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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. 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). 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). 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. [ABSTRACT FROM AUTHOR]

Background: The Stealth Autoguide (Medtronic, Minneapolis, MN) is a robotic auto-targeting device for stereotactic brain biopsy, placement of stereoelectroencephalography electrodes, and laser ablation therapy. This paper evaluates its off-label application as robotic endoscope holder in transnasal and intraventricular neurosurgery. The potential to enhance stability, reduce manual adjustments, and improve surgical precision is discussed, alongside cost-effectiveness and feasibility., Methods: Patients who underwent endoscopic endonasal, transventricular, and microsurgical endoscopic-assisted surgeries using the Stealth Autoguide as robotic holder from August 2023 to March 2024 were included. Surgical data and surgeons' remarks on advantages, disadvantages and limitations of the technique were collected., Results: In this preliminary experience, Stealth Autoguide has proven safe and effective for several approaches. It was successfully used for patients with sellar, parasellar, and suprasellar lesions. Moreover, the holder was used in a third ventriculocisternostomy, a septostomy, and a removal of intraventricular lesion. Finally, the Autoguide has been a useful holder for the endoscope after gross total microsurgical excision of a tumor: The robot aligned the endoscope to the chosen trajectory and allowed the surgeon to "look around the corner" and confirm the extent of resection. No complications occurred in the treated cases, and the system provided great stability and usefulness throughout the surgeries., Conclusions: This experience proves that the Stealth Autoguide can be safely and effectively used as a robotic support for endoscopic procedures. This device ensures precise positioning and manipulation of neuroendoscopes, facilitating visualization and targeting of the desired area. Further researches are needed to verify applications and limitations., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: During the COVID-19 pandemic, a multitude of surveys have analyzed the impact virus spreading on the everyday medical practice, including neurosurgery. However, none have examined the perceptions of neurosurgeons towards the pandemic, their life changes, and the strategies they implemented to be able to deal with their patients in such a difficult time., Methods: From April 2021 to May 2021 a modified Delphi method was used to construct, pilot, and refine the questionnaire focused on the evolution of global neurosurgical practice during the pandemic. This survey was distributed among 1000 neurosurgeons; the responses were then collected and critically analyzed., Results: Outpatient department practices changed with a rapid rise in teleservices. 63.9% of respondents reported that they have changed their OT practices to emergency cases with occasional elective cases. 40.0% of respondents and 47.9% of their family members reported to have suffered from COVID-19. 56.2% of the respondents reported having felt depressed in the last 1 year. 40.9% of respondents reported having faced financial difficulties. 80.6% of the respondents found online webinars to be a good source of learning. 47.8% of respondents tried to improve their neurosurgical knowledge while 31.6% spent the extra time in research activities., Conclusions: Progressive increase in operative waiting lists, preferential use of telemedicine, reduction in tendency to complete stoppage of physical clinic services and drop in the use of PPE kits were evident. Respondents' age had an impact on how the clinical services and operative practices have evolved. Financial concerns overshadow mental health.

