were evaluated. A comparison with the literature was conducted. Results: After a 14-month follow-up, patients that underwent DASD reported a remarkable improvement of the symptoms in all three functional scales, confirmed by the total DHI. The difference between preoperative and postoperative scores is statistically significant. The data describe an ear fullness and tinnitus improvement. The multi-frequency tonal average before and after the surgery does not suggest a worsening of the value for any of 82 patients. Conclusion: The modification of sac surgery includes the endolymphatic duct in the decompression area allowing inner ear functional improvement, vertigo control, ear fullness improvement with minimal risk of facial nerve paralysis, and hearing loss. DASD is an improved old surgical technique.

Dura mater repair represents a final and crucial step in neurosurgery: an inadequate dural reconstruction determines dreadful consequences that significantly increase morbidity and mortality rates. Different dural substitutes have been used with suboptimal results. To overcome this issue, in previous studies, we proposed a laser-based approach to the bonding of porcine dura mater, evidencing the feasibility of the laser-assisted procedure. In this work, we present the optimization of this approach in ex vivo experiments performed on porcine dura mater. An 810-nm continuous-wave AlGaAs (Aluminium Gallium Arsenide) diode laser was used for welding Indocyanine Green-loaded patches (ICG patches) to the dura. The ICG-loaded patches were fabricated using chitosan, a resistant, pliable and stable in the physiological environment biopolymer, moreover, their absorption peak was very close to the laser emission wavelength. Histology, thermal imaging and leak pressure tests were used to evaluate the bonding effect. We demonstrated that the application of 3 watts (W), pulsed mode (Ton 30 ms, Toff 3.5 ms) laser light induces optimal welding of the ICG patch to the dura mater, ensuring an average fluid leakage pressure of 216 ± 105 mmHg, falling within the range of physiological parameters. This study demonstrated that the thermal effect is limited and spatially confined and that the laser bonding procedure can be used to close the dura mater. Our results showed the effectiveness of this approach and encourage further experiments in in vivo models.

The sinking flap syndrome (SFS) is one of the complications of decompressive craniectomy (DC). Although frequently presenting with aspecific symptoms, that may be underestimated, it can lead to severe and progressive neurological deterioration and, if left untreated, even to death. We report our experience in a consecutive series of 43 patients diagnosed with SFS and propose a classification based on the possible etiopathogenetic mechanisms. In 10 years’ time, 43 patients presenting with severely introflexed decompressive skin flaps plus radiological and clinical evidence of SFS were identified. We analysed potential factors involved in SFS development (demographics, time from decompression to deterioration, type, size and cause leading to DC, timing of cranioplasty, CSF dynamics disturbances, clinical presentation). Based on the collected data, we elaborated a classification system identifying 3 main SFS subtypes: (1) primary or atrophic, (2) secondary or hydrocephalic and (3) mixed. Very large DC, extensive brain damage, medial craniectomy border distance from the midline

Cast intraventricular hemorrhage (IVH) is associated to high morbidity/mortality rates. External ventricular drainage (EVD), the most common treatment adopted in these patients, may be unsuccessful due to short-term drain obstruction and requires weeks for cerebrospinal fluid (CSF) clearing, increasing the risks of ventriculits. Administration of intraventricular fibrinolytic agents and endoscopic evacuation have been proposed as alternative treatments, but with equally poor results. We present a retrospective analysis of two groups of patients who respectively underwent endoscope-assisted microsurgical evacuation versus EVD for the treatment of cast IVH. In a 10-year time, 25 patients with cast IVH underwent microsurgical, endoscope-assisted evacuation. Twenty-seven were instead treated by EVD. The two groups were compared in terms of hematoma evacuation, CSF clearing time, infection rates, need for permanent shunting, short/long-term survival, and functional outcome. In endoscope-assisted surgeries, full CSF clearance required 14 ± 3 days in 20 patients and 21 ± 3 days in 5; in the EVD group, 21 ± 3 days were needed in 12 patients, 28 ± 3 days in 11, and 35 ± 3 days in 4. Permanent shunting was inserted respectively in 19 endoscopic and 23 EVD patients. Final mRs score was 0-3 in 13 endoscopic cases, 4-5 in the remaining 12. In the EVD group, 7 subjects scored mRs 0-3, 16 scored 4-5; 4 died. In our experience, endoscope-assisted evacuation of cast IVH reduced ICU staying and CSF clearance times. It also seemed to improve neurological outcome, but without affecting the need for permanent shunt. On the counterside, it increases the number of severely disabled survivors.

