Search

Abstract: The Heartland Area Redwater Project (HARP) for CO2 storage is investigating the technical and economic feasibility of injecting significant volumes of CO2 into the large water-saturated portion of a huge Devonian reef that is capped by a comparatively small oil reservoir, nevertheless the third largest oil pool in western Canada. The reef has a total areal extent of nearly 600 km2, is more than 1,000 meters deep and is up to 275 meters thick. Based on the high water injectivity in the reef, the potential exists to inject sustainably in excess of 1,000 tonnes of CO2 per day per well in the aquifer portion of the reef. Preliminary storage capacity estimates for the aquifer are in the order of one gigatonne of CO2. This storage site has the potential to store CO2 emissions in the order of several tens of Mt/yr from major emitters in central and northeastern Alberta such as oil sands plants, bitumen upgraders, refineries and petrochemical and fertilizer plants. The characteristics of this potential CO2 storage site are presented. [Copyright &y& Elsevier]

Background : Chiari malformation type 1 (CM1) remains a complex neurosurgical condition with ongoing debate regarding its optimal management. Methods : This narrative review examines key controversies surrounding the pathophysiology, surgical indications, and treatment strategies for CM1. Results : We highlight the challenges posed by the wide spectrum of CM variants and the evolving understanding of its association with syringomyelia, basilar invagination, and craniovertebral instability. Emerging surgical techniques, including minimally invasive approaches and the use of new technologies such as endoscopes and exoscopes, are evaluated for their potential to improve outcomes. Recent consensus guidelines are also discussed. Conclusions : The need for individualized treatment plans for CM1 is emphasized, with special focus put on the connection between novel pathophysiological insights, technological advancements and opportunities for a more nuanced surgical management. Further research is necessary to establish solid foundations for more individualized treatments.

Background: In spite of the continuous progresses in pediatric neurosurgery, adamantinomatous craniopharyngioma (AC) remains a challenging tumor due to its proximity to optic pathways, pituitary gland, hypothalamus, and Willis' circle, which can result in significant endocrine, cognitive, and neurological morbidity after treatment with subsequent impact on the patient's quality of life (QoL). The relevance that QoL has today explains the changes in the management of AC observed over the time. The goal of the present article is to provide a historical background, to show the milestones in the changes of the AC treatment, and to analyze the current main options to manage such a challenging tumor., Material and Methods: The pertinent literature has been reviewed. Moreover, a comparison between the past and recent personal series is reported., Results: Three main eras have been identified. The first (named Cushing era) was characterized by the need to realize a harmless surgery and to define the best way to approach AC; the second (microscope era) was characterized by a tremendous technical and technological development, with remarkable results in term of safe tumor resection and control but relatively poor QoL outcomes; and the third one (current period) is characterized by an increasing integration between surgery and adjuvant treatments, with relatively minor tumor control but significant improvement of QoL (comparable overall survival). The authors' experience reflects these changes. Two groups of children were compared: 52 cases (mean follow-up: 17.5 years) belong to the historical series (group 1, 1985-2003, aggressive surgical management) and 41 (mean follow-up: 8.5 years) to the current one (Group 2, 2004-2021, integrated management). No significant differences between the two groups were detected about recurrence rate, surgical mortality, and overall survival. However, Group 2 showed significant lower rates of postoperative panhypopituitarism, obesity, and visual deterioration., Conclusions: Radical surgery allows for a good AC control with a low rate of recurrence but high risk of permanent morbidity. Despite the greater number of recurrences and surgeries, the more conservative policy, based on a combination of treatments, seems to provide the same tumor control with a better QoL. The advances in trans-nasal and trans-ventricular endoscopy, in proton therapy and in the management of the AC cyst are the main factors that allowed such an improvement., (© 2023. The Author(s).)

