The appropriate surgical management of insular gliomas is controversial. Management strategies vary considerably between centers.
To provide robust resection, functional and epilepsy outcome figures, ...study growth patterns and tumor classification paradigms, analyze surgical approaches, mapping/monitoring strategies, surgery for insular glioblastoma, as well as molecular findings, and to identify open questions for future research.
On behalf of the EANS Neuro-oncology Section we performed a systematic review and meta-analysis (using a random-effects model) of the more current (2000–2023) literature in accordance with the PRISMA guidelines.
The pooled postoperative motor and speech deficit rates were 6.8% and 3.6%. There was a 79.6% chance for postoperative epilepsy control. The postoperative KPI was 80–100 in 83.5% of cases. Functional monitoring/mapping paradigms (which may include awake craniotomies) seem mandatory. (Additional) awake surgery may result in slightly better functional but also worse resection outcomes. Transcortical approaches may carry a lesser rate of (motor) deficits than transsylvian surgeries.
This paper provides an inclusive overview and analysis of current surgical management of insular gliomas. Risks and complication rates in experienced centers do not necessarily compare unfavorably with the results of routine neuro-oncological procedures. Limitations of the current literature prominently include a lack of standardized outcome reporting. Questions and issues that warrant more attention include surgery for insular glioblastomas and how to classify the various growth patterns of insular gliomas.
•Pooled 6.8%/3.6% motor/language deficit rates, and 79.6% epilepsy control.•Functional monitoring/mapping paradigms (including awake craniotomies) mandatory.•Possibly lesser rate of deficits with transcortical vs. transsylvian surgery.•Surgery for insular glioblastomas and classification issues need more attention.
BACKGROUND AND PURPOSE—Although the mechanisms that contribute to intracranial aneurysm (IA) formation and rupture are not totally elucidated, inflammation and matrix remodeling are incriminated. ...Because tPA (tissue-type plasminogen activator) controls both inflammatory and matrix remodeling processes, we hypothesized that tPA could be involved in the pathophysiology of IA.
METHODS—Immunofluorescence analyses of tPA and its main substrate within the aneurysmal wall of murine and human samples were performed. We then compared the formation and rupture of IAs in wild-type, tPA-deficient and type 1 plasminogen activator inhibitor–deficient mice subjected to a model of elastase-induced IA. The specific contribution of vascular versus global tPA was investigated by performing hepatic hydrodynamic transfection of a cDNA encoding for tPA in tPA-deficient mice. The formation and rupture of IAs were monitored by magnetic resonance imaging tracking for 28 days.
RESULTS—Immunofluorescence revealed increased expression of tPA within the aneurysmal wall. The number of aneurysms and their symptomatic ruptures were significantly lower in tPA-deficient than in wild-type mice. Conversely, they were higher in plasminogen activator inhibitor–deficient mice. The wild-type phenotype could be restored in tPA-deficient mice by selectively increasing circulating levels of tPA via hepatic hydrodynamic transfection of a cDNA encoding for tPA.
CONCLUSIONS—Altogether, this preclinical study demonstrates that the tPA present in the blood stream is a key player of the formation of IAs. Thus, tPA should be considered as a possible new target for the prevention of IAs formation and rupture.
Mesenchymal tumors of the central nervous system (CNS) include numerous entities, with different pathological features and biological behavior. Mesenchymal non-meningothelial tumors are rare and ...comprise neoplasms that are exclusive to the CNS or show peculiar features when occurring in the CNS compared with other sites. Within this group there are three new entities, classified on the basis of specific molecular alterations and included in the 5th edition of the WHO Classification of CNS Tumors: primary intracranial sarcoma; DICER1-mutant; CIC-rearranged sarcoma; intracranial mesenchymal tumor, FET::CREB fusion-positive. These tumors often show variable morphology, making diagnosis very challenging, although the implementation of molecular techniques has led to better characterization and more precise identification of these entities. However, many molecular alterations have yet to be discovered and some recently reported CNS tumors are currently missing an appropriate classification. Herein, we report the case of a 43-year-old man who presented with an intracranial mesenchymal tumor. Histopathological examination showed a wide spectrum of peculiar morphological features and a non-specific immunohistochemical profile. Whole transcriptome sequencing revealed the presence of a novel genetic rearrangement involving COX14 and PTEN genes, which has never been reported before in any other neoplasm. The tumor did not cluster in any defined methylation class of the brain tumor classifier, but resulted in a calibrated score of 0.89 for the methylation class "Sarcoma, MPNST-like", when analyzed by the sarcoma classifier. Our study is the first to report about this tumor with unique pathological and molecular features, characterized by a novel rearrangement between COX14 and PTEN genes. Other studies are necessary in order to define it as a new entity or as a novel rearrangement involving recently described and incompletely characterized CNS mesenchymal tumors.
Despite the increasing incidence rate of vestibular schwannomas (VS), controversies in their management are still present.
A 35-item multiple-choice survey investigating the current practice patterns ...of VS care was sent to the members of the Italian Society of Otolaryngology, Head and Neck Surgery (SIO) and of the Italian Society of Neurosurgery (SINCH).
Among 66 respondents, 37 (56.0%) claimed to be actively involved in VS management. Most interviewees (35.1%) declared > 20 years of experience and 59.5% claimed to work in an academic practice. The number of cases evaluated in each centre per year varied widely, with 54.0% evaluating > 25 cases/year and only 13.6% > 100 cases/year. Multidisciplinary care for VS evaluation was confirmed by 50.0% of respondents, and multidisciplinary surgical care by 62.2%. Observation and surgery were the most common management options proposed. Further details regarding VS care are presented.
