Background:
Cavernomas arising in the region of the optic apparatus are extremely rare, accounting for <1% of all the central nervous system cavernomas. Most patients are affected by acute visual ...disturbances related to hemorrhagic events. A prompt resection of the lesion together with a decompression of the optic apparatus may lead to a functional improvement. Almost all patients reported in literature were treated by means of a craniotomy, whereas only few papers described the use of a transnasal approach.
Case Description:
We report the case of a 53-year-old woman with a hemorrhagic, cavernous malformation of the optic chiasm region and we discuss the technical nuances of the endoscopic transnasal approach we employed. We also review literature for patients with cavernomas treated with a transsphenoidal approach. In our case, the patient underwent the gross-total resection of the lesion through a fully endoscopic transnasal route and the visual disturbances improved immediately after the operation. The ventral access allowed an adequate exposure of the chiasm/anterior circulation complex, thus avoiding an excessive dissection and retraction of neurovascular structures. Moreover, with the aid of angled scopes, we were able to identify the frail vascular supply of the chiasm by employing the suprachiasmatic corridor as well as the infrachiasmatic one. We stress the need for a careful reconstruction of the skull base to avoid a postoperative cerebrospinal fluid leak.
Conclusions:
With the evolution and spreading of the neuroendoscopic techniques, in selected cases, we advocate the use of the transnasal route for the removal of cavernomas arising in the region of the anterior optic pathways.
To review and discuss surgical treatment options for giant intracranial aneurysms (GIAs), focusing on indications, technical aspects, and results, along with some illustrative cases.
We reviewed the ...data of 82 consecutive patients surgically managed between January 2000 and December 2019 for treatment of a GIA.
Male sex and hemorrhage at presentation were prevalent. The average follow-up was 81.2 ± 45 months. The anterior circulation was involved in 76.8% of GIAs. If the GIA showed a clear neck, minimal atherosclerosis, or intrasaccular thrombosis, and ≤2 branches arising from the neck, it was reconstructed. This procedure was possible in 78% of cases. The technique also involved temporary clipping, remodeling, and thrombectomy, as well as fragmentation techniques. Angioarchitectural features other than these techniques underwent bypass and aneurysm trapping. Most bypasses were extracranial to intracranial and high flow. Flow capacity, collateral circulation, and availability of the donor vessel mainly affected the choice of the type of bypass. Overall, successful exclusion of the GIA was 91.4%. The need for retreatment and complication rate were 3.6% and 19.5%, respectively. A good overall outcome (modified Rankin Scale score 0–3) was achieved in 84.2% of patients, and mortality was 10%.
Microneurosurgical techniques still maintain a significant role for most GIAs, with a high durability and acceptable rate of morbidity and mortality. Clip reconstruction is the first-line surgical treatment option, whereas bypass is indicated in cases of planned or unplanned sacrifice of the parent artery to prevent long-term ischemic complications.
Grade III Spetzler-Martin brain arteriovenous malformations (AVMs) are a specific set of AVMs with high variability in terms of site, size, angioarchitecture, flow dynamics, and involvement of ...eloquent areas. Surgery preceded by preoperative embolization has been reported as a useful treatment option for these lesions. The aim of this study is to report outcomes and personal experience of combined preoperative Onyx embolization and surgical resection on a consecutive series of grade III brain AVMs.
Between 2005 and 2017, 27 grade III AVMs were treated by means of a staged Onyx embolization and subsequent surgical treatment. Site and size of the AVMs, embolization, and surgical specifics as well as complications and outcomes were retrospectively reviewed.
All AVMs were supratentorial, 13 of which were hemorrhagic. Mean nidal volume was 19.5 mL. Average embolization sessions were 1.6. Mean embolization-related obliteration rate and morbidity were 28.8% and 3.7%, respectively. Surgery was performed within 3.7 days on average. In our experience, Onyx embolization made the nidus excision easier, facilitated the hemostasis, and contributed to the early identification of the lesion in cases of small or racemose nidus. The surgical obliteration rate was 92.6%. A good overall outcome (modified Rankin Scale score 0–2) was achieved in 70.4% of patients.
In our experience, preoperative Onyx embolization helped the surgical management of grade III Spetzler-Martin brain AVMs. Careful evaluation of the angioarchitecture, a tailored strategy in the embolization process, and full cooperation within the neurosurgical-neuroendovascular team are mandatory.
