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Objective: This study aims to assess the efficacy and limitations of Computed Tomography Angiography (CTA)-based 3D virtual models for preoperative simulation and intraoperative neuronavigation in the surgical treatment of Distal Anterior Cerebral Artery (DACA) Aneurysms., Methods: A retrospective observational study was conducted, analyzing patients who underwent surgical clipping of DACA aneurysms via an interhemispheric approach from 2016 to 2022. Outcomes measured included qualitative analyses of 3D reconstructions against actual intraoperative anatomy, neuronavigator accuracy, 6-month modified Rankin Scale (mRS), complete exclusion rates, and surgical complications. Patient demographics, clinical characteristics, surgical timing, and intraoperative data were meticulously documented for analysis., Results: Fifteen patients were included in the study, with a mean age of 52 years. The mean Hunt-Hess score at admission was 2.2, encompassing 2 unruptured and 13 ruptured aneurysms. Intraoperative anatomical visualization perfectly matched the preoperative 3D model in 13 cases, with discrepancies in two. Neuronavigation demonstrated a mean accuracy of 1.76 mm, remaining consistent in 14 patients, and accurately tracking the planned trajectory. Postoperative complications occurred in 26.5 % of patients, including two fatalities, with no navigation-related complications. Incomplete aneurysm occlusion was observed in one case. The mean mRS score at 6 months was 2.46., Conclusions: The employment of 3D CTA for preoperative simulation and intraoperative neuronavigation holds significant potential in enhancing the surgical management of DACA aneurysms. Despite some discrepancies and technical limitations, the overall precision of preoperative simulations and the strategic value of intraoperative neuronavigation highlight their utility in improving surgical outcomes., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Introduction: The introduction of flexible fiber technology in the early 2000s revitalized the interest in the CO2 laser for neurosurgical applications, making it suitable for microsurgical procedures. Despite its widespread use, specific indications for the CO2 laser in neurosurgery remains undefined. This study evaluates the efficacy and limitations of the CO2 laser in brain tumor surgery., Materials and Methods: This retrospective observational single-center study analyzed the use of the CO2 laser in intracranial neoplasm surgeries from 2011 to 2021. A total of 94 patients were assessed, focusing on demographics, tumor characteristics, surgical duration, complications, and laser-specific issues. We used a five-tiered scoring system to assess laser effectiveness in both debulking and dissection tasks; with resection extent assessed following established guidelines., Results: The CO2 laser was highly effective in debulking solid tumors, achieving a 76.5% gross total resection rate, while being less effective in softer, highly vascularized tumors. The average effectiveness scores for dissection (2.6±0.8) were significantly lower than for debulking (3.2±1.2). Two major complications were directly associated with laser use. Effectiveness improved over time, particularly in the latter half of the study, and varied across tumor types, with notable utility in meningiomas and vestibular schwannomas but lower scores in glial tumors., Conclusions: The CO2 laser is a valuable tool in neurosurgery, especially for solid tumors in specific anatomical locations. Careful patient selection is crucial, and the laser complements rather than replaces conventional surgical tools. Ongoing technological advancements suggest broader future applications in neurosurgery.

Background: Cerebral abscesses complicated by ventriculitis present significant treatment challenges, often associated with high morbidity and mortality. Traditional management approaches, including systemic antibiotic therapy and external ventricular drainage (EVD), face limitations due to the blood-brain barrier and risks of catheter-related complications. This report discusses a case where the dual-lumen catheter system, an innovative neurosurgical tool integrating continuous irrigation with drainage, was employed., Case Description: A patient presented with a cerebral abscess ruptured into the ventricle, leading to ventriculitis. Conventional treatment options were limited due to the abscess's deep and eloquent location and the associated risk of complications from standard EVD. The dual lumen system was chosen for its ability to provide continuous irrigation and drainage, effectively addressing issues of catheter blockage and enhancing localized antibiotic delivery. The system was used to create a single stereotactic tract for simultaneous treatment of the abscess and ventriculitis. This approach allowed for a more controlled and effective treatment process, resulting in rapid resolution of the conditions without chronic hydrocephalus development or further complications., Conclusion: The use of the dual lumen system represented a significant advancement in this case, addressing the limitations of conventional treatments. Its ability to maintain intracranial pressure within optimal limits while providing localized, continuous treatment was pivotal. This case highlights the potential of the dual lumen catheter in managing complex neurosurgical infections and underscores the need for further research to establish its efficacy in broader clinical applications., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Surgical Neurology International.)

