Neuronavigation-guided biopsy for differential diagnosis of pseudotumoral demyelinating brain lesions

Abstract Marburg's disease (MD) is an extremely rare and aggressive form of multiple sclerosis (MS). In some cases, MD presents with tumefactive demyelinating lesions with a “tumor-like” appearance in MRI images, for which it may be difficult to achieve a form of differential diagnosis between definitive tumors or abscesses. Here we report a case of MD histopathologically confirmed after neuronavigationguided biopsy. Postoperative course was uneventful and following discharge, the patient attended outpatient follow-up appointments and received i.v. cyclophopsphamide, achieving progressive clinical remission. A nine-month follow-up brain MRI scan with gadolinium showed no signs of progressin…

Reconstruction of vertebral body after radiofrequency ablation and augmentation in dorsolumbar metastatic vertebral fracture: Analysis of clinical and radiological outcome in a clinical series of 18 patients

Background: Painful spinal metastases usually occur in malignant neoplastic disease. Treatment for bone metastases has been largely conservative, and it includes the use of high doses of analgesics, radiotherapy, chemotherapy, hormone therapy, and bisphosphonates; however, results are sometimes transient and ineffective. In the presence of neurological involvement a surgical strategy should be considered. Recently, percutaneous procedures such as radiofrequency ablation, vertebroplasty, and kyphoplasty have been introduced as palliative techniques to treat painful vertebral metastases [3, 11, 25]. Methods: In our study we combined the use of radiofrequency ablation with vertebroplasty in th…

TRANS-CRANIAL MRI-GUIDED FOCUSED ULTRASOUND SURGERY (TCMRGFUS): PRELIMINARY ITALIAN (AND WORLD-FIRST) EXPERIENCE AT 1,5 TESLA (first 3 cases treated)

PURPOSE: We present our preliminary results achieved with the first Italian installation of a trans-cranial MRI-guided Focused Ultrasound Surgery (tcMRgFUS) certified system for functional neurosurgery. Moreover, to our knowledge, this is the world-first tcMRgFUS system ever installed on a 1.5T MRI unit. TcMRgFUS is a promising new technology for the non-invasive treatment of neurologic disorders such as Essential Tremor (ET), tremor dominant idiopathic Parkinson's Disease (PD) and Neuropathic Pain (NP). This is a new method for focal targeting and lesioning of specific regions in the brain through intact skull by using high intensity focused ultrasound beam to achieve thermal ablation and …

Is there still a role for lesioning in functional neurosurgery? Preliminary Italian (and world-first) experience with a trans-cranial MRI-guided focused ultrasound surgery system operating at 1.5 Tesla

Letter: Thalamotomy-Like Effects From Partial Removal of a Ventral Intermediate Nucleus Deep Brain Stimulator Lead in a Patient With Essential Tremor: Case Report

A thoracic vertebral localization of a metastasized cutaneous Merkel cell carcinoma: Case report and review of literature

Background: Merkel cell carcinoma (MCC) is a rare neuroendocrine skin tumor, which may be related to sun exposure. It can metastasize to lungs, liver and bone, leading to severe morbidity and mortality. Vertebral metastases from MCC are rare. The authors report the tenth case in the literature, a 59-year-old patient with MCC, which was primarily localized in the scalp, and later provoked distant metastasis to the thoracic spinal column. Case Description: A 59-year-old woman was admitted at our Unit of Neurosurgery with a 4-month history of progressive and severe dorsal back pain, without neurological signs. The patient had been surgically treated for a recidivated MCC in the occipital regio…

Is there still a role for lesioning in functional neurosurgery: the Italian experience of delivering focused ultrasound high energy through a 1,5 tesla MR apparatus.

WhatsAPP in neurosurgery: the best practice is in our hands

Emergency surgery in a patient with large spontaneous spinal epidural hematoma determining excellent neurological recovery: Review of the literature

Study design: Case report. Objectives: We report a case of a 75-year-old woman suffering from voluminous idiopathic spontaneous spinal epidural hematoma (SSEH) that was rapidly diagnosed and successfully treated. Methods: Clinical presentation was characterized by sudden and intense back pain that rapidly evolved into plegia of the right leg and severe paresis of the left leg. Hypoesthesia below T6 and urinary retention were also present. Magnetic resonance imaging showed a significant posterior spinal compression from T6 through L3 caused by an epidural hematoma that involved 10 metameric levels, extending for ∼20 cm, with a maximum thickness of 1.6 cm from T12 to L1. Results: Within 12 h,…

Neurosurgical Odyssey: Case of Anaplastic Meningiomatosis.