•Evaluation of the effectiveness and safety of preoperative, staged Onyx embolization in 27 grade III brain AVMs.•Nidus excision easier, hemostasis facilitated, and early identification of the lesion in small or racemose nidus.•Surgical obliteration rate 92.6%; good overall outcome (mRS score 0–2) achieved in 70.4% of patients.•Angioarchitectural evaluation, a tailored strategy, and full cooperation within the team are mandatory.
Extrinsic compression of the subaxial vertebral artery (VA) may cause rotational occlusion syndrome (ROS) and contribute to vertebrobasilar insufficiency potentially leading to symptoms and in severe ...cases, to posterior circulation strokes. The present literature review aimed to report the main clinical findings, diagnostic work-up, and surgical management of the subaxial VA-ROS, the diagnosis of which can be difficult and is often underestimated. An illustrative case is also presented. A thorough literature search was conducted to retrieve manuscripts that have discussed the etiology, diagnosis, and treatment of ROS. Total 41 articles were selected based on the best match and relevance and mainly involved case reports and small cases series. The male/female ratio and average age were 2.6 and 55.6±11 years, respectively. Dizziness, visual disturbances, and syncope were the most frequent symptoms in order of frequency, while C5 and C6 were the most affected levels. Osteophytes were the cause in >46.2% of cases. Dynamic VA catheter-based angiography was the gold standard for diagnosis along with computed tomography angiography. Except in older patients and those with prohibitive comorbidities, anterior decompressive surgery was always performed, mostly with complete recovery, and zero morbidity and mortality. A careful neurological evaluation and dynamic angiographic studies are crucial for the diagnosis of subaxial VA-ROS. Anterior decompression of the VA is the cure of this syndrome in almost all cases.
The data presented in this brief paper aims to summarize the overall results of 82 consecutive patients surgically treated over 20 years for a giant intracranial aneurysm (GIA) in the context of the ...endovascular era. Data were retrospectively collected from the database of two different tertiary referral Italian hospitals. A retrospective analysis of the patients’ cohort was performed. Data are presented as they relate to the demographic and clinical aspects, the prevalence of GIAs according to anterior and posterior circulation, aneurysm angioarchitectural features, surgical treatment options, complications, outcome, and main microneurosurgical techniques required explicitly for GIAs, namely temporary clipping, aneurysm remodeling, thrombectomy, fragmentation, and bypass. Furthermore, data about the effects of implementing the flow-diverter/flow-disruptor on the surgical case volume over the years are also reported.
The data presented herein are related to our previously published research article titled “Surgical Management of Giant Intracranial Aneurysms: Overall Results of a Large Series” (2020) 1.
The exact molecular pathways underlying the multifactorial natural history of intracranial aneurysms (IAs) are still largely unknown, to the point that their understanding represents an imperative ...challenge in neurovascular research. Wall shear stress (WSS) promotes the genesis of IAs through an endothelial dysfunction causing an inflammatory cascade, vessel remodeling, phenotypic switching of the smooth muscle cells, and myointimal hyperplasia. Aneurysm growth is supported by endothelial oxidative stress and inflammatory mediators, whereas low and high WSS determine the rupture in sidewall and endwall IAs, respectively. Angioarchitecture, age older than 60 years, female gender, hypertension, cigarette smoking, alcohol abuse, and hypercholesterolemia also contribute to growth and rupture. The improvements of aneurysm wall imaging techniques and the implementation of target therapies targeted against inflammatory cascade may contribute to significantly modify the natural history of IAs. This narrative review strives to summarize the recent advances in the comprehension of the mechanisms underlying the genesis, growth, and rupture of IAs.
Examination of the current trends and future perspectives of the cell-based therapies in neurosurgery.
A PubMed/MEDLINE-based systematic review has been performed combining the main Medical Subject ...Headings (MeSH) regarding the cell- and tissue-based therapies with the “Brain”, “Spinal Cord”, “Spine” and “Skull” MeSH terms. Only articles in English published in the last 10 years and pertinent to neurosurgery have been selected.
A total of 1,173 relevant articles have been chosen. Somatic cells and gene-modification technologies have undergone the greatest development. Immunotherapies and gene therapies have been tested for the cure of glioblastoma, stem cells mainly for brain and spinal cord traumatic injuries. Stem cells have also found a rationale in the treatment of the cranial and spinal bony defects, and of the intervertebral disc degeneration, as well.
Most of the completed or ongoing trials concerning the cell-based therapies in neurosurgery are on phase 2. Future perspectives involve the need to overcome issues related to immunogenicity, oncogenicity and routes for administration. Refinement and improvement of vector design and delivery are required within the gene therapies.