Background: Penetrating spinal injuries occasionally lead to dural tears (DT) and cerebrospinal fluid (CSF) leaks that risk both infectious and neurological complications. Here, we reviewed two cases and the literature regarding the safety/efficacy and limitations of repairing traumatic DT utilizing pedicled multifidus muscle flaps., Case Description: Two males, ages 73 and 50, presented with Brown-Sequard syndromes and DT/CSF fistulas attributed to knife-induced spinal injuries at the D3-D4 and D11-D12 levels. Intraoperatively, DT was repaired utilizing pedicle multifidus muscle flaps. Postoperatively, both patients demonstrated partial recovery of neurological function along with no residual symptoms/signs of DT/CSF fistulas., Conclusion: Penetrating traumatic spinal injuries may result in DT/CSF fistulas that can be adequately repaired utilizing pedicle multifidus muscle flaps., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Surgical Neurology International.)

Intradiploic meningiomas are rare neoplasms, often mistaken for metastases or malignant bone tumors. Surgical management can be challenging, considering their diffusive bony invasion. Two main critical decisions need to be taken: the timing for cranial vault reconstruction and the choice of the adequate material for cranioplasty. We believe that this case underscores the complexity of such lesions, the importance of a prompt devascularization, and the pivotal role of an immediate reconstruction to avoid the additional morbidity of a re-do surgery. Here, we report a case of 68-year-old men who presented with slow growing right parietal bone swelling he noted many years before, but for which he didn't seek medical attentions, associated with mild contralateral hemiparesis. Neuroradiological examinations revealed a giant extradural intradiploic tumor affecting the right temporo-parietal bone and conditioning significant compression of the underlying brain. We planned a surgical strategy to deafferent the tumor and to reduce the intraoperative bleeding. At first, a circumferential craniectomy centered upon the lesion was performed, then it was devascularized by means of surgical ligation of the ipsilateral superficial temporal artery (STA) and middle meningeal artery (MMA); these steps allowed a subsequent en block tumor excision, despite its large size, without significant blood loss and respecting the oncological principles. At the end, a contextual calvarial reconstruction was performed using a precurved titanium mesh. The patient was discharged seven days after surgery with complete recovery of the left-sided motor deficit. Thereafter, he underwent scheduled outpatient evaluations and radiological examinations. At 1-year follow-up, the Modified Rankin Scale (MRS) was 1, with no evidence of recurrent disease. To conclude, surgical complications can be reduced adopting an optimal preoperative work-up and a tailored surgical strategy focused on early tumor deafferentation. Moreover, an immediate cranial vault reconstruction avoids the risks related to a second procedure.