Grade 3 meningiomas are rare malignant tumors that can originate de novo or from the progression of lower grade meningiomas. The molecular bases of anaplasia and progression are poorly known. We aimed to report an institutional series of grade 3 anaplastic meningiomas and to investigate the evolution of molecular profile in progressive cases. Clinical data and pathologic samples were retrospectively collected. VEGF, EGFR, EGFRvIII, PD-L1; and Sox2 expression; MGMT methylation status; and TERT promoter mutation were assessed in paired meningioma samples collected from the same patient before and after progression using immunohistochemistry and PCR. Young age, de novo cases, origin from grade 2 in progressive cases, good clinical status, and unilateral side, were associated with more favorable outcomes. In ten progressive meningiomas, by comparing molecular profile before and after progression, we identified two subgroups of patients, one defined by Sox2 increase, suggesting a stem-like, mesenchymal phenotype, and another defined by EGFRvIII gain, suggesting a committed progenitor, epithelial phenotype. Interestingly, cases with Sox2 increase had a significantly shortened survival compared to those with EGFRvIII gain. PD-L1 increase at progression was also associated with worse prognosis, portending immune escape. We thus identified the key drivers of meningioma progression, which can be exploited for personalized treatments.

Purpose: Once believed a result of pathophysiological correlations, the association between Chiari 1 malformation (CM1) and epilepsy has since been considered as a coincidence, due to missing etiologic or clinical matching points. At present, the problem is being newly debated because of the increasing number of CM1 diagnoses, often among children with seizures. No specific studies on this topic are available yet. The present study aimed at updating the information on this topic by reporting on a series of children specifically enrolled and retrospectively analyzed for this purpose. Methods: All children admitted between January 2015 and June 2020 for epilepsy and CM1 were considered (Group 1). They were compared with children admitted in the same period for symptoms/signs related to CM1 and/or syringomyelia (Group 2). Syndromic patients were excluded, as well as those with tumoral or other overt intracranial lesions. All patients received a complete preoperative work-up, including MRI and EEG. Symptomatic children with CM1/syringomyelia were operated on. The pertinent literature was reviewed. Results: Group 1 was composed of 29 children (mean age: 6.2 years) showing CM1 and epilepsy with several types of seizures. A share of 27% had CM1-related symptoms and syringomyelia. The mean tonsillar ectopia was 7.5 mm. Surgery was performed in 31% of cases. Overall, 62% of children are currently seizure-free (including 5/9 children who were operated on). Tonsillar herniation and syringomyelia regressed in 4/9 cases and 4/8 cases, improved in 4/9 cases and 3/8 cases, and remained stable in 1/9 and 1/8 cases, respectively. CM1 signs/symptoms regressed completely in 6/8 cases and improved or remained stable in one case in each of the two remaining patients. Group 2 consisted of 77 children (mean age: 8.9 years) showing symptoms of CM1 (75%) and/or syringomyelia (39%). The mean tonsillar ectopia was 11.8 mm. Non-specific EEG anomalies were detected in 13 children (17%). Surgery was performed in 76.5% of cases (18 children were not operated on because of oligosymptomatic). Preoperative symptoms regressed in 26%, improved in 50%, remained stable 22%, and worsened in 2%; CM1 radiologically regressed in 39%, improved in 37%, remained unchanged in 22%, and worsened in 2%; and syringomyelia/hydromyelia regressed in 61%, improved in 30%, and was stable in 9%. No statistically significant differences between the two groups were detected regarding the M/F ratio, presence of syringomyelia/hydromyelia, or CM1/syringomyelia outcome; moreover, no correlation occurred between seizure-free condition and PF decompression in Group 1, or between disappearance of EEG anomalies and PF decompression in Group 2. A significant difference between the two groups was noticed regarding the mean age at admission (p = 0.003), amount of tonsillar herniation (p < 0.00001), and PF decompression (p = 0.0001). Conclusions: These findings do not support clinical correlations between CM1 and epilepsy. Their course depends on surgery and antiepileptic drugs, respectively. The analysis of the literature does not provide evidence of a relationship between seizures and cerebellar anomalies such as CM1. Rather than being linked to a syndrome that could explain such an association, the connection between the two now has to be considered to be random.

The onco-functional balance in neuro-oncology requires maximizing tumor removal while rigorously preserving patients' neurological status. When postoperative worsening prevents the implementation of oncologic treatments, palliative care service offers an individualized path for symptom and psychosocial distress relief. Here, we report on a series of 25 patients operated on for malignant brain tumor who did not undergo adjuvant treatments after neurosurgery; they represented 3.9% of the whole institutional surgical series. These patients were significantly older and had a lower preoperative Karnofsky performance status than the whole cohort. Importantly, in 22 out of 25 (88%) cases, a surgical complication occurred, leading to clinical worsening in 21 patients. For the end of life, the majority of patients chose a hospice care facility (72%). While a careful selection of brain tumor patients candidate to neurosurgery is required, palliative care service provided invaluable help in coping with patients' and caregivers' needs.