The last decade has been characterised by a progressive evolution of neurosurgery from a purely mechanical phase to a new biological one. This trend has followed the rapid and parallel development of translational medicine and nanotechnologies.
The introduction of new technologies, the optimisation of the already existing ones, and the reduction of costs are among the main challenges of the foreseeable future.
Neuroscience; Immunology; Biotechnology; Molecular biology; Cancer research; Regenerative medicine; Oncology; Evidence-based medicine; Clinical research; CAR T-Cell therapy; Cell- and tissue-based therapy; Genetic therapy; Glioblastoma; Immunotherapy; Neurosurgery; Stem cells
•Bariatric surgery could have neurosurgery-related complications.•Etiopathological mechanisms can be intracranial pressure alterations.•Etiopathological mechanisms can be macro-and micro-nutrients ...deficiencies.•Etiopathological mechanisms can be autonomic and endocrine control alterations.
Bariatric surgery is gaining popularity as the treatment of choice of morbid obesity since this condition is constantly increasing over the last decades. Several complications have emerged as the number of surgeries and follow-up data increase. No systematic review of the neurosurgery-related potential complications has been performed to date. Objective of this work is to fill this gap. We reviewed the literature for bariatric surgery-related complications involving the neurosurgical practice. Moreover, we present explicative cases dealing with peri- and post-operative therapeutic precautions. Three pathological mechanisms emerged. The first is related to intracranial pressure alterations and may imply either intracranial hypertension or hypotension syndromes in the operative or post-operative periods. The second is the deficiency of macro- and micro-nutrients which are potential risk factors for neuro- or myelo-encephalopathies, fetal malformations and spine disorders. The third is a dysregulation of both autonomic and endocrine / pituitary control. Neurosurgeons must be aware of the several, multifactorial neurosurgery-related complications of bariatric surgery as their prevalence is likely to be higher in the next few years.
The implementation of intraoperative augmented reality fiber tractography (iAR-FT) into the surgical workflow for high-grade supratentorial gliomas has been shown to be effective and safe in ...maximizing the extent of resection and progression-free survival through the surgeon's enhanced 3-dimensional awareness of the spatial localization of fiber tracts.1-3
Primary motor area tumors present special challenges due to the high eloquence of the precentral gyrus and risk of postoperative onset or worsening of motor deficits, as well as limited postoperative plasticity.4
Although essential, electrical stimulation mapping (ESM) techniques have a number of limitations with respect to primary motor pathways, including a higher risk of intraoperative stimulation-evoked seizures, a risk of false negatives in the presence of preoperative deficits, a nonnegligible risk of permanent deterioration even in the presence of negative stimulation maps, and, most importantly, limited spatial resolution.4-8
The rationale for integrating ESM and iAR-FT is to compensate for the limitations of the former in terms of morphologic and spatial representation of fiber tracts.
The benefits of coupling iAR-FT with ESM techniques allow for continuous integrated anatomical-functional feedback during surgery.
In Video 1 we describe the key technical aspects and benefits of iAR-FT-assisted surgery for maximal safe gross total resection of a primary motor area grade IV astrocytoma.
Background: Proof of the efficacy and safety of a xenogeneic mesenchymal stem cell (MSCs) transplant for spinal cord injury (SCI) may theoretically widen the spectrum of possible grafts for ...neuroregeneration.
Methods: Twenty rats were submitted to complete spinal cord transection. Ovine bone marrow MSCs, retrovirally transfected with red fluorescent protein and not previously induced for neuroglial differentiation, were applied in 10 study rats (MSCG). Fibrin glue was injected in 10 control rats (FGG). All rats were evaluated on a weekly basis and scored using the Basso-Beattie-Bresnahan (BBB) locomotor scale for 10 weeks, when the collected data were statistically analyzed. The spinal cords were then harvested and analyzed with light microscopy, immunohistochemistry, and immunofluorescence.
Results: Ovine MSCs culture showed positivity for Nestin. MSCG had a significant and durable recovery of motor functions (P <.001). Red fluorescence was found at the injury sites in MSCG. Positivity for Nestin, tubulin βIII, NG2 glia, neuron-specific enolase, vimentin, and 200 kD neurofilament were also found at the same sites.
Conclusions: Xenogeneic ovine bone marrow MSCs proved capable of engrafting into the injured rat spinal cord. Transdifferentiation into a neuroglial phenotype was able to support partial functional recovery.
PDF