Objective: To assess safety and efficacy of minimally invasive evacuation of Spontaneous Supratentorial Intracerebral Hemorrhage (SSICH) by means of tailored minicraniotomies and intraoperative ultrasound (iUS) assistance., Methods: Retrospective analysis of 55 patients who underwent microsurgical evacuation of SSICH using minicraniotomy and iUS assistance, between January 2015 and January 2022. Surgical complications, mortality rate, recurrent bleeding, percentage of hematoma evacuation and reliability of iUS were collected and investigated. The clinical outcomes were measured by the modified Rankin Scale (mRS) at 6 months. Subgroup analysis was performed to assess the differences between the pre-operative GCS (3-9 versus 10-14), the residual hematoma volume (<10ml versus >10ml) and the location (deep versus lobar)., Results: 3 patients had an unfavourable outcome owing to surgery. The 6-month overall mortality accounted for 10,9%. Symptomatic recurrent bleeding occurred in 3 cases. 2 patients (3.6%) developed brain swelling treated with decompressive hemicraniectomy. With reference to clinical outcome, 39 patients (70,9%) had a good functional outcome (GFO) and the average 6-month mRS was 2,75±1,97. Hematoma volume decreased from 54,2±12,8mL pre-evacuation (range 30-95mL) to 11,1±12,5mL post-evacuation (range 0-35mL), with an average reduction of 78,15%±16,4% (P < 0.001). iUS was reliable to correctly check hematoma evacuation during the procedure in 46 patients (83.6%). Pre-operative GCS>9 and residual hematoma <10ml were found to be associated with higher probability to have GFO (P < 0.01)., Conclusions: Evacuation of SSICH using minicraniotomy with iUS assistance is a straightforward, affordable, and reproducible technique. Its safety and efficacy profiles appear consistent with other published studies., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Colloid cysts are benign lesions of the roof of the third ventricle, often diagnosed incidentally; sometimes they can cause hydrocephalus due to obstruction of the foramina of Monroe. Symptomatic cysts could be resected either microsurgically (transcallosal or transcortical) or endoscopically. Although both strategies are effective and have advantages and disadvantages, there is no consensus on the choice of the optimal approach. Transcallosal resection, although more invasive than endoscopy, allows adequate bimanual manipulation of the cyst and is associated with high rates of complete resection, the use of neuronavigator and intraoperative ultrasound optimizes surgical trajectory and improves safety of the procedure with complication rates comparable to endoscopy. Endoscopy is less invasive but complete resection of solid cysts can be challenging., Case Description: In Video 1, we show resection of a solid partially calcified colloid cyst using a transcallosal bilateral transforaminal approach to anterior third ventricle male, 65 years old; headache and mild memory impairment for 6 months; admitted at our emergency department because of a brief loss of consciousness. Neurologic examination was normal. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a colloid cyst at the level of anterior third of the third ventricle (1.5 cm in diameter) with hypointense appearance in T2 sequences suggesting a solid calcific component. The ventricular system was enlarged. Colloid cyst risk score 3/5 (diameter >0.7 cm, headache, risk zone I) considered an intermediate-risk subgroup according to Alford et al . On this basis, we proposed the surgical treatment. We chose a transcallosal microsurgical resection. The patient gave consent for the procedure. A preoperative planning with a computer-generated 3D model is performed to simulate the approach. Craniotomy, interhemispheric dissection, and callosotomy were planned with the neuronavigator and with the aid of intraoperative ultrasound to optimize the trajectory and perform a limited and tailored callosotomy. The 1.5 cm callosotomy allows to approach both lateral ventricles, the cyst was progressively dissected working bilaterally through both foramina of Monroe without injuries of the fornices. Resection at term is complete. Postoperative MRI and CT scan confirmed complete excision without complications; the patient was discharged after a week in good neurological condition with complete regression of headache., Conclusion: Microscopic transcallosal resection of the colloid cyst of the third ventricle allows for complete resection with low complication rates. The use of preoperative 3D planning and integrated neuronavigation with intraoperative ultrasound helps to reduce invasiveness., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Surgical Neurology International.)

Background: Cerebral toxoplasmosis is a relatively rare disorder that usually affects immunocompromised patients. The most common scenario occurs among human immunodeficiency virus (HIV)-positive patients. In those patients, toxoplasmosis is the most frequent cause of expansive brain lesion and continues to cause elevated morbidity and mortality. In typical cases of toxoplasmosis, both computed tomography and magnetic resonance imaging reveal single/ multiple nodular or ring-enhancing lesions with surrounding edema. Nevertheless, cases of cerebral toxoplasmosis with atypical radiological features have been reported. Diagnosis can be obtained by finding organisms in the cerebrospinal fluid or in stereotactic biopsy samples of the brain lesion. If untreated, cerebral toxoplasmosis is uniformly fatal, so prompt diagnosis is mandatory. A prompt diagnosis is necessary, as untreated cerebral toxoplasmosis is uniformly fatal., Case Description: We discuss imaging and clinical findings of a patient - not aware of being HIV-positive - with a solitary atypical brain localization of toxoplasmosis mimicking a brain tumor., Conclusion: Although relatively uncommon, neurosurgeons should be aware of the potential occurrence of cerebral toxoplasmosis. High index of suspicion is needed for timely diagnosis and prompt initiation of therapy., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Surgical Neurology International.)