Objective: Tumors located within the Meckel's cave (MC) pose a significant surgical challenge. Although several corridors to access this complex region have been described, the endoscopic transpterygoid approach (ETPA) and the endoscopic transorbital superior eyelid approach (ETOA) have emerged in recent years, as viable alternatives to traditional microsurgical transcranial approaches (MTA). To date, there is a limited literature on surgical series considering endoscopic-assisted approaches to the MC., Methods: We conducted a retrospective analysis of patients with primary MC tumors treated at our Institution between 2015 and 2022, specifically those managed via the ETPA assisted by intraoperative Endoscopic Diving Technique (EDT). Lesion resection extent was evaluated using pre- and post-intervention radiological images and surgical videos. Moreover, a literature review on ETPA was performed., Results: This series comprises 7 patients affected by 4 trigeminal schwannomas, 1 benign notochordal cell tumor, 1 dermoid cyst and 1 mesenchymal tumor. In 71 % of cases, trigeminal neuralgia was the presenting symptom. Post-operative clinical improvement was observed in all but one case. Notably, 85.7 % of patients achieved total or near-total resection (NTR), with the remaining case undergoing subtotal resection (STR). No significant intraoperative complications occurred, and no recurrences were observed during the mean follow-up period of 41 months., Conclusions: In selected cases, the ETPA offers a direct and safe path to lesions located into the MC. This approach circumvents complications and constraints associated with ETOA or MTA. Moreover, the use of the EDT reduces manipulation of critical neurovascular structures, enhancing the efficacy of the ETPA., Competing Interests: Declaration of Competing Interest The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Ziconotide is an intrathecal drug administered for the treatment of chronic pain. The current literature lacks an exhaustive benefit/risk assessment on this drug. We herein focus on Ziconotide's pharmacology and clinical applications., Methods: Literature research was conducted to identify studies on Ziconotide administration for the treatment of chronic pain, published between January 1990 and March 2023 and located via PubMed, Embase, Medline, Cinahl, and Web of Science, using the following keywords: Ziconotide, Omega conotoxin, Prialt, SNX-111, intrathecal therapy, and neuropathic pain. Only publications written in English were selected., Results: Among the 86 selected studies, we found 4 Randomized Controlled Trials (RCTs) and 3 prospective long-term studies concerning the intrathecal use of Ziconotide as a monotherapy in chronic pain. Other studies described the intrathecal infusion of Ziconotide combined with other drugs. Overall, Ziconotide has been proved to have strong efficacy for relieving chronic pain, although patients with co-morbid psychiatric disorders require a careful monitoring when treated with Ziconotide., Conclusions: Overall, the use of Ziconotide, as a monotherapy or in conjunction with other therapies for the treatment of chronic pain, was reported to be efficacious. Overall, its use in patients with chronic pain refractory to other pharmacologic agents outweighs the possible adverse consequences, thus resulting in a favorable benefit/risk assessment.

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.

The treatment of pathologies located within and surrounding the orbit poses considerable surgical challenges, due to the intricate presence of critical neurovascular structures in such deep, confined spaces. Historically, transcranial and craniofacial approaches have been widely employed to deal with orbital pathologies. However, recent decades have witnessed the emergence of minimally invasive techniques aimed at reducing morbidity. Among these techniques are the endoscopic endonasal approach and the subsequently developed endoscopic transorbital approach (ETOA), encompassing both endonasal and transpalpebral approaches. These innovative methods not only facilitate the management of intraorbital lesions but also offer access to deep-seated lesions within the anterior, middle, and posterior cranial fossa via specific transorbital and endonasal corridors. Contemporary research indicates that ETOAs have demonstrated exceptional outcomes in terms of morbidity rates, cosmetic results, and complication rates. This study aims to provide a comprehensive description of endoscopic-assisted techniques that enable a 360° access to the orbit and its surrounding regions. The investigation will delve into indications, advantages, and limitations associated with different approaches, while also drawing comparisons between endoscopic approaches and traditional microsurgical transcranial approaches., (© 2024. The Author(s), under exclusive license to Springer Nature Switzerland AG.)

