Abstract Objective Tentorial meningiomas represent an heterogeneous group of tumors. Most of the published series deal with either a small number of patients or consider different locations as a ...whole, making indications for treatment and prognosis difficult to be drawn.We analysed the surgical management of the lateral tentorial meningiomas, a homogenous and rare sub-group. Methods 52 later tentorial meningiomas were operated between 1990 and 2010. Clinical, radiological features and surgical management of these patients were reviewed. Tumors were further subcategorized in posterior/intermediate and in supra/infratentorial subgroups. Surgical outcome, long-term results and prognostic factors are described. Results Mean age was 57 years(41 female,11 male). Mean tumor size was 46 mm; most had an infratentorial location(36vs16). Prevailing presenting symptoms were headache(n=28), vertigo/gait disturbances(n=25), confusion and visual disturbances(n=16). The infratentorial group presented with poorer clinical condition before as well as after operation. Extent of tumor resection was Simpson I in 10 patients, II in 26, III in 6 and IV in 10. Subtotal resection was statistically correlated with sinus invasion and tumor size. There was no surgical mortality. Permanent complications occurred in 3 patients. At latest follow-up(mean: 119 months)42/46 resumed their normal daily activity. Six cases recurred and remained stable after radiosurgery. Conclusion Lateral tentorial meningomas are an homogeneous entity characterized by simple surgical approaches and favourable outcome(no mortality and low overall morbidity).Infratentorial location was more frequent and characterized by poorer outcome.The limiting factors for surgical removal were tumor size and sinus invasion. The latter point strengths the rationale for their classification into posterior and intermediate.
Multilingualism has become a worldwide phenomenon that poses critical issues about the language assessment in patients undergoing awake neurosurgery in eloquent brain areas. The accuracy and ...sensitivity of multilingual perioperative language assessment procedures is crucial for a number of reasons: they should be appropriate to detect deficits in each of the languages spoken by the patient; they should be suitable to identify language-specific cortical regions; they should ensure that each of the languages of a multilingual patient is tested at an adequate and comparable level of difficulty. In clinical practice, a patient-tailored approach is generally preferred. This is a necessary compromise since it is impossible to predict all the possible language combinations spoken by individuals and thus the availability of standardized testing batteries is a potentially unattainable goal. On the other hand, this leads to high inconsistency in how different neurosurgical teams manage the linguistic features that determine similarity or distance between the languages spoken by the patient and that may constrain the neuroanatomical substrate of each language. The manuscript reviews the perioperative language assessment methodologies adopted in awake surgery studies on multilingual patients with brain tumor published from 1991 to 2021 and addresses the following issues: (1) The language selected for the general neuropsychological assessment of the patient. (2) The procedures adopted to assess the dimensions that may constrain language organization in multilingual speakers: age and type of acquisition, exposure, proficiency, and use of the different languages. (3) The type of preoperative language assessment used for all the languages spoken by the patient. (4) The linguistic tasks selected in the intraoperative setting. The reviewed data show a great heterogeneity in the perioperative clinical workup with multilingual patients. The only exception is the task used during language mapping, as the picture naming task is highly preferred. The review highlights that an objective and accurate description of both the linguistic profile of multilingual patients and the specific properties of the languages under scrutiny can profitably support clinical management and decision making in multilingual awake neurosurgery settings.
Merkel cell carcinoma (MCC) is a rare aggressive primary skin carcinoma with an incidence of 44 cases per 100,000. The natural course of MCC often results in rapid growth and early metastasis. On the ...other hand, the spinal cord is rarely affected and frequently features the end stage of the disease. The aim of this paper was to clarify the management of patients with spine metastasis from a skin lesion and showed a case-based update.
A 73-year-old female was admitted to the Neurosurgical Department in December 2021 for a sudden right hemiparesis with bladder dysfunction and a history of cutaneous Merkel cell carcinoma. A magnetic resonance imaging (MRI) of the central nervous system (CNS) showed an intradural-extramedullary right-sided C6-C7 tumor with mass effect and edema of the cervical cord. The patient underwent a C6-C7 laminectomy with microsurgical total resection of the intradural extramedullary lesion. The neuropathological examination identified a metastasis from Merkel cell carcinoma. Nowadays, evidence for spinal metastasis from malignities skin cancer is generally lacking, probably because they are extremely rare. The exact time of life expectancy is controversial, and some clinicians use a cutoff of 3 months to determine whether surgical intervention should be offered, while others advocate at least 6 months of life expectancy.
To the best of our knowledge, we showed the first case of solitary intradural extramedullary cervical spine metastasis from MCC. We recommend to consider metastasis of MCC in the differential diagnosis of spinal metastasis.