Objective: To assess utility and feasibility of a low-cost system to simulate clipping strategy for cerebral aneurysms using patient-specific surgically oriented three-dimensional (3D) computed tomography angiography with virtual craniotomy., Methods: From 2017 to 2021, 53 consecutive patients scheduled for aneurysm clipping underwent preoperative planning using 3D computed tomography angiography with virtual craniotomy. The model was oriented in the surgical position to observe the anatomy through surgical corridors. Clipping was planned considering 3 parameters: shape of the clip, clip type (standard vs. fenestrated), and clipping strategy (simple vs. multiple). We used a scoring system (0-3) to assess the concordance of virtual planning with real surgery by assigning 1 point for each correctly predicted parameter. Qualitative assessment of 3D models was a secondary end point., Results: In 51 patients, 3D images perfectly matched the real anatomy shown in surgical videos. Concordance scores of 0, 1, 2, and 3 occurred with a frequency of 5%, 14%, 38%, and 43%, respectively. Concerning the shape of the clip, clip type, and clipping strategy, the concordance occurred in 73%, 80%, and 59%, respectively. Compared with simple clipping, strategies with multiple clippings were more difficult to predict correctly. Concordance scores of 0, 1, 2, and 3 occurred with a frequency of 5.7%, 5.7%, 31.4%, and 57.1%, respectively, in simple clipping and 4.8%, 28.6%, 47.6%, and 19%, respectively, in multiple clipping., Conclusions: In our experience, use of 3D computed tomography angiography with virtual craniotomy is an easy and useful solution to plan clipping strategy. The surgeon's awareness of the surgical anatomy is improved. Although this method has some technical limitations, it represents a low-cost alternative if complex and expensive simulation systems are not available., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Brain shift may cause significant error in neuronavigation, leading the surgeon to possible mistakes. Intraoperative magnetic resonance imaging (MRI) is the most reliable technique in brain tumor surgery. Unfortunately, it is highly expensive and time consuming and, at the moment, it is available only in few neurosurgical centers., Methods: In this case series the surgical workflow for brain tumor surgery is described where neuronavigation of preoperative MRI, intraoperative computed tomography (CT) scan, and ultrasound (US) as well as rigid and elastic image fusion between preoperative MRI and intraoperative US and CT, respectively, was applied to 4 brain tumor patients in order to compensate for surgically induced brain shift by using a commercially available software (Elements Image Fusion 4.0 with Virtual iMRI Cranial; Brainlab AG, München, Germany)., Results: Four illustrative cases demonstrated successful integration of different components of the described intraoperative surgical workflow. The data indicate that intraoperative navigation update is feasible by applying intraoperative 3-dimensional US and CT scanning as well as rigid and elastic image fusion applied depending on the degree of observed brain shift., Conclusions: Integration of multiple intraoperative imaging techniques combined with rigid and elastic image fusion of preoperative MRI may reduce the risk of incorrect neuronavigation during brain tumor resection. Further studies are needed to confirm the present findings in a larger population., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: DLGNT is a rare tumor, commonly diagnosed in pediatric age; in most cases, the pathology presents a slow and indolent evolution. We present a case report of a young adult affected by DLGNT characterized by aggressive and atypical behavior., Case Description: A 21-year-old male presented with mild paraparesis and hypoesthesia with a D2 level. MRI scan of the brain and spine showed a dorsal intramedullary lesion; a diffuse craniospinal leptomeningeal thickening was also present. After a week, the neurological status deteriorated rapidly with paraparesis worsening and onset of acute hydrocephalus. The patient underwent external ventricular drain positioning; a C7-D4 laminectomy was subsequently performed with partial tumor resection. Histological examination revealed a DLGNT with aggressive aspects (Ki67 30%). Postoperatively, the patient showed an immediate mild worsening of the lower limbs deficit. After a few days, severe further neurological deterioration occurred with progressive motor deficit to the upper limbs and ultimately respiratory failure. Mechanical ventilation was necessary and the patient was transferred to the ICU; during the following weeks, he developed tetraplegia and underwent ventriculoperitoneal shunt positioning. By the time, the histological diagnosis was available, the clinical status would not allow radiotherapy or chemotherapy. The patient deceased approximately 90 days after hospitalization due to respiratory complications., Conclusion: DLGNT is a rare tumor; diagnosis requires a high index of suspicion and confirmation with biopsy. Although most cases have an indolent course, some patients may have aggressive forms. High proliferation index, hydrocephalus occurrence, and massive craniospinal leptomeningeal spread appear to be associated with worse prognosis., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Surgical Neurology International.)

