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Aneurysms of the basilar trunk represent an exceptional challenge to the neurosurgeon, due to high mortality and surgical morbidity. We present a 69-year-old man with a giant dolichoectatic thrombotic basilar trunk aneurysm (BTA), who underwent right orbitozygomatic craniotomy, posterior cerebral artery (PCA) to right middle cerebral artery (MCA) bypass and trapping of the BTA. Unfortunately, patient died after surgery due to multiple foci of intraparenchymal haemorrhage and thrombosis of a short segment proximal to aneurysm trapped and his body was donated to the hospital, giving us the unique opportunity to compare intraoperative details with anatomical dissection findings, according to our previously published cadaveric neurosurgical research. The great and unique opportunity of this reported case, to learn by watching and watching again what has been done during surgery, to observe small vessels and brainstem perforators and to look at stiches of the bypass, SVG and the position of the clips, permits to refine the theoretical and practical skills for the treatment of complex aneurysms such as that one reported.

Background Odontoid C2 fractures account for 9% to 15% of adult cervical spine fractures. The aim of this study is to report the incidence of a previous described Y-shaped trabecular bone structure (TBS) in the odontoid process in a larger sample of patients who performed a CT cervical scan following a cervical trauma to investigate if its absence can increase the risk of the odontoid process fracture of the axis. Methods A retrospective review of 245 patients who performed a CT cervical scan in our University Hospital, as results of cervical spine injury, was performed during a 12-month period between May 2020 and May 2021. Results The presence of a Y-shaped TBS at the odontocentral synchondrosis level was observed in 165 patients that is 67.3% of whole population included in this study. Eighteen patients (7.3%) reported an odontoid type II C2 fracture. Among patients with odontoid type II C2 fracture, the Y-shaped TBS at the odontocentral synchondrosis level was observed in 8 (44.4%) of them. The presence of the Y-shaped TBS at the odontocentral synchondrosis level was statistically more frequently observed in patients without odontoid process fracture (69.2% Vs 30.8%) compared to patients who developed odontoid process fracture (44.4 % Vs 55.6%) after a cervical trauma (p = 0.03). Conclusions This study showed the crucial role of this Y-shaped TBS in biomechanical structural dynamics of the C1-C2 joint and its significant clinical relevance in odontoid fractures of the axis.

Trigeminal neuralgia (TN) caused by vertebrobasilar artery (VBA) compression is a rare event, reported between 2 and 6% (Linskey et al. J Neurosurg 81:1-9,1992, Vanaclocha et al.World Neurosurg 96:516-529,2016) of the time. Microvascular decompression (MVD) is advised for drug-resistant pain and, although technically challenging, is associated with an excellent outcome in current literature (Apra et al.Neurosurg Rev 40:577-582,2017, Cruccuet al. EurJ Neurol 15:1013-1028,2008, Linskey et al. J Neurosurg 81:1-9,1992). The authors performed a systematic review and meta-analysis of the literature examining the rate of MVD for trigeminal neuralgia caused by VBA compression and the post-operative outcome. The systematic search of three databases was performed for studies published between January 1990 and October 2020. Random-effects meta-analysis was used to pool the analyzed outcomes, and random-effects meta-regression was used to examine the association between the effect size and potential confounders. Funnel plot followed by Egger’s linear regression was used to test publication bias. We included 9 studies, and the overall rate of TN due to VBA compression was 3.4% (95% CI 2.5–4.3%, p

Background Systemic immunity and inflammation indexes (SI) derived from blood cells have gained increasing attention in clinical oncology as potential biomarkers that are associated with survival. Materials and methods We tested 12 different SI using blood tests from patients with isocitrate dehydrogenase 1 and 2 wild-type glioblastomas, treated with radio-chemotherapy. The primary endpoint was their overall survival. Results A total of 77 patients, comprising 43 males and 34 females, with a median age of 64 years (age range 26–84), who were treated between October 2010 and July 2020, were included in the present analysis (approved by a local ethics committee). In the univariate Cox regression analysis, all the indexes except two showed a statistically significant impact on OS. In the multivariate Cox regression analysis, neutrophil × platelet × leukocyte/(lymphocyte × monocyte) (NPW/LM) and neutrophil × platelet × monocyte/lymphocyte (NPM/L) maintained their statistically significant impact value. Conclusions This univariate analysis confirms the potential of systemic inflammation indexes in patients with glioblastoma, while the multivariate analysis verifies the prognostic value of NPW/LM and NPM/L.

Despite extensive investigations, the choice of graft material for reconstructive duraplasty after foramen magnum decompression for Chiari type I malformation (CMI) is still a topic of discussion. The authors performed a systematic review and meta-analysis of the literature examining the post-operative complications in adult patients with CMI after foramen magnum decompression and duraplasty (FMDD) using different graft materials. Our systematic review included 23 studies with a total of 1563 patients with CMI who underwent FMDD with different dural substitutes. The most common complications were pseudomeningocele (2.7%, 95% CI 1.5–3.9%, p < 0.01, I2 = 69%) and CSF leak (2%, 95% CI 1–2.9%, p < 0,01, I2 = 43%). The revision surgery rate was 3% (95% CI 1.8–4.2%, p < 0.01, I2 = 54%). A lower rate of pseudomeningocele was observed with autologous duraplasty when compared with synthetic duraplasty (0.7% [95% CI 0–1.3%] vs. 5.3% [95% CI 2.1–8.4%] p < 0.01). The rate of CSF leak and revision surgery was lower after autologous duraplasty than after non-autologous dural graft (1.8% [95% CI 0.5–3.1%] vs. 5.3% [95% CI 1.6–9%], p < 0.01 and 0.8% [95% CI 0.1–1.6%] vs. 4.9% [95% CI 2.6–7.2%] p < 0.01, respectively). Autologous duraplasty is associated with a lower rate of post-operative pseudomeningocele and reoperation. This information should be considered when planning duraplasty after foramen magnum decompression in patients with CMI.