Foramen magnum meningioma poses a challenge for neurosurgeons. Prognosis has generally improved with diagnostic and surgical advances over the past two decades; however, it may ultimately depend more ...on the surgeon's ability to tailor the approach and interpret intraoperative risks in single cases. The series comprised 64 patients operated on for ventral and ventrolateral foramen magnum meningioma. All patients underwent preoperative magnetic resonance imaging and received surgery via the dorsolateral route, rendering the series homogeneous in neuroradiological workup and surgical treatment. Particular to this series was that the majority of patients were of advanced age (
n
= 29; age, >65 years), had serious functional impairment (
n
= 30, Karnofski score <70), and large tumors (mean diameter, 3.5 cm). Total tumor removal was achieved in 52 (81 %) patients; operative mortality was nil. Early outcome varied depending on difficulties encountered at surgery (cranial nerve position and type of involvement in particular) and type of preoperative dysfunction. Long-tract signs and cerebellar deficits improved in 74 and 77 % of cases, respectively, but only 27 % of cranial nerve deficits did so. Surgical complications most often involved the cranial nerves: cranial nerve impairment, especially of the 9th through the 12th cranial nerves, due to stretching or encasement was noted in 44 cases. At final outcome assessment, two thirds of the cranial nerve deficits cleared, and all but two patients returned to a normal productive life. One patient was reoperated on during the follow-up period. Foramen magnum meningiomas behave like clival or spinal tumors depending on their prevalent extension. A dorsolateral approach tailored to tumor position and extension and meticulous surgical technique allow for definitive control of surgical complications. Scrupulous postoperative care may prevent dysphagia, a major persistent complication of surgery. Long-term observation of indolent tumor behavior at follow-up suggests that incomplete resection may be a viable surgical treatment option.
In the last few years much has been published to validate new technology in brain mapping for clinical purposes, but there have been few clinical results. In this report we describe our five-year ...experience in the surgical management of malignant gliomas around motor areas with an evaluation of the impact of functional magnetic resonance imaging (fMRI) plus navigator and intraoperative neurophysiology (IN). End-points were extent of removal, morbidity, and survival. Variables describing patient and tumor characteristics and treatment modalities were statistically weighted in relation to treatment outcome. Tumor depth (
P
= 0.01), midline shift ≥1 cm. (
P
= 0.05), and insular location (
P
= 0.001) negatively affected extent of removal, whereas IN (
P
< 0.001) and fMRI plus navigator (
P
= 0.02) contributed to increasing the rate of total removal (73%, 71% vs. 40%). Postoperative motor impairment was mild and transient in a minority of cases (20%). General complications, as defined by the Glioma Outcome Project, occurred in 23% of cases. IN was the only factor associated with acute postoperative motor deterioration (
P
< 0.001). IN and age >65 years (
P
= 0.01) were associated with the occurrence of complications. Overall survival was significantly higher in patients operated with IN or fMRI plus navigator (
P
< 0.01). Comparing different surgical strategies used in the same period, we observed that supportive technologies in glioma surgery have their primary impact on the quality of resection and survival. IN led to transient motor impairment and some additional complications which did not affect functional outcome.
The most appropriate management of recurrent glioblastoma is still controversial. In particular, the role of surgery at recurrence remains uncertain.
From our Institutional data warehouse we analyzed ...270 consecutive patients who received second surgery for recurrent glioblastoma, to assess survival after second surgery, and to evaluate prognostic factors.
Complete resection was found in 128 (47.4%) and partial resection in 142 patients (52.6%). Median survival from second surgery was 11.4 months (95% CI: 10.0-12.7). Multivariate analysis showed that age (p = 0.001), MGMT methylation (p = 0.021) and extent of surgery (p < 0.001) are associated with better survival.
A complete resection should be the goal for second resection and younger age and MGMT methylation status might be considered in the selection of patients.
The aim of this study was to explore the feasibility of intraoperative visuospatial mapping with the same criteria currently used to define essential language areas.
The authors compared surgical ...procedures in 2 patients with similar tumors (Grade II oligodendroglioma in the right parietal lobe) undergoing awake, image-assisted surgery for lesion removal with intraoperative neurophysiological monitoring. The line bisection task was used in both patients but with different criteria.
In the first case, the authors respected any area, even within the tumor, where significant interference was found (a stimulation-induced error in 2 of 3 applications defined an essential area). In the second case, they removed 1 essential area located in the tumor and recorded an uneventful clinical response soon thereafter. They continued to monitor the patient without stimulation and stopped the resection when the patient was close to the criteria valid for defining spatial neglect. The signs of spatial neglect were present for 3 days postoperatively and then cleared spontaneously. Subtotal tumor removal was achieved in both cases.
Evidence in the present study reveals that areas for visuospatial functions cannot be assessed with the same criteria used for language functions, since essential areas located in the tumor can be safely removed.