Objective: Surgical indications for cerebral cavernous malformations (CCMs) remain significantly center- and surgeon-dependent; available grading systems are potentially limited, as they do not include epileptologic and radiologic data. Several experienced authors proposed a new grading system for CCM and the first group of patients capable of providing its statistical validation was analyzed., Methods: A retrospective series of 289 CCMs diagnosed between 2008 and 2021 was collected in a shared anonymous database among 9 centers. The new grading system ranges from -1 to 10. For each patient with cortical and cerebellar cavernous malformations the grading system was applied, and a retrospective outcome analysis was performed. We proposed a score of 4 as a cutoff for surgical indication., Results: Operated patients with a score ≥4 were grouped with non-operated patients with a score <4, as they constituted the group that received correct treatment according to the new grading system. Patients with a score ≥4, who underwent surgery and had an improved outcome, were compared to patients with a score ≥4 who were not operated (P = 0.04), and to patients with a score <4 who underwent surgery (P < 0.001)., Conclusions: This preliminary statistical analysis demonstrated that this new grading would be applicable in surgical reality. The cutoff score of 4 correctly separated the patients who could benefit from surgical intervention from those who would not. The outcome analysis showed that the treated patients in whom the grading system has been correctly applied have a better outcome than those in whom the grading system has not been applied., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Aim: To report on the endoscopic endonasal pituitary hemi-rotation approach (EPHRA) in a preclinical setting and in a preliminary clinical experience., Material and Methods: EPHRA was performed in five fresh-frozen head and neck specimens (a total of 10 sides) and in a selected case of a right-sided dorsum sellae chordoma., Results: The approach described allowed exposure of the lateral part of the upper clivus in all the specimens and in the case reported. To evaluate the maximum possible degree of hypophyseal hemi-rotation, the hemi-rotation angle (HRA) of the approach was measured and reported for all sides of the specimens. In 9 out of 10 cadaver head sides, and in the clinical case, it was possible to avoid sectioning of the inferior hypophyseal artery. No complications occurred during or after the procedure., Conclusion: EPHRA represents an addition to the techniques already described and finds indications in case of non-massive neoformations of the lateral upper clivus. Clinical applications and limitations still need to be clarified in further clinical studies.

Objective  We illustrate a cavernous sinus chondrosarcoma treated with an endoscopic endonasal transethmoidal-transsphenoidal approach. Design  Case report of a 15-year-old girl with diplopia and esotropia due to complete abducens palsy. Preoperative images showed a right cavernous sinus lesion with multiple enhanced septa and intralesional calcified spots ( Fig. 1 ). Considering tumor location and the lateral dislocation of the carotid artery, an endoscopic endonasal approach was performed to relieve symptoms and to optimize the target geometry for adjuvant conformal radiotherapy. Setting  The study was conducted at University of Insubria, Department of Neurosurgery, Varese, Italy. Participants  Skull base team was participated in the study. Main Outcome Measures  A transethmoidal-transsphenoidal approach was performed by using a four-hand technique. We used a route lateral to medial turbinate to access ethmoid and the sphenoid sinus. During the sphenoid phase, we exposed the medial wall of the cavernous sinus ( Fig. 2 ) and the lesion was then removed using curette. Skull base reconstruction was performed with fibrin glue and nasoseptal flap. Results  No complications occurred after surgery, and the patient experienced a complete recovery of symptoms. A postoperative magnetic resonance imaging showed a small residual tumor inside the cavernous sinus ( Fig. 1 ). After percutaneous proton-bean therapy, patient experienced only temporary low-grade toxicity with local control within 2 years after treatment completion. Conclusion  Endoscopic endonasal extended approach is a safe and well-tolerated procedure that is indicated in selected cases (intracavernous tumors, soft tumors not infiltrating the vessels and/or the nerves). A tailored approach according to tumor extension is crucial for the best access to the compartments involved. The link to the video can be found at: https://youtu.be/TsqXjqpuOws ., Competing Interests: Conflict of Interest None declared., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Objectives  We illustrate endoscopic endonasal odontoidectomy for the Chiari-I malformation respecting craniovertebral junction (CVJ) stability. Design  Case report of a 12-year-old girl affected by the Chiari-I malformation. Magnetic resonance imaging (MRI) showed tonsillar herniation, basilar invagination, and dental retroversion, causing angulation and compression of the bulbomedullary junction. Patient underwent endoscopic third ventriculostomy (ETV) with reduction of ventricular size and resolution of gait disturbances, but she complained the Valsalva-induced headaches, hiccup, and dysesthesias in the lower limbs. Endoscopic endonasal odontoidectomy was chosen to decompress the cervicomedullary junction. Setting  The research was conducted at University Hospital "Ospedale di Circolo," Department of Neurosurgery at Varese in Italy. Participants  Patients were from neurosurgical and ENT (ear, nose, and throat) skull base team. Main Outcome Measures  A bilateral paraseptal approach was performed, using a four-hand technique. After resection of posterior edge of the nasal septum, the choana is entered and a rhinopharynx muscle-mucosal flap is dissected subperiosteal and transposed in oral cavity. The CVJ is exposed and, using neuronavigation and neuromonitoring, odontoidectomy is fulfilled until dura is reached, preserving the anterior arch of C1. Reconstruction is obtained suturing the flap previously harvested. Results  Postoperative course was unremarkable and the patient experienced improvement of symptoms. Postoperative MRI documented the appearance of tight cerebrospinal fluid (CSF) film anterior to bulbomedullary junction and in retrotonsillar spaces, opening of the bulbomedullary angle, and slight tonsils reduction. No CVJ instability was occurred with any need of posterior fixation. Conclusion  Endoscopic endonasal odontoidectomy is a feasible approach for CVJ malformation. In this case, bulbar decompression was achieved preserving CVJ stability and avoiding posterior fixation. The link to the video can be found at: https://youtu.be/VIobocHfCuc ., Competing Interests: Conflict of Interest None declared., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