Microvascular decompression (MVD) is considered an effective treatment for trigeminal neuralgia (TN). However, the anatomical and clinical variables associated with a better outcome are not fully examined. The authors performed a systematic review and meta-analysis of the literature investigating the immediate and long-term clinical results of MVD for TN, and the impact of the anatomical features of the neurovascular conflict on the outcome. The systematic search of three databases was performed for studies published between January 1990 and November 2021. PRISMA guidelines were followed. Random-effects meta-analysis was used to pool the analyzed outcomes, and random-effect meta-regression was used to examine the association between the effect size and potential confounders. A funnel plot followed by Egger's linear regression was used to test publication bias. A total of 9 studies were included in this analysis, including 2102 patients with trigeminal neuralgia. The immediate post-operative rate of BNI I was 82.9%, whereas surgical failure (BNI IV-V) was reported in approximately 2.6% of patients. CSF leak was the most common postoperative complication (2.4%). The rate of BNI I at last follow up was 64.7% (p 0.01), showing a significant negative correlation after multiple meta-regression with the rate of patients with isolated venous conflict (p 0.01). On the other hand, the evidence of an arterial conflict proved is positive association with a favorable outcome (p 0.01). At the last follow-up, BNI IV-V was reported in 19.2% (95% CI 8.9-29.5%, p 0.01, I

Syringomyelia and Chiari malformation are classified as rare diseases on Orphanet, but international guidelines on diagnostic criteria and case definition are missing. Aim of the study: to reach a consensus among international experts on controversial issues in diagnosis and treatment of Chiari 1 malformation and syringomyelia in adults. A multidisciplinary panel of the Chiari and Syringomyelia Consortium (4 neurosurgeons, 2 neurologists, 1 neuroradiologist, 1 pediatric neurologist) appointed an international Jury of experts to elaborate a consensus document. After an evidence-based review and further discussions, 63 draft statements grouped in 4 domains (definition and classification/planning/surgery/isolated syringomyelia) were formulated. A Jury of 32 experts in the field of diagnosis and treatment of Chiari and syringomyelia and patient representatives were invited to take part in a three-round Delphi process. The Jury received a structured questionnaire containing the 63 statements, each to be voted on a 4-point Likert-type scale and commented. Statements with agreement

Despite the adoption of novel therapeutical approaches, the outcomes for glioblastoma (GBM) patients remain poor. In the present study, we investigated the prognostic impact of several clinico-pathological and molecular features as well as the role of the cellular immune response in a series of 59 GBM. CD4+ and CD8+ tumor-infiltrating lymphocytes (TILs) were digitally assessed on tissue microarray cores and their prognostic role was investigated. Moreover, the impact of other clinico-pathological features was evaluated. The number of CD4+ and CD8+ is higher in GBM tissue compared to normal brain tissue (p < 0.0001 and p = 0.0005 respectively). A positive correlation between CD4+ and CD8+ in GBM is present (rs = 0.417—p = 0.001). CD4+ TILs are inversely related to overall survival (OS) (HR = 1.79, 95% CI 1.1–3.1, p = 0.035). The presence of low CD4+ TILs combined with low CD8+ TILs is an independent predictor of longer OS (HR 0.38, 95% CI 0.18–0.79, p = 0.014). Female sex is independently related to longer OS (HR 0.42, 95% CI 0.22–0.77, p = 0.006). Adjuvant treatment, methylguanine methyltransferase (MGMT) promoter methylation, and age remain important prognostic factors but are influenced by other features. Adaptive cell-mediated immunity can affect the outcomes of GBM patients. Further studies are needed to elucidate the commitment of the CD4+ cells and the effects of different TILs subpopulations in GBM.

Parkinson's disease (PD) is the most common cause of parkinsonism, a clinical syndrome that includes bradykinesia, tremor, and postural instability. Secondary causes of parkinsonism include chronic traumatic encephalopathy. However, clear physiopathologic association between spinal cord injury (SCI) and PD has not been well described yet. We describe a rare/unusual case of a patient with C7–D1 fracture/listhesis who, 12 days after the trauma, developed a progressive cognitive impairment together with mandibular tremor. Seven days after the onset of symptoms, because of the persistence of mandibular tremor and Glasgow Coma Scale (GCS) score of 4, therapy with L-DOPA/benserazide was started, which resulted in gradual reduction of symptoms and complete recovery of consciousness. This could be the first report of PD appearing only 12 days after an SCI in the acute stage. Early differential diagnosis on the first manifestations of this kind of symptoms should be considered in patients with SCI to set up the right therapy essential for improving the outcome and preventing devastating consequences. This might also provide insights into the potential pathophysiologic responses of the brain after primary (immediate) and secondary (delayed) damages.

There is an unmet need for new biomarkers able to predict both the outcomes of up-front therapy and the compliance of elderly patients diagnosed with glioblastoma. For this purpose, temporal muscle thickness is a promising tool to be investigated.Data from 52 glioblastoma patients older than 65 years, treated with post-operative radio or radio-chemotherapy and referred to Pisa University Hospital, were retrieved. The thickness of temporal muscle (TMT) was divided into quartiles and correlated with overall survival (Our primary endpoint). Survival curves were calculated using Kaplan-Meier method, and log-rank test was used to evaluate the differences between curves.Patients in the lower quartile of TMT, with TMT thinner than 7 mm, have survived longer; both univariate and multivariate analyses showed a statistically significant correlation between TMT and overall survival (P = 0.012 and P = 0.003, respectively).Future prospective and more extensive studies focused on elderly glioblastoma patients are needed to confirm the role of TMT as prognostic value on OS and to help explaining this association.

The present study aims to investigate the role of the first magnetic resonances (MRI) following radio-chemotherapy (RT-CT) in patients diagnosed with high-grade glioma.We retrospectively recorded radiological evaluations following RT-CT, symptoms related to disease progression (avoiding any sign due to radiotherapy or chemotherapy) and the change of therapeutic strategy.In March 2021, at data analysis, the data of 149 patients diagnosed with high-grade glioma and treated between May 2013 and July 2020 were retrieved for the present analysis. Two out of 122 (1.6%), 5 out of 106 (4.7%) and 8 out of 92 (8.6%) asymptomatic patients received the diagnosis of disease recurrence at the time of the first, second and third MRI, respectively. Otherwise, 16 out of 27 (59.2%), 16 out of 24 (66.6%) and 13 out of 16 (82.2%) symptomatic patients changed their therapy after the first, second and third MRI, respectively. Among patients that experienced radiological signs of distant progression, 10 out of 14 were symptomatic and changed their therapy.MRIs performed by 6 months after the end of RT-CT lead to change treatment strategy mostly in symptomatic patients.