Background:  Resection of tumors adjacent to motor pathways carries risks of both postoperative motor deficit and incomplete resection. Our aim was to assess usefulness and limitations of a multimodal strategy that combines intraoperative ultrasound (iUS) guided resection with intraoperative neurophysiology., Methodology:  This is a prospective study of 25 patients with brain lesions adjacent to motor areas who underwent intracranial surgery with assistance of the iUS guidance system and intraoperative neurophysiological monitoring and mapping. Pathologies treated included 19 gliomas, 3 metastases, 1 anaplastic meningioma, 1 arteriovenous malformation (AVM), and 1 ependymoma. The iUS-guided lesion removal accuracy and the extent of resection were estimated and compared with a 30-day postoperative brain MRI. The results were assessed considering the extent of resection related to 6-month motor function outcome., Results:  iUS was accurate in checking the extent of resection in 17 patients, whereas in 8 cases the decline of the iUS images quality did not allow a valuable assessment. Positive mapping was obtained in 16 patients. Gross total resection was achieved in 16 patients. In five of nine cases with subtotal resection, surgery was stopped because a functional area was reached. In four patients, tumor removal was limited due to the difficulty of identifying neoplastic tissue. Motor function worsening was transient in six patients and permanent in two., Conclusions:  The integrated use of intraoperative neuromonitoring to identify motor areas and iUS to identify tumor-tissue interface could help increase the rate of radical resection respecting the eloquent areas., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: To assess the usefulness, feasibility, and limitations of pedicled multifidus muscle flaps (PMMFs) for the treatment of inaccessible dural tears during spine surgery., Methods: The technique of PMMF harvesting was investigated together with relevant anatomy. We prospectively evaluated 8 patients treated with the PMMF technique between January 2017 and December 2019. Results were compared with a retrospective series of 9 patients treated with a standard technique between January 2014 and December 2016. Inclusion criteria were inaccessible dural tear or dural tear judged not amenable to direct repair because of tissue loosening. Exclusion criteria were surgical treatment of intradural disease. Clinical and demographic data of all patients were collected. Clinical evaluations were performed according to American Spinal Injury Association criteria and Oswestry Disability Index. Preoperative and postoperative computed tomography was performed in all patients. The primary end point was wound healing (cerebrospinal fluid leakage, infection, and fluid collection); secondary end points were neurologic outcome and complications., Results: Control group: 1 death as a result of wound infection secondary to cerebrospinal fluid fistula and 2 patients needed lumbar subarachnoid drain; neurologic outcome: 3 patients improved and 6 were unchanged. Flap group: no wound-related complications were observed; neurologic outcome: 3 patients improved and 5 were unchanged. No flap-related complications were described. Flap harvesting was feasible in all cases, with an average 20 minutes adjunctive surgical time., Conclusions: The PMMF technique was feasible and safe; in this preliminary experience, its use is associated with lower complications as a result of dural tears but larger series are needed to confirm its effectiveness., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The aim of this study was to compare the results of two different titanium cranioplasties for reconstructing skull defects: standard precurved mesh versus custom-made prostheses., Methods: Retrospective analysis of 23 patients submitted to titanium cranioplasty between January 2014 and January 2019. Ten patients underwent delayed cranioplasty using custom-made prostheses; and 13 patients were treated using precurved titanium mesh (ten delayed cranioplasties, and three single-stage resection- reconstructions). Demographic, clinical, and radiological data were recorded. Results and complications of the two methods were compared, including duration of surgery, cosmetic results (visual analog scale for cosmesis [VASC]), and costs of the implants., Results: Complications: one epidural hematoma in the custom-made group, one delayed failure in precurved group due to wound dehiscence with mesh exposure. There were no infections in either group. All custom-made prostheses perfectly fitted on the defect; eight of 13 precurved mesh prostheses incompletely covered the defect. Custom-made cranioplasty obtained better cosmetic results (average VASC 94 vs. 68), shorter surgical time (141min vs. 186min), and -fewer screws was needed to fix the prostheses in place (6 vs. 15). However, satisfactory results were obtained using precurved mesh in cases of small defects and in single-stage reconstruction. Precurved mesh was found to be cheaper (€1,500 vs. €5,500)., Conclusion: Custom-made cranioplasty obtained better results and we would suggest that this should be a first choice, particularly for young patients with a large cranial defect. Precurved mesh was cheaper and useful for single-stage resection-reconstruction. Depending on the individual conditions, both prostheses have their place in cranioplasty therapies., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Surgical Neurology International.)