Quality of life in brain tumour patients is an emerging issue and has prompted neurosurgeons to reconsider the need for cognitive assessment in the course of treatment. In particular, to date there ...has been a lack of comprehensive neuropsychological assessment performed preoperatively and in the acute postoperative period. We examined 29 patients with glioma, analysing several functional domains—intelligence, executive functions, memory, language, praxis, gnosis and mood state—in order to establish the effect of tumour and surgery on cognition. At baseline, using test- and domain-based criteria, 79% and 38% of patients, respectively, were impaired, the former related to tumour factors such as oedema (
P
< 0.05), larger size (
P
< 0.05) and higher grade (
P
= 0.001). Verbal memory, visuospatial memory and word fluency were the most frequently affected functions, partly associated with depression. Postoperatively, again using test- and domain-based criteria, 38% and 55% of patients, respectively, were unchanged, 24% and 21% improved, and 38% and 24% worsened; 24% and 62% of patients were intact, respectively. The extent of removal did not influence the outcome. Improvement involved previously impaired functions and was correlated with high-grade tumours. Worsening regarded executive functions was related to tumour size and was partly explained by radiological findings on postoperative magnetic resonance imaging (MRI). This preliminary study, focussing on the effects of tumour and surgery, showed that tumour significantly affects cognitive functions, mainly due to the mass effect and higher grading. Surgical treatment improved the functions most frequently affected preoperatively and caused worsening of executive functions soon after operation, leaving the overall cognitive burden unchanged and capable of improvement prospectively.
Falcotentorial meningiomas (FTM) stand out for their rarity, inconsistent definition, and surgical complexity. It is appropriate to deal with them in the context of medial tentorial meningiomas ...(TMs).
Clinical and radiologic characteristics of medial TMs, comprising the typical features of FTM and TM, along with surgical management and short-term and long-term outcomes, are reported.
FTM (n = 16) were typically supratentorial, large, edematous tumors that caused mainly headache and hemianopia; TM (n = 12) were infratentorial, smaller not edematous tumors that caused mainly headache and gait ataxia. The most frequent venous pattern was straight sinus infiltration in one third of cases of FTM and occlusion in one half of cases of TM. Total removal (Simpson grade I–II) was obtained in 46.4% of cases and subtotal removal (Simpson grade III–IV) in 53.6%. Suprainfratentorial extension in FTM and incomplete venous invasion in TM were the factors most likely opposing complete removal. The overall acute complications rate was 32.1% (higher for FTM), transient for most cases. Patients with supratentorial meningiomas performed significantly worse preoperatively (Karnofsky Performance Status ≤70 in 75% of cases); patients with infratentorial symptoms/signs recovered worse postoperatively. Stereotactic radiosurgery with subtotal removal was used as adjuvant treatment in 8 cases. Only 2 recurrences, both atypical tumors, occurred at 57.6 months (mean) follow-up.
As a general rule, careful venous management, tailored surgical approach for FTM, and cautious tumor removal for TM can yield good and stable results. Total removal accounts for half the cases in both groups, whereas FTM was associated with worse postoperative complications.
•We present a series with large tumors and a high clinical burden.•Falcotentorial must be differentiated from posteromedial incisural and torcular.•Sinus reconstruction is not advised for straight and torcular sinuses.•Collateral venous flow may be not evident inside the tentorium and the falx.•Tailored approach and multiple trajectories are surgical priorities.
Purpose
Syringomyelia is a misleading disease since the problem always lies elsewhere. Arachnoiditis, because it is radiographically difficult to discern, is an especially insidious cause. To better ...guide selection from among surgical treatment options for syringomyelia, we reviewed our case series of patients without Chiari malformation or spinal injury.
Methods
Excluding syringomyelia due to Chiari malformation, spinal cord injury, and tumors, 32 patients (mean age 44 years) were operated on between 1995 and 2013 and followed up for a mean of 53.8 months. Presumed causes at diagnosis, clinical and radiological findings, type of operation, clinical and radiological outcome were reviewed.
Results
Duration of clinical history varied widely (range 6–164 months). Clinical assessment was based on the McCormick classification (15 independent, 17 dependent). Causes included birth trauma, pyogenic meningitis, tuberculous meningitis, postoperative scarring, dysraphism, and basilar impression. Treatment was local decompression with arachnoid lysis and shunts. Hindbrain-related syringomyelia was differentiated from non hindbrain-related syringomyelia. Hindbrain arachnoiditis was significantly associated with radiological findings at the foramen magnum (
p
= 0.01) and craniocervical decompression (
p
< 0.03), with good clinical and radiological outcome at 6 months and later follow-up controls (
p
= 0.02), whereas uneven results were observed in cases of non-hindbrain arachnoiditis.
Conclusions
To remove the cause of syringomyelia, surgical planning will rely on thorough clinical history and accurate imaging to determine the site of cerebrospinal fluid obstruction. Craniocervical decompression to dissect basal arachnoiditis in the posterior fossa can be recommended in hindbrain syringomyelia. Treatment of non-hindbrain arachnoiditis is more controversial, probably owing to uncertainties about the extent of adhesions.
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