International audience; Background and purpose: Delayed cerebral ischemia strongly impacts clinical outcome after aneurysmal SAH. The effect of antiplatelet therapy on delayed cerebral ischemia has been described with heterogeneous results. Our aim was to analyze the efficacy of antiplatelet therapy on delayed cerebral ischemia and clinical outcome in patients with SAH.Data sources: A systematic search of 3 databases was performed for studies published from 1990 to 2019.Study selection: According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies comparing the rates of delayed cerebral ischemia and clinical outcomes among patients with SAH with and without antiplatelet therapy.Data analysis: Random-effects meta-analysis was used to pool the following: delayed cerebral ischemia, mortality, and good outcome rates.Data synthesis: Including 7 studies, 1060 and 1762 patients with SAH were endovascularly or surgically treated with (cases) and without (controls) antiplatelet therapy, respectively. Overall, antiplatelet therapy did not significantly decrease delayed cerebral ischemia rates compared with the control group (219/1060 versus 485/1762, OR = 0.781; 95% CI, 0.46-1.31; P = .33). Among patients treated endovascularly, there was a trend toward lower delayed cerebral ischemia rates after antiplatelet therapy (157/778 versus 413/1410, OR = 0.552; 95% CI, 0.273-1.115; P = .06). Long-term (>2 weeks) antiplatelet therapy tended to be associated with a lower incidence of delayed cerebral ischemia (63/438 versus 96/353, OR = 0.379; 95% CI, 0.12-1.2; P = .06). The good-outcome rate was significantly higher (803/1144 versus 1175/1775, OR = 1.368; 95% CI, 1.117-1.676; P = .002) and the mortality rate was significantly lower (79/672 versus 97/571, OR = 0.656; 95% CI, 0.47-0.91; P = .01) among the antiplatelet therapy group.Limitations: Heterogeneity was high for most outcomes.Conclusions: Overall, the incidence of delayed cerebral ischemia seems not to be significantly reduced among the antiplatelet therapy group. However, delayed cerebral ischemia tended to be lower among subjects with both long-term antiplatelet therapy and endovascular treatment and antiplatelet administration. Poor outcome and mortality rates were significantly reduced among the antiplatelet therapy group.

International audience; The surgical resection of insular gliomas remains a challenge. Middle cerebral artery perforating arteries and deep functional pathways affect the extent of resection and the rate of post-operative morbidity. The authors performed a systematic review and meta-analysis of the literature examining early and permanent post-operative deficits in patients who underwent resection of insular gliomas using awake craniotomy with direct electrical stimulation (DES) versus surgery under general anesthesia. A systematic search of three databases was performed for studies published between 1990 and 2018. Random-effect meta-analysis was used to pool the rate of early and permanent post-operative deficits. Random-effect meta-regression was used to examine the association between the rate of post-operative deficit and the anesthesia protocol. We included eight studies evaluating 227 patients with insular glioma. The rate of permanent sequelae was lower after awake craniotomy with DES (3.5% vs 15.7%; P = .001), and early deficits were lower after surgery under general anesthesia (27.3% vs 47.7%; P = .04). Awake surgery was significantly more common among patients with tumor located within the dominant hemisphere (P < .001). No significant association arose between the rates of post-operative deficits and the use of intraoperative neuronavigation and the neurophysiological monitoring. Furthermore, neither extent of resection nor tumor histology influenced the onset of permanent sequelae. Awake craniotomy with DES is associated with a significantly lower rate of permanent neurological morbidity after an early increase of transient post-operative deficits. These data support the use of awake mapping in insular glioma resection.

Background. The impact of different patterns of glioblastoma (GBM) recurrence has not yet been fully established in patients suitable for a second surgery. Through the present observational study carried out at Pisa University Hospital, we aimed to examine the impact of different patterns of GBM failure on patients’ survival and second surgery outcomes.Methods. Overall survival was assessed according to clinical characteristics, including pattern of recurrence, in a prospective cohort of recurrent GBM patients. Survival curves were calculated using the Kaplan-Meier method and the log-rank test was applied to evaluate the differences between curves.Results. Contact with ventricles, a second surgery and meningeal spread had a statistically impact on patient survival after the diagnosis of GBM recurrence (P=0.032, P=0.019 and PConclusions. The local recurrence pattern could be a promising field of interest for patients with recurrent GBM suitable for a second surgery.

Glioblastoma (GBM) is the most common primary malignant brain tumour in adults. Despite the combination of novel therapeutical approaches, it remains a deadly malignancy with an abysmal prognosis. GBM is a polymorphic tumour from both molecular and histological points of view. It consists of different malignant cells and various stromal cells, contributing to tumour initiation, progression, and treatment response. GBM’s microenvironment is multifaceted and is made up of soluble factors, extracellular matrix components, tissue-resident cell types (e.g., neurons, astrocytes, endothelial cells, pericytes, and fibroblasts) together with resident (e.g., microglia) or recruited (e.g., bone marrow-derived macrophages) immune cells. These latter constitute the so-called immune microenvironment, accounting for a substantial GBM’s tumour volume. Despite the abundance of immune cells, an intense state of tumour immunosuppression is promoted and developed; this represents the significant challenge for cancer cells’ immune-mediated destruction. Though literature data suggest that distinct GBM’s subtypes harbour differences in their microenvironment, its role in treatment response remains obscure. However, an in-depth investigation of GBM’s microenvironment may lead to novel therapeutic opportunities to improve patients’ outcomes. This review will elucidate the GBM’s microenvironment composition, highlighting the current state of the art in immunotherapy approaches. We will focus on novel strategies of active and passive immunotherapies, including vaccination, gene therapy, checkpoint blockade, and adoptive T-cell therapies.