Metastases involving the clivus and craniocervical junction (CCJ) are extremely rare. Skull base involvement can result in cranial nerve palsies, while an extensive CCJ involvement can lead to spinal instability. We describe an unusual case of clival and CCJ metastases presenting with VI cranial nerve palsy and neck pain secondary to CCJ instability from metastatic bladder urothelial carcinoma. The patient was first treated with an endoscopic endonasal approach to the clivus for decompression of the VI cranial nerve and then with occipitocervical fixation and fusion to treat CCJ instability. At the 6-month follow-up, the patient experienced complete recovery of VI cranial nerve palsy. To the best of our knowledge, the simultaneous involvement of the clivus and the CCJ due to metastatic bladder carcinoma has never been reported in the literature. Another peculiarity of this case was the presence of both VI cranial nerve deficit and spinal instability. For this reason, the choice of treatment and timing were challenging. In fact, in case of no neurological deficit and spinal stability, palliative chemo- and radiotherapy are usually indicated. In our patient, the presence of progressive diplopia due to VI cranial nerve palsy required an emergent surgical decompression. In this scenario, the extended endoscopic endonasal approach was chosen as a minimally invasive approach to decompress the VI cranial nerve. Posterior occipitocervical stabilization is highly effective in avoiding patient’s neck pain and spinal instability, representing the approach of choice.

Coil migration and extrusion outside the cranial compartment after embolization of cerebral aneurysms represents a very rare complication of the endovascular procedures and few cases are reported in the literature. Instability of the vascular malformation wall and the resolution of the intramural hematoma, especially in pseudoaneurysm, might generate extravascular migration of the coils in the first months after embolization. However, to the best of our knowledge, an extrusion of coil 10 years after embolization has never been reported. We reported the unique case of a patient with coil extrusion into the naso- and oropharynx 10 years after internal carotid artery pseudoaneurysm embolization. The pseudoaneurysm occurred after an internal carotid artery injury during an endoscopic endonasal surgery for a clival giant cell tumor.

Background: Surgical treatment of spinal metastases should be tailored to provide pain control, neurological deficit improvement, and vertebral stability with low operative morbidity and mortality. The aim of this study was to analyze the predictive value of some preoperative factors on overall survival in patients undergoing surgery for spinal metastases. Methods: We retrospectively analyzed a consecutive series of 81 patients who underwent surgery for spinal metastases from 2015 and 2021 in the Clinic of Neurosurgery of Ancona (Italy). Data regarding patients’ baseline characteristics, preoperative Karnofsky Performance Status Score (KPS), and Frankel classification grading system, histology of primary tumor, Tokuhashi revised and Tomita scores, Spine Instability Neoplastic Score, and Epidural Spinal Cord Compression Classification were collected. We also evaluated the interval time between the diagnosis of the primary tumor and the onset of spinal metastasis, the type of surgery, the administration of adjuvant therapy, postoperative pain and Frankel grade, and complications after surgery. The relationship between patients’ overall survival and predictive preoperative factors was analyzed by the Kaplan–Meier method. For the univariate and multivariate analysis, the log-rank test and Cox regression model were used. P ≤ 0.05 was considered as statistically significant. Results: After surgery, the median survival time was 13 months. In our series, the histology of the primary tumor (P < 0.001), the Tomita (P < 0.001) and the Tokuhashi revised scores (P < 0.001), the preoperative KPS (P < 0.001), the adjuvant therapy (P < 0.001), the postoperative Frankel grade (P < 0.001), and the postoperative pain improvement (P < 0.001) were significantly related to overall survival in the univariate analysis. In the multivariate analysis, the Tomita (P < 0.001), Tokuhashi revised scores (P < 0.001), and the adjuvant therapy were confirmed as independent prognostic factors. Conclusion: These data suggest that patients with limited extension of primitive tumor and responsive to the adjuvant therapy are the best candidates for surgery with better outcome.