Introduction: Hydrocephalus is variously associated to syndromic craniosynostosis (CS), while it is randomly encountered in monosutural CS. Pathogenesis is still debated and reliable criteria for the diagnosis of overt hydrocephalus are lacking. Additionally, optimal treatment is controversial since it should balance the need to relieve intracranial hypertension and the risk of recurrence favored by lowering intracranial pressure., Methods: A thorough review of the literature has been performed. Accordingly, pathogenic theories, diagnostic issues, and treatment options on hydrocephalus presenting in the context of CS are discussed., Results: The association of hydrocephalus to simple CS is considered a fortuitous event. Its treatment is usually driven by the etiology and clinical relevance of hydrocephalus, favoring treatment before surgical correction to reduce CSF-related complications. On the other side, pathogenesis of hydrocephalus in the context of syndromic CS has been mainly related to factors that are secondary to the synostostic process, such as craniocerebral disproportion and venous hypertension. Hydrocephalus complicates 12-15% of syndromic CS, though its incidence is more relevant in FGFR2-related CS and raises up to 88% in Pfeiffer syndrome. Overt hydrocephalus should be properly differentiated by non-tense ventriculomegaly that is more frequent in Apert syndrome. Since intracranial hypertension is constant in syndromic CS even in the absence of active hydrocephalus, radiological monitoring of ventricular size along with intracranial pressure monitoring is essential. Active hydrocephalus occurs more frequently in infants, though stable ventriculomegaly may evolve into overt hydrocephalus after cranial expansion. If hydrocephalus is not clinically prominent, cranial expansion should be favored as first surgical step. Although posterior cranial expansion may address posterior cranial fossa constriction and stabilize ventricular dilation, effectiveness in long-term control of hydrocephalus is not clear. ETV is an effective treatment option, though success rate is affected by the presence of brain malformations and patient age. Extrathecal CSF shunting should be used as last resource due to the increased risk of complications in this context., Conclusions: The pathogenesis of hydrocephalus complicating syndromic CS should be further investigated. Concomitantly, the definition of reliable diagnostic criteria is advocated in order to promptly and properly identify active hydrocephalus. Finally, treatment algorithm should refine the best timing and treatment options aiming to relieve intracranial hypertension on one side and reduce the risk of restenosis on the other side., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: The purpose of this study was to evaluate the outcome of fractures of the distal radius with metaphyseal and diaphyseal involvement treated with fixed angle volar plates., Materials and Methods: Twenty-one patients with fracture of the radius involving the diaphyseal, metaphyseal and epiphyseal parts were treated with fixed angle plate fixation through an extended volar Henry's approach. Circle wire loops, screws and intrafocal wire fixations were associated in 12 cases. Coexisting ulnar fractures were fixed with plates or K-wires in 8 cases. All patients were prospectively followed using radiographs, physical examination, and DASH (Disabilities of the Arm, Shoulder and Hand) scores., Results: All fractures except one, which needed a secondary bone graft to achieve consolidation, united by an average of 90 days. One case developed a radioulnar synostosis. Radiographs showed optimal reduction in 17 of 21 cases, with restoration of radial length in all cases and a neutral average ulnar variance. Nonanatomical reduction was associated with the worst results (P = 0.0006). Flexion and extension averaged 62.8° and 73.8°, and pronation and supination 85.2° and 80.2°, respectively. The average DASH scores were 30 points at 3 months, 14 points at 6 months, and 6.7 points at the time of final follow-up (at an average of 11 months). According to the Mayo wrist rating system, 14 patients showed excellent results, 5 showed good results, and 2 showed fair results., Conclusion: Fixed angle volar plates were demonstrated to be a safe and efficient treatment in these challenging fractures.