Despite recent advances in diagnosis and treatment of the disease, the prognosis of patients with glioblastoma multiforme (GBM) remains poor. While the value of molecular pattern profiles at first diagnosis has been demonstrated, only few studies have examined these biomarkers at the time of recurrence. The aim of this study was to explore the impact of extent of resection at repeated craniotomy on overall survival (OS) of patients with recurrent GBM. In addition, we investigated the molecular pattern profiles at first and second surgery to evaluate possible temporal evolution of these patterns and to assess the effect of these modifications on OS.We conducted a retrospective cohort study of 63 patients (mean age 59.2 years) surgically treated at least two times for recurrent GBM between 2006 and 2020.Median OS and progression-free survival (PFS) were 22 months (range 2-168 months) and 10 months (range 1-96 months), respectively. The OS following gross-total resection (GTR) at recurrence for patients with initial GTR (GTR/GTR) was significantly increased (42.6 months) compared with sub-total resection (STR) at reoperation after initial GTR (GTR/STR) (19 months) and with GTR at reoperation after initial STR (STR/GTR) (17 months) (p = 0.0004). Overall surgical morbidity resulted 12.7% and 11.1% at first and at second surgery, respectively. Changes in genetic profiles between first and second surgery of 1p/19q co-deletion, MGMT promoter methylation and p53 mutations occurred in 5.6%, 1.9% and 9.3% of cases, respectively. MGMT promoter methylation appeared to affect OS in univariate analysis at first (p = 0.038) and second surgery (p = 0.107), whereas p53 mutation appeared to affect OS only at second surgery (p = 0.01). In a multivariate analysis female sex (HR = 0.322, 95% CI 0.147-0.705; p = 0.005), PFS (HR = 0.959, 95% CI 0.934-0.986; p = 0.003), GTR at first and second surgery (HR = 0.195, 95% CI 0.091-0.419; p 0.0001) and adjuvant chemotherapy at recurrence (HR = 0.407, 95% CI 0.206-0.809; p = 0.01) were associated with longer OS.This study confirmed the role of extent of resection (EOR) at first and at recurrence as a significant predictor of outcome in patients with recurrent GBM. In addition, this study highlighted the concept of a dynamic evolution of GBM genome after initial surgical resection, supporting the need of further studies to investigate the clinical and therapeutic implications of the changes in genetic profiles after initial surgery.

Background Pneumonia induced by 2019 Coronavirus (COVID-19) is characterized by hypoxemic respiratory failure that may present with a broad spectrum of clinical phenotypes. At the beginning, patients may have normal lung compliance and be responsive to noninvasive ventilatory support, such as CPAP. However, the transition to more severe respiratory failure - Severe Acute Respiratory Syndrome (SARS-CoV-2), necessitating invasive ventilation is often abrupt and characterized by a severe V/Q mismatch that require cycles of prone positioning. The aim of this case is to report the effect on gas exchange, respiratory mechanics and hemodynamics of tripod (or orthopneic sitting position) used as an alternative to prone position in a patient with mild SARS-CoV-2 pneumonia ventilated with helmet CPAP. Case presentation A 77-year-old awake and collaborating male patient with mild SARS-CoV-2 pneumonia and ventilated with Helmet CPAP, showed sudden worsening of gas exchange without dyspnea. After an unsuccessful attempt of prone positioning, we alternated three-hours cycles of semi-recumbent and tripod position, still keeping him in CPAP. Arterial blood gases (PaO2/FiO2, PaO2, SaO2, PaCO2 and A/a gradient), respiratory (VE, VT, RR) and hemodynamic parameters (HR, MAP) were collected in the supine and tripod position. Cycles of tripod position were continued for 3 days. The patient had a clinically important improvement in arterial blood gases and respiratory parameters, with stable hemodynamic and was successfully weaned and discharged to ward 10 days after pneumonia onset. Conclusions Tripod position during Helmet CPAP can be applied safely in patients with mild SARS-CoV-2 pneumonia, with improvement of oxygenation and V/Q matching, thus reducing the need for intubation.

Cerebellar arteriovenous malformations (AVMs) represent 10%–15% of all intracranial AVMs and are associated with a greater risk for hemorrhagic presentation compared with supratentorial AVMs. When they reach the cerebellopontine angle cistern, neurovascular compression syndromes, including trigeminal neuralgia and hemifacial spasm, can occur. Due to the aggressive natural history of cerebellar AVM, an effective treatment strategy is required. In this video, the authors demonstrate the technical nuances of microsurgical resection of an unruptured cerebellar AVM in a 24-year-old female presenting with trigeminal neuralgia. The patient underwent right retrosigmoid craniotomy and complete resection of the AVM with resolution of trigeminal neuralgia.The video can be found here: https://youtu.be/6GmNjgFQwx8

The amygdaloid body is a limbic nuclear complex characterized by connections with the thalamus, the brainstem and the neocortex. The recent advances in functional neurosurgery regarding the treatment of refractory epilepsy and several neuropsychiatric disorders renewed the interest in the study of its functional Neuroanatomy. In this scenario, we felt that a morphological study focused on the amygdaloid body and its connections could improve the understanding of the possible implications in functional neurosurgery. With this purpose we performed a morfological study using nine formalin-fixed human hemispheres dissected under microscopic magnification by using the fiber dissection technique originally described by Klingler. In our results the amygdaloid body presents two divergent projection systems named dorsal and ventral amygdalofugal pathways connecting the nuclear complex with the septum and the hypothalamus. Furthermore, the amygdaloid body is connected with the hippocampus through the amygdalo-hippocampal bundle, with the anterolateral temporal cortex through the amygdalo-temporalis fascicle, the anterior commissure and the temporo-pulvinar bundle of Arnold, with the insular cortex through the lateral olfactory stria, with the ambiens gyrus, the para-hippocampal gyrus and the basal forebrain through the cingulum, and with the frontal cortex through the uncinate fascicle. Finally, the amygdaloid body is connected with the brainstem through the medial forebrain bundle. Our description of the topographic anatomy of the amygdaloid body and its connections, hopefully represents a useful tool for clinicians and scientists, both in the scope of application and speculation.