We present the case of a 42-year-old woman with a 5-week history of headache, progressive dysphagia, dysphonia, and hoarseness. A brain magnetic resonance imaging revealed an extra-axial cyst of the left lateral cerebellomedullary cistern. The subsequent histopathologic examination diagnosed a neuroenteric cyst. This case sheds light on the pivotal role of histologic identification of neuroenteric cyst, which could be crucial for further diagnostic investigations, especially in pediatric patients., (Copyright © 2020. Published by Elsevier Inc.)

In this tumultuous time, the entire world has been shaken up by the COVID-19 outbreak. Italy has had one of the highest infection-related mortality rates. Bergamo, a city in eastern Lombardy, was among the most affected. Here, the authors describe the main healthcare actions taken at their institution to stem the crisis, with particular concern regarding the fate of their neurosurgery department. Among the different topics, the authors particularly focus on the retraining of neurosurgeons, organization of activities, and what should be the role of neurosurgeons during a pandemic.

Objective: To describe a novel bilaterally pedicled pericranial flap for anterior cranial base reconstruction after removal of complex frontobasal cancers extending to the frontal region, thus precluding the use of standard reconstructive techniques., Methods: In selected oncologic cranial base surgeries, the use of the standard galea frontalis pericranial flap for reconstructive purposes may be precluded by tumor infiltration. In such cases, dura mater reconstruction and exclusion of frontal sinuses from the intracranial space can be performed using a large superficial temporal artery bilaterally pedicled pericranial flap obtained from both temporoparietal regions. Surgical technique, indication, contraindication, complications, and degree of resection are recorded to evaluate the efficacy of this surgical method., Results: A 48-year-old man affected by a recurrence of frontobasal squamous cell carcinoma was surgically treated by combined transcranial and endoscopic endonasal resection. A large pericranial flap pedicled bilaterally on the parietal branches of the superficial temporal artery was obtained, transposed anteriorly, carefully watertight sutured to the dural defect, and used to exclude cranialized frontal sinuses as well. The reconstruction was successful, and the patient was discharged home on the tenth postoperative day without any complications and/or development of cerebrospinal fluid leak. Contrast-enhanced magnetic resonance imaging 3 months after surgery was clear from disease with consolidated surgical outcomes., Conclusions: This novel pericranial flap seems to be easily obtained and effective for anterior cranial base reconstruction when the use of a traditional galea frontalis flap is precluded for oncologic reasons and there are concerns for the possible development of contaminations and cerebrospinal fluid leaks., (Copyright © 2019 Elsevier Inc. All rights reserved.)