The present study provides the first overview on the current practice patterns of VS care in Italy. Although integrated in most centres, a multidisciplinary model of care needs to be encouraged. Wide heterogeneity in experience and practices is mostly influenced by the surgeon's different specialties and by the lack of shared guidelines.
Neurosurgery is a rapidly developing field of medicine. Therefore, staying keeping track of the advancements in the field is paramount for trainees as well as fully trained neurosurgeons. This book, ...fully available online, is a part of our effort of improving availability of medical information for anyone who needs to keep up-to-date.
BackgroundThere is no consensus regarding the best treatment option for unruptured aneurysms of the posterior communicating artery (PCom) presenting with oculomotor nerve palsy (ONP). We aimed to ...assess predictors of ONP recovery in a multicenter series of consecutive patients.Materials and methodsA retrospective review of prospective databases in three tertiary neurosurgical centers was carried out, selecting patients with ONP caused by unruptured PCom aneurysms, treated by surgical clipping or embolization, between January 2006 and December 2013. Patient files and imaging studies were used to extract ophthalmological assessments, treatment outcomes, and follow-up data. Predictors of ONP recovery during follow-up were explored using univariate and multivariate analyses.ResultsWe identified 55 patients with a median ONP duration before treatment of 11 days (IQR 4.5–18); the deficit was complete in 27 (49.1%) and incomplete in 28 (50.9%) cases. Median aneurysm size was 7 mm (IQR 5–9). Twenty-four (43.6%) patients underwent surgical clipping and 31 (56.4%) embolization as the primary treatment. Overall, ONP improved in 40 (72.7%) patients and persisted/recurred in 15 (27.3 %). Surgery, interval to complete treatment <4 weeks, aneurysm recurrence during follow-up, and retreatment during follow-up were significantly correlated with ONP outcome in the univariate analysis. In the multivariate analysis, independent predictors of ONP improvement were interval to complete treatment <4 weeks (OR 5.15, 95% CI 1.37 to 23.71, p=0.015) and aneurysm recurrence during follow-up (OR 0.1, 95% CI 0.02 to 0.47, p=0.003).ConclusionThere was no significant difference in ONP recovery between surgical clipping and embolization. The best predictor for ONP recovery was timely, complete, and durable aneurysm exclusion.
Current neurosurgical training can rely on innovative methods that have been provided, especially in recent years, by the remarkable and constant evolution of surgical techniques, instruments and ...additional dedicated tools. Moreover, the increasingly widespread access to educational material in the forms of lectures, surgical videos and anatomical dissections represents an innovative and helpful resource, which is easily available to young surgeons. Nevertheless, the international scientific literature agrees that anatomical dissection of cadavers remains fundamental in the long process of neurosurgical education and constitutes an invaluable tool for anatomical and surgical research.
Spontaneous intracranial hypotension (SIH) is a disorder of low cerebrospinal fluid (CSF) volume secondary to CSF leakage through a dural defect along the neuraxis with an estimated incidence of 5 ...people per 100,000.Great debate persists on the optimal treatment of this pathology, and clinical results are often contradictory. SIH may be initially approached via conservative measures, such as bed rest that is often supplemented with hydration, caffeine, and theophylline, which overall relieve symptoms in a small subset of patients at 6 months. Epidural blood patching (EBP) is generally the next consideration in symptom management. It is the most commonly performed intervention for spinal CSF leaks, as the first option or following the failure of conservative treatment. Further procedures may be performed in the case of EBP partial or temporary response and if the spinal CSF leak has been definitively localized (Beck et al., Neurology 87:1220-26, 2016). In those cases, if the CSF leak is well localized, the surgical closure of the spinal CSF leak may be considered.SIH is a complex but treatable CSF disorder. Despite recent advances in the field of neuroimaging and the different therapeutic options available, the appropriate management remains controversial and should be tailored to the patient.
The introduction of recent innovations in the field of intraoperative imaging and neuronavigation, such as the O-arm StealthStation, allows for obtaining crucial intraoperative data by performing ...safer and controlled surgical procedures. As part of the improvement of surgical visual magnification and wide expansion of surgical corridors, the 3D 4 K exoscope (EX) has nowadays become an interesting and useful tool. The transoral approach (TOA) is the historical gold-standard direct microsurgical route to ventral craniovertebral junction (CVJ).
We herein report our experience, consisting of ten cases via TOA concerning the simultaneous application of an O-arm with a StealthStation navigation system (Medtronic, Memphis, TN) and an imaging system, along with the 3D 4 K exoscopes in the TOA, for the treatment of CVJ pathologies.
No intraoperative neurophysiological changes or postoperative infections occurred, but neurological improvement was evident in all the patients. A complete decompression and a stable instrumentation and fusion of the CVJ were accomplished in all cases at the maximum follow-up time.
With EX, the role of the surgeon becomes self-sufficient with better individual surgical freedom compared to endoscopic surgery and excellent 3D vision and magnification. O-arms offer absolutely reliable intraoperative support for more-effective CVJ decompression. Nevertheless, with O-arm-assisted neuronavigation, it can be difficult to navigate C1 lateral masses and C2 isthmi, and converting 3D into 2D real-time navigation can be quite complicated. Finally, the combination of an EX with an O-arm appears more time-consuming compared to the old-fashion one.
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