Object The novel severe acute respiratory syndrome (SARS)-CoV-2 outbreak has been declared a pandemic in March, 2020. An increasing body of evidence suggests that patients with the coronavirus disease (COVID-19) might have a heterogeneous spectrum of neurological symptoms Methods A systematic search of two databases was performed for studies published up to May 29th, 2020. PRISMA guidelines were followed. Results We included 19 studies evaluating 12,157 patients with laboratory-confirmed COVID-19 infections. The median age of patients was 50.3 (IQR 11.9), and the rate of male patients was 50.6% (95% CI 49.2–51.6%). The most common reported comorbidities were hypertension and diabetes (31.1%, 95% CI 30–32.3% and 13.5%, 95% CI 12.3–14.8%, respectively). Headache was reported in 7.5% of patients (95% CI 6.6–8.4%), and dizziness in 6.1% (95% CI 5.1–7.1%). Hypo/anosmia, and gustatory dysfunction were reported in 46.8 and 52.3%, of patients, respectively. Symptoms related to muscular injury ranged between 15 and 30%. Three studies reported radiological confirmed acute cerebrovascular disease in 2% of patients (95% CI 1.6–2.4%). Conclusions These data support accumulating evidence that a significant proportion of patients with COVID-19 infection develop neurological manifestations, especially olfactory, and gustatory dysfunction. The pathophysiology of this association is under investigation and warrants additional studies, Physicians should be aware of this possible association because during the epidemic period of COVID-19, early recognition of neurologic manifestations otherwise not explained would raise the suspect of acute respiratory syndrome coronavirus 2 infection. Electronic supplementary material The online version of this article (10.1007/s00415-020-09978-y) contains supplementary material, which is available to authorized users.

Objective To study the role of laser interstitial thermal therapy in recurrent glioblastoma and to assess its effect in the overall survival and in progression-free survival. Methods A MEDLINE and Pubmed search was performed for the key words “laser interstitial thermal therapy”, “LITT” and “glioblastoma”. Studies investigating overall survival and progression-free survival of recurrent glioblastoma after laser interstitial thermal therapy were selected. Results A total of 17 studies met the selection criteria, accounting for 203 patients with recurrent glioblastoma who underwent 219 laser interstitial thermal therapy treatments. The median age was 57.4 years and there was male predominance (65.8 % male Vs 34.2 % female). The most common location resulted frontal lobe (29 %), followed by temporal (23.9 %), parietal (21.4 %) and occipital lobes (2.6 %). Additional locations included thalamus, corpus callosum and cerebellum (23.1 %). Pre-treatment median tumor size was 8.9 cm3. Morbidity was 6.4 % with a median hospital stay of 3.5 days. The most common complications were seizures (2%), motor deficits (1.5 %), wound infection (1.5 %), transient hemiparesis (1%) and hemorrhage (0.5 %). No deaths were reported due to LITT procedure. The median progression-free survival and the median overall survival after laser interstitial thermal therapy resulted 5.6 months and 10.2 months, respectively. The median overall survival from diagnosis was 14.7 months. All patients underwent adjuvant chemotherapy after treatment. Conclusion Laser interstitial thermal therapy provides an effective treatment with low morbidity for selected patients harboring recurrent glioblastoma. Laser interstitial thermal therapy should be included in the armamentarium of neurosurgical oncologist for treatment of recurrent glioblastomas.

Solitary fibrous tumors (SFTs) are uncommon mesenchymal lesions originally described as pleura-based neoplasms. Intradural juxtamedullary SFTs are rare, hard, and scarcely vascularized and generally present a conspicuous extramedullary exophytic component without dural attachment and nerve root involvement. Gross-total resection is the mainstay of treatment, although the absence of an arachnoidal plane and the firm adherence to the spinal cord make resection challenging. We describe the case of a 74-yr-old female patient presenting with a history of progressive spastic tetraparesis due to a cervical juxtamedullary SFT. The patient was not able to walk and magnetic resonance imaging (MRI) of the cervical spine demonstrated a possible intramedullary lesion at C2-C3 with homogeneous enhancement after gadolinium injection. Given the progressive nature of symptoms, the patient elected to have surgical resection of the tumor. The patient underwent C2-C3 laminoplasty and tumor resection under neurophysiologic monitoring. The tumor presented extremely hard without dural attachment or nerve root involvement and was progressively debulked using microsurgical techniques and ultrasonic aspirator. The identification of a plane between the mass and the spinal cord white matter allowed for a gross total resection. Permanent pathological analysis eventually demonstrated SFT. The patient's neurological condition was unchanged postoperatively. MRI performed 2 mo after the operation demonstrated gross total resection of the lesion. At the 6-mo follow-up visit, the patient was able to walk with assistance. The patient signed the Institutional Consent Form to undergo the surgical procedure and to allow the use of her images and videos for any type of medical publications.

Optimal management of intracranial pressure (ICP) among aneurysmal subarachnoid hemorrhage (aSAH) patients requiring external ventricular drainage (EVD) is controversial. To analyze predictors of delayed cerebral ischemia (DCI)-related cerebral infarction after aSAH and the influence of ICP values on DCI, we prospectively collected consecutive patients with aSAH receiving coiling and requiring EVD. Predictors of DCI-related cerebral infarction (new CT hypodensities developed within the first 3 weeks not related to other causes) were studied. Vasospasm and brain hypoperfusion were studied with CT angiography and CT perfusion (RAPID-software). Among 50 aSAH patients requiring EVD, 21 (42%) developed DCI-related cerebral infarction, while 27 (54%) presented vasospasm. Mean ICP ranged between 2 and 19 mmHg. On the multivariate analysis, the mean ICP (OR = 2, 95%CI = 1.01-3.9, p = 0.042) and the mean hypoperfusion volume on Tmax delay 6 (OR = 1.2, 95%CI = 1.01-1.3, p = 0.025) were independent predictors of DCI. To predict DCI-related cerebral infarction, Tmax delay 6 s presented the highest AUC (0.956, SE = 0.025), with a cutoff value of 18 ml showing sensitivity, specificity, PPV, NPV, and accuracy of 90.5% (95%CI = 69-98.8%), 86.2% (95%CI = 68.4-96%), 82.6% (95%CI = 65.4-92%), 92.5% (95%CI = 77-98%), and 88% (95%CI = 75-95%), respectively. The AUC of the mean ICP was 0.825 (SE = 0.057), and the best cutoff value was 6.7 mmHg providing sensitivity, specificity, PPV, NPV, and accuracy of 71.4% (95%CI = 48-89%), 62% (95%CI = 42-79%), 58% (95%CI = 44-70%), 75% (95%CI = 59-86%), and 66% (95%CI = 51-79%) for the prediction of DCI-related cerebral infarction, respectively. Among aSAH patients receiving coiling and EVD, lower ICP ( 6.7 mmHg in our study) could potentially be beneficial in decreasing DCI-related cerebral infarction. Brain hypoperfusion with a volume 18 ml at Tmax delay 6 s presents a high sensibility and specificity in prediction of DCI-related cerebral infarction.