Introduction: Chronic subdural hematoma (CSDH) is a common pathology with a recurrence rate ranging from 2 to 37%. Recently, several studies have suggested the possible relationship between the increase in Neutrophil to Lymphocyte Ratio (NLR) and the poor outcome of different pathologies. The aim of this study is to investigate the potential correlation between the pre-operative NLR value and the risk of CSDH recurrence. Methods: From January 2015 to December 2019, 261 CSDH patients were surgically treated at our Department. Data regarding patients' baseline characteristics and their hematologic parameters were retrospectively collected from medical records, while the maximum thickness of the hematoma was measured on pre-operative CT scans. Patients with concomitant cerebrovascular, infective, inflammatory, haematological, or neoplastic diseases, INR > 1.5, previous craniotomy, ventriculoperitoneal or ventriculo-atrial shunt or missing data were excluded from the study.Minimum and maximum follow-up were 4 months and 3 years respectively. Results: A total of 104 patients were enrolled in this study. Mean age was 77.5 ± 14.1 and 77.2 ± 14.2 years respectively in the non-recurrence and recurrence groups (p value, 0.924). Preoperative maximum hematoma thickness resulted 2.2 ± 0.5 cm in patients without recurrence and 2.4 ± 0.6 cm in those with CSDH recurrence (p value, 0.113). Mean pre-operative NLR was higher (12.7 ± 10.4 vs 6.3 ± 4.8) in the recurrence group than in the non-recurrence one. This difference resulted significant (p value, 0.001) at statistical analysis. Conclusions: Pre-operative NLR is an easily obtainable marker, which may be helpful in clinical practice to stratify the risk of CSDH recurrence.

Introduction: Despite potential advantages, a broad diffusion of the CO2 laser for neurosurgical procedures has been historically precluded by operative limitations, such as its cumbersome design, the bulky set-up, and lower optical quality of the micromanipulators. Nonetheless, in the last decades, significant technologic improvements of CO2 lasers, together with a better ergonomics and quality of accessories, have made CO2 laser surgery easier and reproducible. The introduction of surgical microscanners, in particular, has allowed to perform a safer, more precise and faster laser microsurgery, while having a perfect view of the operating field (being a noncontact technique). Hereby, we report our preliminary surgical experience with the laser SmartXide2 CO2 scanning aided laser system, developed by DEKA (Calenzano, Italy). Materials and Methods: We treated 10 patients suffering from various lesions (two vestibular schwannomas, two brain metastases, two gliomas, one petroclival and one foramen magnum meningiomas, one spinal neurinoma, and one spinal meningioma) with the aid of the SmartXide2 CO2 laser system to evaluate its potential and benefits in different neurosurgical scenarios. The laser system was a DEKA Smartxide2 60W, equipped with the high precision micromanipulator (Easyspot Hybrid version), coupled with a surgical scanner (HiScan Surgical) and connected to a Leica M720 OH5 (Leica Microsystems GmbH, Wetzlar, Germany) neurosurgical microscope through a dedicated adapter. The focal length of the microscope was set on 300-mm EFL and the CO2 laser was focused by means of the micromanipulator's zoom on the plane of view, to produce the best effect on tissue. At this focal length the micromanipulator produces a spot of 190 ?m, thus being highly precise and effective in ablation and cut. Results: The CO2 laser was used, together with the traditional neurosurgical instruments, in every step of the procedures, from the initial pial incision for intra-axial tumors, as well as from the early extra-axial lesions debulking, to the progressive ablation and removal of the lesions, and, at the end of the operations, for the hemostasis of the surgical cavity. No injury to the surrounding neurovascular structures was observed. In particular, in the vestibular schwannomas, the CO2 laser allowed a safe removal of the tumors around the VII to VIII complex and the lower cranial nerves. Immediate postoperative neuroimaging always confirmed the complete tumor removal, and showed a marked reduction of the preoperative surrounding edema with no evidence of cerebral/medullary contusions. Conclusion: In our experience, the SmartXide2 CO2 laser, coupled with Easyspot Hybrid and Hiscan Surgical, turned out to be a suitable system for the resection of different cerebral and spinal lesions. It is an effective and precise tool to perform different neurosurgical steps and procedures. Moreover, having no consumable accessories is also cost effective. Therefore, the SmartXide2 CO2 laser may represent, in selected cases, a helpful and safe surgical instrument. It addresses some of the ergonomic limitations of the laser systems and is able to cut/ablate and coagulate the tissue at the same time, with minimal lateral thermal spread, thus preserving the surrounding neurovascular structures.