Physicians can encounter problems in prescribing opioids for some patients with chronic pain such as multiple unsanctioned dose escalations, episodes of lost or stolen prescriptions, and positive urine drug screenings for illicit substances. This study explored the usefulness of questions on abuse history in predicting problems with prescribing opioids for patients at a hospital-based pain management program. One hundred forty-five (145) patients who were taking long- and short-acting opioids for their pain were classified as high or low risk on the basis of their responses to interview questions about 1) substance abuse history in their family, 2) past problems with drug or alcohol abuse, and 3) history of legal problems. The treating physicians completed a questionnaire about problems that they had encountered with their patients. Problem behaviors were verified through chart review. No differences in demographic characteristics were found between those classified as high and low risk. Patients who admitted to a family history of substance abuse, a history of legal problems, and drug or alcohol abuse were prone to more aberrant drug-related behaviors, including a higher incidence of lost or stolen prescriptions and the presence of illicit substances in their urine (P < 0.05). Patients classified as high risk also had a significantly higher frequency of reported mental health problems and motor vehicle accidents. More of these patients smoked cigarettes, tended to need a cigarette within the first hour of the day, took higher doses of opioids, and reported fewer adverse effects from the medications than did those without such a history (P < 0.05). This study demonstrates that questions about abuse history and legal problems can be useful in predicting aberrant drug-related behavior with opioid use in persons with chronic noncancer pain.

Background and Objectives: To acquire an accurate knowledge of the relationship of the sympathetic chain to the vertebral column., Methods: In dissections on 65 cadavers the authors located the sympathetic chain and its ganglia in three dimensions with respect to the vertebral column: cephalad-caudad in the sagittal plane; ventrally and laterally in the horizontal (axial) plane. The relationship of the sympathetic chain to the psoas muscle and that of the psoas muscle to the vertebral column was also established. Transparent markers were placed at each disk space and colored markers at each grossly recognizable ganglion. Photographs and measurements were then made., Results: In the sagittal plane, the lumbar ganglia were most often present opposite the middle of the body of the third vertebra and at the disks above and below. In the horizontal plane, the ganglia lay from 0 to 0.5 cm posterior to the anterior border of the third lumbar vertebra and 1.8 to 3.0 cm laterally from the center of the third lumbar vertebra. The sympathetic chain always lay anterior to the psoas muscle., Conclusions: Although the location of the ganglia is quite variable, the best approach for sympathetic block is to advance the needle paravertebrally through the fascia of the psoas muscle slightly cephalad to the midpoint of the body of L3.

Eight years' experience with the two-person technique has revealed further advantages. A glass syringe and extension tubing filled with saline are connected to the epidural needle. A small bubble of air remains in the syringe but not in the tubing. One person concentrates on the advancement of the needle. The second person exerts sufficient pressure on the plunger of the syringe to produce intermittent minimal flow of saline. The effect is that of barbotage. In several instances the saline at needle end of the tubing unexpectedly became opaque or discolored. The advantages are attributable to the small volume of the extension tubing filled with saline.

In a series of 67 displaced ankle fractures, the significance of the following factors is evaluated: age, sex, obesity, adequacy of the post-reduction position of the malleoli, restoration of distal tibio-fibular syndesmosis, talo-crural angle, talar tilt, width of medial clear space, severity of injury, traumatic mechanism, treatment. The statistical study is developed using stepwise discriminant analysis up to multiple linear regression. The significant parameters are the talo-crural angle, residual malleolar displacement, the integrity of the syndesmosis, and obesity. The discrimination is very good (p < 0.01).

The authors refer their experience in management of thalamic fractures of the heel. Their series includes 22 patients with 24 fractures and comprises the 12-year period 1975-87. They assess the results based on radiological, clinical, functional and occupational criteria, emphasizing the role of the posterior subtalar joint, which imposes an anatomical reconstruction on the orthopaedist, since the final results are conditioned by its arthritic degeneration. Complex fractures with important displacement need surgical treatment with reduction and synthesis. In simple fractures with or without slight displacement, conservative treatment using cast immobilization is now the treatment of choice.

Proper lens maintenance is required if contact lens wear is to be successful. Poor compliance or inadequate cleaning may lead to contact lens failures and potentially damage to the eye. With phase contrast microscopy, we addressed the effect of cleaning systems on the physical integrity of a surface-modified lens--the Silcon contact lens. Several cleaners were evaluated for their ability to clean Silcon lenses with minimal damage to the lens surface. The data demonstrated that: all cleaning techniques alter the surface appearance; scratches develop more readily on lenses received with surface irregularities; wettability does not correlate with the extent of surface scratching; recommended cleaning procedures do not directly alter the wettability of the contact lens material; and phase contrast microscopy may be a useful addition to laboratory quality control.