BACKGROUND: Treatment management and outcomes of unruptured nonsaccular aneurysms are different compared with their saccular counterparts. PURPOSE: Our aim was to analyze the outcomes after flow diversion among nonsaccular unruptured lesions. DATA SOURCES: A systematic search of 3 data bases (2005–2019) was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. STUDY SELECTION: We included studies reporting flow diversion for nonsaccular unruptured aneurysms of the posterior and distal anterior circulations. Anterior circulation lesions were included if located distal to the petrocavernous and supraclinoid ICA (MCA, A1, anterior communicating artery, A2). Giant dolichoectatic holobasilar lesions were excluded because of their poor treatment outcomes. DATA ANALYSIS: Aneurysm occlusion and complication rates were calculated (random effects meta-analysis). DATA SYNTHESIS: We included 15 studies (213 aneurysms). The long-term adequate occlusion rate was 85.3% (137/168; 95% CI, 78.2%–92.4%; I(2) = 42.3%). Treatment-related complications were 17.4% (41/213; 95% CI, 12.45%–22.4%; I(2) = 0%). Overall, 15% (37/213; 95% CI, 10%–20%; I(2) = 0%) were ischemic events. Procedure-related morbidity was 8% (20/213; 95% CI, 5%–12%; I(2) = 0%). Fusiform or dissecting types had comparable adequate occlusion (116/146 = 83%; 95% CI, 74%–92%; I(2) = 48% versus 33/36 = 89%; 95% CI, 80%–98%; I(2) = 0%; P = .31) and complication rates (35/162 = 17%; 95% CI, 10%–25%; I(2) = 24% versus 11/51 = 19%; 95% CI, 10%–31%; I(2) = 0%; P = .72). Aneurysm size (>10 versus ≤10 mm) was independently associated with a higher rate of complications (OR = 6.6; 95% CI, 1.3–15; P = .02). The rate of ischemic events after discontinuation of the antiplatelet therapy was 5% (5/93; 95% CI, 2%–9%; I(2) = 0%). LIMITATIONS: Small and retrospective studies were available for this meta-analysis. CONCLUSIONS: Unruptured nonsaccular aneurysms located in the posterior and distal anterior circulations can be effectively treated with flow diversion. Nevertheless, treatment-related complications are not negligible, with about 15% ischemic events and 8% morbidity. Larger size (>10 mm) significantly increases the risk of procedure-related adverse events.

Idiopathic normal pressure hydrocephalus (iNPH) is a debated entity with controversial pathogenesis, diagnostic criteria, and predictors of response after ventriculoperitoneal shunt (VPS). Parkinsonian signs are frequently reported in the clinical picture, sometimes due to the coexistence of an underlying neurodegenerative parkinsonism and sometimes in the absence thereof. To distinguish these two scenarios is crucial, since they may carry different long-term response to CSF drainage. 123I-FP-CIT-SPECT was believed to be helpful in this regard, however its role in predicting surgical outcome has been disputed. We illustrate a patient presented with gait disturbance, urinary incontinence, and asymmetrical parkinsonian signs, who underwent a 3T brain MRI and a 123I-FP-CIT-SPECT. VPS was performed. The patient repeated a 123I-FP-CIT-SPECT, 18 months after the operation, and was clinically followed up for 24 months. Our patient displayed clinical and radiological criteria for iNPH and an abnormal asymmetrical uptake in 123I-FP-CIT-SPECT, consistent with her asymmetrical parkinsonism. However, the organization of the substantia nigra studied with iron-sensitive sequences in 3T brain MRI scan appeared intact. The patient revealed an improvement both clinically and in 123I-FP-CIT-SPECT at postsurgical follow-up. Our report suggests that abnormal 123I-FP-CIT-SPECT may not necessarily reveal an overlap with neurodegenerative parkinsonism; its partial reversibility may suggest that the mechanical effect exerted on the striatum by ventriculomegaly ultimately leads to downregulation of dopaminergic transporters which may improve after VPS.

Foramen magnum decompression (FMD) is widely accepted as the standard treatment for syringomyelia associated with Chiari type I malformation (CMI). Despite extensive clinical investigations, relevant surgical details are still matter of debate. The authors performed a systematic review and meta-analysis of the literature examining the radiological outcome of syringomyelia in adult patients with CMI after different surgical strategies. PRISMA guidelines were followed. A systematic search of three databases was performed for studies published between 1990 and 2018. Our systematic review included 13 studies with a total of 276 patients with CMI associated with syringomyelia. Overall, the rate of post-operative radiological improvement at last follow-up was 81.1% (95% CI 73.3–88.9%; p

Background: Long-standing overt ventriculomegaly in adults (LOVA) is an uncommon type of adult chronic hydrocephalus. In recent years, conflicting case series described different outcomes after treatment of LOVA with endoscopic third ventriculostomy (ETV) or ventriculoperitoneal shunt (VPS). The aim of this study is to report a single institutional surgical experience of patients with LOVA in order to evaluate the clinical outcome of those patients treated with one or, sometimes, both surgical procedures, analyzing the main clinical features of these patients, before and after surgery. Methods: We conducted a retrospective study on 31 patients with diagnosis of LOVA, who were treated in our University Hospital between December 2010 and October 2020. We reported gender, age, clinical presentation, surgical treatment, and clinical outcome according to the Kiefer index (KI). Evans’ index, head circumference, aqueductal stenosis and expanded/destroyed sella turcica were assessed on preoperative MRI. Results: The most common clinical manifestation was gait disturbances (100%) followed by urinary incontinence in 23 (74.2%) patients and cognitive deficits in 22 (71%) patients. On preoperative MRI, the overall mean Evans’s Index was 0.49, whereas the overall mean head circumference was 57.3 cm. Twenty-three patients (74.2%) had obliterated cortical sulci, 20 (64.5%) patients had aqueductal stenosis, and 22 (71%) patients had an expanded/destroyed sella turcica on preoperative MRI. Fifteen (48.4%) patients underwent ETV and sixteen (51.6%) were treated with VPS as first surgical procedure. Four (26.6%) out of fifteen patients treated with ETV required a subsequent VPS. The overall median age of patients was 64 (IQR: 54.5–74) and the overall median follow-up was 57 months (IQR 21.5–81.5). Overall morbidity was 22.5%. Mean recovery index (RI), according to KI, was 3.8 ± 4.3 and 2.2 ± 5.6 (p = 0.05) at last follow-up in patients treated with ETV and VPS, respectively. Conclusions: The choice of surgical treatment of LOVA remains under discussion. Although EVT is a tempting option for patients with LOVA, conversion to VP shunt is not uncommon.