Background Despite potential advantages, broad carbon dioxide (CO2) laser diffusion in neurosurgery was historically prevented by several operative limitations. Nonetheless, in recent decades, significant improvements, in particular the development of surgical scanners, have made CO2 laser surgery easier and reproducible. The aim of this study was to report our preliminary experience with the SmartXide2 CO2 laser system. Methods The SmartXide2 laser system is a CO2 laser with a radiofrequency-excited laser source, a surgical scanner, and a high-precision micromanipulator, which are connected to the surgical microscope. Ten different brain and spinal tumors were treated to evaluate the laser system potential in different neurosurgical scenarios. Four illustrative cases were presented. Results The CO2 laser was used together with the traditional instruments in every step of the procedures, from the initial pial incision (intra-axial tumors) or early debulking (extra-axial lesions), to progressive tumor removal, and, lastly, for surgical cavity hemostasis. No injury to the surrounding neurovascular structures was observed. Postoperative neuroimaging confirmed complete tumor removal and showed a marked reduction of preoperative surrounding edema without signs of cerebral/medullary contusions. Conclusions In selected cases, the SmartXide2 CO2 laser system could be a helpful, reliable, and safe surgical instrument to treat different cerebral and spinal lesions. It addresses some of the limitations of laser systems and is able to cut/ablate and coagulate the tissue simultaneously, with minimal lateral thermal spread, preserving the surrounding eloquent neurovascular structures. Moreover, having no consumable accessories, it is also cost-effective.

Tumours of the infratemporal fossa (ITF) are rare and include primary tumours, contiguity lesions and metastases. Surgical resection is the gold standard. The fronto-orbito-zygomatic (FOZ) approach is commonly used in order to obtain safe access to the lateral skull base and ITF to resect intra- and extra-cranial tumours. We here describe our series of ITF lesions extending to the middle cranial fossa and/or orbit, treated by single- or two piece FOZ.All cases of single- or two-piece FOZ approach for an infratemporal fossa lesion extending to the middle cranial fossa operated at our Institution from January 2014 to January 2018 were retrospectively reviewed. The follow-up was for a minimum of four months and a maximum of 60 months. The inclusion criteria were lesions involving the ITF with an extension to the middle cranial fossa and/or orbit. Baseline characteristics of patients, tumour localisation, tumour extension, diffusion route, histology, extent of tumour resection, postoperative treatment, and post-operative complications were evaluated.Nine patients underwent a surgical procedure with a FOZ approach, two of them with a single-piece approach and the remainder with a two-piece one. All patients had an ITF localisation. Gross total removal (GTR) was achieved in 7/9 patients. Only one patient, with non-total removal (NTR), underwent radiotherapy.For the treatment of ITF fossa tumours extending to the orbit and or middle cranial fossa, we believe that both FOZ techniques are effective and allow a good medial extension toward the cavernous sinus and parasellar region. But a two-piece craniotomy may ensure a more medial extension and a wider angle of work compared to a one-piece craniotomy.

In 2018, the SINch (Italian Society of Neurosurgery) Neuro-Oncology Section, AINO (Italian Association of Neuro-Oncology) and SIN (Italian Association of Neurology) Neuro-Oncology Section formed a collaborative Task Force to look at the diagnosis and treatment of low-grade gliomas (LGGs). The Task Force included neurologists, neurosurgeons, neuro-oncologists, pathologists, radiologists, radiation oncologists, medical oncologists, a neuropsychologist and a methodologist. For operational purposes, the Task Force was divided into five Working Groups: diagnosis, surgical treatment, adjuvant treatments, supportive therapies, and follow-up. The resulting guidance document is based on the available evidence and provides recommendations on diagnosis and treatment of LGG patients, considering all aspects of patient care along their disease trajectory.