Introduction: There are no guidelines about the management of glioblastoma multiforme (GBM) during pregnancy: treatment of these patients presents therapeutic and ethical challenges., Case Description: Two patients, respectively, 28 years old at the 14 th week of gestation with a thalamic GBM and 38 years old at the 28 th week of gestation with fronto-mesial GBM. Patients and their relatives were deeply informed about the natural history of GBM and potential risks and benefits of surgery, radiotherapy (XRT), and chemotherapy (CTX) for both, mother and fetus. The first patient's will was to preserve her fetus from any related, even minimal, risk of XRT, and CTX until safe delivery despite progression of GBM, accepting only surgery (tumor debulking and shunting of hydrocephalus). The second one asked to deliver the baby as soon as possible (despite the risks of prematurity) to receive the standard treatments of GBM. The two patients survived, respectively, 16 and 46 months after delivery. The first patient's son is in good clinical conditions; the second one suffered problems linked to prematurity., Conclusions: Standard treatment of GBM in a pregnant woman could improve the mother's survival but can expose the fetus to several potential risks. Ethically, relatives should understand that mother has anyway a poor prognosis and, at the same time, fetus prognosis depends on mother's condition and therapy. It is not possible to warrant absence of risk for both. Considering the absence of guidelines and the relatively poor current data available about management of GBM in a pregnant woman, after a deep explanation of the situation, we think that the will of the mother and her relatives should prevail., Competing Interests: There are no conflicts of interest.

Objective: To assess usefulness and limitations of flexible fiber carbon dioxide (CO 2 ) laser in the microsurgical treatment of intraventricular tumors., Methods: We reviewed a series of 9 patients treated with microsurgical resection of intraventricular tumors using a flexible fiber CO 2 laser. The lesions involved the third ventricle (8) and the frontal horn of the right lateral ventricle (1). Histology revealed 6 craniopharyngiomas, 1 pituitary macroadenoma, 1 subependymoma, and 1 neurocytoma. In all cases, an interhemispheric transcallosal approach was performed. The laser was used during callosotomy, fornix column sectioning, tumor debulking, and to facilitate tumor dissection. We used a 5-tiered score system to assess laser's efficacy in each surgical step (approach, dissection, debulking): grade 1: laser was not at all helpful, grade 5: laser was extremely helpful. Limits of the instrument also are discussed., Results: Gross total resection was achieved in 6 cases and subtotal resection in the remaining 3. Three patients had pulmonary complications treated without clinical sequelae. No laser-related complication was described. Mean utility score observed was 4.2 (range 3-5) during approach, 2.8 (range 2-4) during tumor dissection; and 3.3 (range 2-5) during tumor debulking. Main limits were low hemostatic effect and inefficiency versus calcified and highly vascularized tumors., Conclusions: The CO 2 laser proved to be a useful and safe tool that could be used for intraventricular pathology; its design is suitable for narrow surgical corridors like interhemispheric fissure and foramen of Monro; its main utility is the ability to create precise and relatively bloodless cut (callosotomy, tumor debulking); low hemostatic effect is its main limit., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Traumatic intracranial aneurysms (TICA) are often associated with poor prognosis and should be diagnosed as soon as possible to prevent delayed intracranial hemorrhage and high rates of morbidity/mortality related to bleeding. Diagnosis requires a high index of suspicion. The goal of treatment is to exclude the aneurysm issue with surgical or endovascular methods., Case Description: We report the case of a 19-year-old boy who suffered a cranio-orbital trauma; 2 weeks after initial trauma he deteriorates with a new intracranial bleeding. Immediate angiography resulted negative. Delayed follow-up by magnetic resonance angiography showed an unruptured aneurysm of anterior cerebral artery that was successfully clipped., Conclusions: A TICA should be suspected in case of delayed deterioration in head-injured patient, prompt diagnosis and treatment could improve prognosis and reduce morbidity and mortality., Competing Interests: There are no conflicts of interest.