The risk of ventriculostomy-related hemorrhage among patients requiring antiplatelet therapy (AT) for the endovascular treatment of acutely ruptured intracranial aneurysms needed further investigation. The authors performed a systematic review and meta-analysis of the literature examining the EVD-related hemorrhage rate among patients with and without AT (controls). According to PRISMA guidelines, a comprehensive review of studies published between January 1990 and April 2018 was carried out. The authors identified series with > 5 patients reporting the EVD-associated hemorrhage rate among the AT group and the control group. Variables influencing outcomes were analyzed using a random-effects meta-analysis model. We included 13 studies evaluating 516 (with AT) and 647 (without AT) patients requiring ventriculostomy. EVD-related hemorrhage rates were higher among the AT group (125/516 = 20.9%, 95% CI = 11.9–30%, I2 = 90% vs 57/647 = 9%, 95% CI = 5.5–12.5%, I2 = 45.8%) (p

Background Treatment of intrinsic lesions of the ventral brainstem is a surgical challenge that requires complex skull base antero- and posterolateral approaches. More recently, endoscopic endonasal transclival approach (EETA) has been reported in the treatment of selected ventral brainstem lesions. Objective In this study we explored the endoscopic ventral brainstem anatomy with the aim to describe the degree of exposure of the ventral safe entry zones. In addition, we used a newly developed method combining traditional white matter dissection with high-resolution 7T magnetic resonance imaging (MRI) of the same specimen coregistered using a neuronavigation system. Methods Eight fresh-frozen latex-injected cadaver heads underwent EETA. Additional 8 formalin-fixed brainstems were dissected using Klingler technique guided by ultra-high resolution MRI. Results The EETA allows a wide exposure of different safe entry zones located on the ventral brainstem: the exposure of perioculomotor zone requires pituitary transposition and can be hindered by superior cerebellar artery. The peritrigeminal zone was barely visible and its exposure required an extradural anterior petrosectomy. The anterolateral sulcus of the medulla was visible in most of specimens, although its close relationship with the corticospinal tract makes it suboptimal as an entry point for intrinsic lesions. In all cases, the use of 7T-MRI allowed the identification of tiny fiber bundles, improving the quality of the dissection. Conclusion Exposure of the ventral brainstem with EETA requires mastering surgical maneuvers, including pituitary transposition and extradural petrosectomy. The correlation of fiber dissection with 7T-MRI neuronavigation significantly improves the understanding of the brainstem anatomy.

Despite technological advances in endovascular therapy, surgical clipping of paraclinoid aneurysms remains an indispensable treatment option and has an acceptable profile risk. Intraoperative monitoring of motor and somatosensory evoked potentials has proven to be an effective tool in predicting and preventing postoperative motor deficits during aneurysm clipping.1,2 We describe the case of a 61-yr-old Japanese woman with a history of hypertension and smoking. During follow-up for bilateral aneurysms of ophthalmic segment of the internal carotid artery (ICA), left-sided aneurysm growth was detected. A standard pterional approach with extradural clinoidectomy was used to approach the aneurysm. After clipping, a significant intraprocedural change in motor evoked potential (MEP) amplitude was observed despite native vessel patency was confirmed through micro-Doppler and indocyanine green video angiography.3-5 After extensive dissection of the sylvian fissure and exposure of the communicating segment of ICA, the anterior choroidal artery was found to be compressed and occluded by the posterior clinoid because of an inadvertent shift of the ICA after clip application and removal of brain retractors. Posterior clinoidectomy was performed intradurally with microrongeur and MEP amplitude returned readily to baseline values. Computed tomography (CT) angiogram demonstrated complete exclusion of the aneurysm, and magnetic resonance imaging (MRI) was negative for postoperative ischemic lesions on diffusion weighted images. The patient tolerated the procedure well and was discharged home on postoperative day 3 with modified Rankin Scale (mRS) 0. The patient signed the Institutional Consent Form to undergo the surgical procedure and to allow the use of her images and videos for any type of medical publications.

Autosomal dominant polycystic kidney disease (ADPKD) is a genetic disorder associated with high incidences of intracranial aneurysms. We performed a systematic review with the purpose of clarifying the prevalence, risk of rupture, and appropriate management of intracranial aneurysms in the ADPKD population. PRISMA guidelines were followed. We conducted a comprehensive literature search of three databases (PubMed, Ovid MEDLINE, and Ovid EMBASE) on all series reporting ADPKD patients with intracranial aneurysms. Our systematic review included 16 articles with a total of 563 patients with ADPKD and intracranial aneurysms. The prevalence of unruptured aneurysms was 11.5% (95% CI = 10.1–13%), whereas 1.9% (95% CI = 1.3–2.6%) of aneurysms were ruptured. Hypertension was present in 79.3% of patients with ADPKD and renal impairment in 65%. The mean size of ruptured aneurysms was slightly higher than unruptured (6 mm vs. 4.4 mm). The most common locations of unruptured and ruptured aneurysms were the ICA (40.5%) and MCA (45%), respectively. Asymptomatic patients studied with four-vessel angiography experienced 25% transient complications. Overall, 74% unruptured aneurysms were surgically treated with lower complication rates compared to endovascular treatment (11% vs. 27.7%). Among conservatively treated aneurysms, 2.9% ruptured at follow-up (rupture rate 0.4%/patient-year). Finally, the growth rate was 0.4% per patient-year, and the incidence of de novo aneurysm formation was 1.4% per patient-year. The prevalence of unruptured intracranial aneurysms in the ADPKD population is approximately 11%. Given the non-negligible rate of procedural complications, the management of these patients must be cautious and individualised. The rupture rate appears comparable to that of the general population. On the other hand, the 1.4% rate per patient-year of de novo aneurysms is non-negligible. These findings should be considered when counselling ADPKD patients regarding the appropriate management of intracranial aneurysms.

The sphenopalatine ganglion (SPG) has been assumed to be involved in the genesis of several types of facial pain, including Sluder's neuralgia, trigeminal neuralgia, persistent idiopathic facial pain, cluster headache, and atypical facial pain. The gold standard treatments for SPG-related pain are percutaneous procedures performed with the aid of fluoroscopy or CT. In this technical note the authors present, for the first time, an SPG approach using the aid of a neuronavigator.

Background The safety and efficacy of FD among distal AC aneurysms must be proved. Purpose To analyze the outcomes after FD among MCA, AcomA, and DACA aneurysms. Data sources A systematic search of three databases was performed for studies published from 2005 to 2018. Study selection According to PRISMA guidelines, we included studies reporting FD of distal AC aneurysms. Data analysis Random-effects meta-analysis was used to pool aneurysm occlusion and complication rates. From the individual patient data, univariate and multivariate analysis were used to test predictors of occlusion and complications. Data synthesis We included 27 studies (484 aneurysms). Long-term adequate occlusion rate (OKM C-D) was 82.7 % (295/364, 95 % CI = 77.4 %–87.9 %, I2 = 52 %). Treatment-related complications were 12.5 % (63/410, 95 % CI = 9 %–16 %%, I2 = 18.8 %), with 5.4 % (29/418, 95 % CI = 3.2–7.5 %, I2 = 0 %) of morbidity. MCA location was an independent factor associated with lower occlusion (OR = 0.5, P = 0.03) and higher complication rates (OR = 1.8, P = 0.02), compared to AcomA and DACA aneurysms. PED (vs other stents) gave better occlusion rates (OR = 2.6, P = 0.002), whereas large/giant aneurysms were associated with higher odds of complications (OR = 2.2, P = 0.03). The rates of occlusion and narrowing of arteries covered by flow-diverter stents were 6.3 % (29/283, 95 % CI = 3.5 %–9.1 %, I2 = 4.2 %) and 23.8 % (69/283, 95 % CI = 15.7 %–32 %, I2 = 80 %), respectively. Symptoms related to occlusion and narrowing of the jailed arteries were 3.5 % (6/269, 95 % CI = 1.1 %–5 %, I2 = 0 %) and 3 % (6/245, 95 % CI = 1 %–4 %, I2 = 0 %), respectively. Limitations Small and retrospective series. Conclusions FD among distal AC aneurysms is effective, leading to adequate aneurysm occlusion in 83 % of cases. However, this strategy presents some limitations among MCA, and for larger lesions especially related to the higher rate of complications. Compared to the other devices, PED seems to be associated with a higher occlusion rate.

Background Clopidogrel is routinely used to decrease ischemic complications during neurointerventional procedures. However, the efficacy may be limited by the antiplatelet resistance. Purpose To analyze the efficacy of prasugrel (PS) compared to clopidogrel (CP) in the cerebrovascular field. Data sources A systematic search of two large databases was performed for studies published from 2000 to 2018. Study selection According to PRISMA guidelines, we included studies reporting treatment-related outcomes of patients undergoing neurointerventional procedures under PS, and studies comparing PS and CP. Data analysis Random-effects meta-analysis was used to pool the following: overall rate of complications, ischemic and hemorrhagic events, influence of the dose of PS. Data synthesis Including 7 studies, 682 and 672 unruptured intracranial aneurysms were treated under PS (cases) and CP (controls), respectively. Low-dose (20 mg/5 mg) (loading and maintenance doses) of PS compared with the standard dose of CP (300 mg/75 mg) showed a significant reduction of the complication rate (OR = 0.36, 95% CI = 0.17–74, P = 0.006, I2 = 0%). Overall, ischemic complication rate was significantly higher among the CP group (40/672 = 6%, 95% CI = 3%–13%, I2 = 83% vs 16/682 = 2%, 95% CI = 1%–5%, I2 = 73%, P = 0.03). Low and high loading doses of PS were associated with 0.6% (5/535, 95% CI = 0.1%–1.6%, I2 = 0%) and 9.3% (13/147, 95% CI = 0.2%–18%, I2 = 60%) of intra-periprocedural hemorrhages, respectively (P = 0.001), whereas low and high maintenance doses of PS were associated with 0% (0/433) and 0.9% (2/249, 95% CI = 0.3%–2%, I2 = 0%) of delayed hemorrhagic events, respectively (P = 0.001). Limitations Retrospective series and heterogeneous endovascular treatments. Conclusions In our study, low-dose of prasugrel, compared with clopidogrel premedication, is associated with an effective reduction of the ischemic events with an acceptable rate of hemorrhagic complications.

Background Management of external ventricular drainage (EVD) among aneurysmal subarachnoid hemorrhage (aSAH) patients remain controversial, and there are no consensus guidelines reporting optimal values of intracranial pressure (ICP). Objective To analyze predictors of delayed cerebral ischemia (DCI) after aSAH and the influence of ICP values on DCI. Methods We prospectively collected patients with aSAH requiring EVD. Predictors of DCI (new CT hypodensities developed within the first 3 weeks not related to others causes) were studied. Vasospasm and brain hypoperfusion were studied with CTA and CTP (RAPID software). Results Among 50 aSAH patients treated with EVD, 21 (42%) developed DCI, while 27 (54%) presented vasospasm. Mean ICP ranged between 2 mmHg and 19 mmHg. On the multivariate analysis, mean ICP (OR = 2, 95% CI = 1.01–3.9, P = 0.04) and mean volume of the hypoperfusion on Tmax delay > 6 (OR = 1.2, 95% CI = 1.01–1.3, P = 0.02) were the only independent predictors of DCI. To predict DCI, Tmax delay > 6 seconds presented the highest AUC (0.956), with a cutoff value of 18 mL showing sensitivity, specificity, PPV, NPV, and accuracy of 90.5% (95% CI = 69%–98.8%), 86.2% (95% CI = 68.4%–96%), 82.6% (95% CI = 65.4%–92%), 92.5% (95% CI = 77%–98%), 88% (95% CI = 75%–95%), respectively. The AUC of the mean ICP was 0.825, and the best cutoff value was 6.7 mmHg providing sensitivity, specificity, PPV, NPV, and accuracy of 71.4% (95% CI = 48%–89%), 62% (95% CI = 42%–79%), 58% (95% CI = 44%–70%), 75% (95% CI = 59%–86%), 66% (95% CI = 51%–79%) for the prediction of DCI, respectively. Conclusion ICP 6 seconds can predict more than 80% of DCI ( Fig. 1 , Fig. 2 ).