Background: The use of intraoperative ultrasound (iUS) has increased in the last 15 years becoming a standard tool in many neurosurgical centers. Our aim was to assess the utility of routine use of iUS during various types of intracranial surgery. We reviewed our series to assess ultrasound visibility of different pathologies and iUS applications during the course of surgery., Materials and Methods: This is a retrospective review of 162 patients who underwent intracranial surgery with assistance of the iUS guidance system (SonoWand). Pathologic categories were neoplastic (135), vascular (20), infectious (2), and CSF related (5). Ultrasound visibility was assessed using the Mair classification, a four-tiered grading system that considers the echogenicity of the lesion and its border visibility (from 0 to 3; grade 0, pathology not visible; grade 3, visible with clear border with normal tissue). iUS applications included lesion localization, approach planning to deep-seated lesions, and lesion removal., Results: All pathologies were visible on iUS except one aneurysm. On average, extra-axial tumors were identified more easily and had clearer limits compared to intra-axial tumors (extra-axial 17% grade 2, 83% grade 3; intra-axial 5.5% grade 1, 46.5% grade 2, 48% grade 3). iUS provided precise and safe transcortical trajectories to deep-seated lesions (71 patients; tumors, hemangiomas, ICHs); iUS was judged to be less useful to approach skull base tumors and aneurysms. iUS was used to judge extent of resection in 152 cases; surgical artifacts reduced sonographic visibility in 25 cases: extent of resection was correctly checked in 127 patients (53 gliomas, 15 metastases, 39 meningiomas, 4 schwannomas, 4 sellar region tumors, 6 hemangiomas, 3 AVMs, 2 abscesses)., Conclusions: iUS was highly sensitive in detecting all types of pathology, was safe and precise in planning trajectories to intraparenchymal lesions (including minimally mini-invasive approaches), and was accurate in checking extent of resection in more than 80% of cases. iUS is a versatile and feasible tool; it could improve safety and its use may be considered in routine intracranial surgery.

Background: The primary motor cortex, which is part of the corticobasal ganglia loops, may be an alternative option for the surgical treatment of Parkinson disease., Objective: To report on the 1-year safety and efficacy of unilateral extradural motor cortex stimulation in Parkinson disease., Methods: A quadripolar electrode strip was extradurally implanted over the motor cortex. Stimulation was continuously delivered through the electrode paddle contralateral to the most affected clinical side. Subjects were prospectively evaluated by the Unified Parkinson's Disease Rating Scale (UPDRS) and the Parkinson's Disease Quality of Life Questionnaire. In addition, an extensive cognitive and behavioral assessment and electroencephalogram recording were performed., Results: Nine patients were included in this study. No surgical complications or adverse events occurred. Moreover, no cognitive or behavioral changes were observed. Under the off-medication condition, the UPDRS III at baseline was decreased by 14.1%, 23.3%, 19.9%, and 13.2%, at 1, 3, 6, and 12 months, respectively. The motor effects were bilateral, appeared after 3 to 4 weeks of stimulation, and outlasted the stimulation itself for 3 to 4 weeks in 1 case of stimulator accidental switching off. The UPDRS IV was decreased by 40.8%, 42.1%, and 35.5% at 1, 3, and 12 months, respectively. The scores on the Parkinson's Disease Quality of Life Questionnaire were increased at months 3, 6, and 12., Conclusion: Extradural motor cortex stimulation is a safe procedure. After 12 months, the patients demonstrated a moderate improvement of motor symptoms (particularly axial symptoms) and quality of life.

Purpose: The aim of the study was to compare the outcome with respect to age of implant, aetiology and duration of epilepsy., Methods: One hundred thirty-five drug-resistant epileptic patients, excluded from ablative surgery, were submitted to vagal nerve stimulation (1995-2007). Aetiology was cryptogenic in 57 and symptomatic in 78 patients. Ages of implant were 0.5-6 years (18 patients), 7-12 years (32 patients), 13-18 years (31 patients) and more than 18 years (54 patients). Epilepsy types were Lennox-Gastaut (18 patients), severe multifocal epilepsy (33 patients) and partial (84 patients). Duration of epilepsy is 3 months to 57 years. Clinical outcome was determined by comparing the seizure frequency after stimulation at 3-6-12-18-24-36 months with the previous 3 months. 'Responders' were the patients experiencing a seizure frequency reduction of 50% or more during follow-up. In statistical analysis, Wilcoxon and McNemar tests, general linear model for repeated measures, logistic regression and survival analysis were used., Results: The seizure frequency reduction was significant in the group as a whole between baseline and the first follow-up (Wilcoxon test). The percentage of responder increases with time (McNemar test p = 0.04). Univariate analysis showed a significant effect of the age of implant on seizure frequency reduction: Adult patient had worst clinical outcome than children (p < 0.001) and adolescents (p = 0.08). Patients with severe multifocal epilepsy had better percentage seizure reduction compared with Lennox-Gastaut and partial (p = 0.03). Lesser duration of epilepsy had positive influence on outcome. Multivariate analysis confirmed age of implant to be the strongest factor influencing prognosis. Furthermore, positive is the association between lesional aetiology and young age., Conclusions: The best responder could be a young lesional epileptic patient; after 3 years of follow-up, the percentage of responders is still in progress.

Introduction: Staphylococcus lugdunensis is an unusually virulent coagulase-negative staphylococcus that has rarely been implicated in central nervous system infections., Case Presentation: Two children hospitalized in the Neurosurgery Unit developed ventriculitis caused by methicillin-resistant Staphylococcus lugdunensis following placement of external ventriculostomy drains. The causative organisms were identified by molecular studies. The patients recovered without significant sequelae after high doses of intrathecal vancomycin., Conclusion: Distinguishing Staphylococcus lugdunensis from other coagulase-negative staphylococcus species is crucial because it carries a substantial risk for severe central nervous system infections displayed by patients with implanted cerebrospinal fluid devices. Clinicians should not underestimate the importance of the isolation of this species from cerebrospinal fluid specimens.

Purpose: To correlate ictal hyperperfusion single-photon emission computed tomography (SPECT) area during provoked seizures to the epileptogenic zone (EZ), as defined by depth recordings in adult drug-resistant patients., Methods: We included in the study eight drug-resistant epilepsy patients, subjected to both noninvasive and invasive (stereo-electroencephalography, SEEG) presurgical evaluation in the Epilepsy Surgery Center of the Catholic University in Rome, from 2001 to 2003. All patients were subjected to interictal and provoked ictal SPECT scans during scalp video-EEG monitoring. The ictal hyperperfusion area assessed by visual image analysis and, when possible, by statistical parametric mapping (SPM), was compared with the EZ, as assessed by SEEG, to define whether they colocalized., Results: For each provoked seizure, we obtained a SPECT hyperperfusion area. In five patients, the SPECT hyperperfusion area was included in the EZ as assessed by SEEG. The effectiveness of provoked SPECT was confirmed by comparison with SEEG data, SPM analysis (four patients), and spontaneous ictal SPECT (two patients). Our data were obtained in adult drug-resistant epilepsy patients whose EZ was either located in or extended to extratemporal regions in all but two patients., Conclusions: Provoked ictal SPECT confirmed its efficacy and accuracy in the presurgical evaluation because of the colocalization to the EZ. Although the low number of patients precluded any statistical correlation with the surgical outcome, it is worth pointing out that the five patients in whom the hyperperfusion area was included in the EZ showed very satisfactory results.

Objective: Recent data suggest that vagus nerve stimulation (VNS) can inhibit cytokine release by inflammatory cells. Accordingly, an association between impaired cardiac parasympathetic function, as assessed by heart rate variability (HRV), and increased markers of inflammation has recently been reported. In this study we assessed the effect of direct left VNS on inflammatory markers and HRV in patients with refractory epilepsy., Methods: A 24-hour electrocardiogram Holter recording was performed both at baseline and after 3 months of left VNS in 8 patients (age 32 +/- 24 years, 2 men) who underwent implantation of a VNS device because of refractory epilepsy. Tumor necrosis factor-alpha, interleukin-6 and C-reactive protein serum levels were measured, as markers of inflammation, at the same times., Results: No significant changes were found after 3 months of left VNS, compared to baseline, both for HRV variables and inflammatory markers. Also, no consistent correlation could be demonstrated between HRV parameters and inflammatory markers in these patients., Conclusions: Our data in epileptic patients without cardiovascular disease failed to show a significant effect of left VNS on cardiac autonomic function and on systemic inflammation at short-term follow-up., ((c) 2008 S. Karger AG, Basel.)

This study evaluated the efficacy and tolerability of idebenone, a new neuroactive drug, in 33 patients aged from 50 to 80 years. They were affected by chronic cerebrovascular disease (CCVD) and their last cerebrovascular accident had taken place at least 3 months prior to enrollment. All these subjects presented a score within the range of the following psychometric scales: Hamilton Scale for Depression <24; Hachinski Dementia Score >/=18 and < 25; Mini Mental State >/=16 and

Clinical trials have been conducted to evaluate the effectiveness of Matrix in osteoarthritis, mainly as regards the advantages offered by its physiological mechanism of action. The experiment, lasting 6 months, was performed on two hundred patients in four different Hospital Departments and one University Center. The results showed a considerable improvement both in pain and in mobility. No relevant side effects were found; only 3% of patients, with oral administration, noticed slight nausea and found it necessary to interrupt treatment.