According to the World Health Organization grading, meningiomas are classified as grade I (benign), grade II (atypical), and grade III (anaplastic). Most of them (81%) are benign, 15% are atypical, and 4% are anaplastic. Metastasis is a rare event in meningiomas, occurring in <1% of cases. In most types of tumors, distant metastasis is an incontrovertible indication of malignancy. This is not so clearly the case with meningiomas, mostly in the multiple localization of these tumors, known as meningiomatosis. Here we would like to share our experience with a unique case of an atypical meningioma, which evolved in an anaplastic multiple meningiomatosis, invading the brain and associated wit…

Percutaneous Pedicle-Lengthening Osteotomy in Minimal Invasive Spinal Surgery to Treat Degenerative Lumbar Spinal Stenosis: A Single-Center Preliminary Experience

Background Lumbar spinal stenosis (LSS) is a narrowing of the spinal canal due to spinal degeneration, and its main clinical symptom is neurogenic claudication. Surgical treatment is pursued for patients who do not improve with conservative care. Patients with symptomatic LSS who also have significant medical comorbidities, although clearly in need of intervention, are unattractive candidates for traditional open lumbar decompressive procedures. Thus it is important to explore minimally invasive surgical techniques to treat select patients with LSS. Methods This retrospective case series evaluated the clinical and radiographic outcomes of a new minimally invasive procedure to treat LSS: pe…

Surgical nuances on the treatment of giant dumbbell cervical spine schwannomas: description of a challenging case and review of the literature

We report a case of a giant intra and extradural cervical schwannoma in a patient affected by a severe myelo-radiculopathy. Clinical features, diagnosis and the issues concerning the surgical management of this benign tumor are discussed. We also review similar cases previously reported in the literature. A 50-year old caucasian woman was complaining of a 1 year of neck pain and worsening motor impairment in all four limbs causing the inability to walk. Neuroradiological assessment revealed a suspected schwannoma involving the nerve roots from C3 to C5, compressing and deviating the spinal cord. The vertebral artery was also encased within the lesion, but still patent. A posterior cervical …

Chirurgia trans-cranica mediante ultrasuoni focalizzati ad alta intensità su guida RM: esperienza preliminare a 1,5T

Da qualche anno la chirurgia mediante ultrasuoni focalizzati ad alta intensità guidati da Risonanza Magnetica (Magnetic Resonance guided Focused Ultrasound Surgery, MRgFUS) si sta diffondendo anche in Italia per la palliazione del dolore da metastasi ossee, per il trattamento di tumori ossei primitivi (benigni e non), dei fibromi e dell’adenomiosi uterina; sono già stati inoltre pubblicati i risultati preliminari del trattamento di alcuni tumori epatici, pancreatici, prostatici e della mammella mediante MRgFUS. Questa innovativa tecnica prevede l’utilizzo di un’apparecchiatura di Risonanza Magnetica per il monitoraggio della procedura e sfrutta le caratteristiche fisico- meccaniche degli …

Impasse in the management of recurrent basal cell carcinoma of the skull with sagittal sinus erosion

Abstract Basal cell carcinoma (BCC) is a non melanocytic skin cancer that arises from basal cells, affecting commonly fair-skinned human beings. Although the tumor is well known for local recurrences, extension into the intracranial space is reported. A case of a giant BCC of the scalp invading the middle and posterior third of the superior sagittal sinus (SSS) is reported. A 70-year-old male with a basal cell carcinoma history presented with a massive bleeding from the SSS invaded by the tumor. Since the patient refused surgery the bleeding was managed through direct compression by applying a thrombin-based hemostatic agents and sterile dressings. This procedure was performed daily in orde…

Surgical Highways to the Craniovertebral Junction: Is It Time for a Reappraisal?

Background: The craniovertebral junction (CVJ) can be affected by a variety of congenital or acquired anomalies. Because of its complexity, a careful evaluation of bones and ligamentous structures in all three planes is required. This can be achieved by studying the CVJ in terms of several anatomical and radiological lines that have been visualized to facilitate understanding of its surgical anatomy. In this study we aimed to review the state-of-the art craniometric CVJ lines and approaches. Methods: In December 2016 a PubMed search was performed, including the search terms ‘CVJ surgical approach/line’, ‘cervical approach’, ‘craniometric measurement’, ‘CVJ anatomy’ and ‘ventral/dorsal/far-l…

Spinal cord stimulation: An alternative concept of rehabilitation?

Background: Chronic low back and leg pain is a disabling condition, affecting, in most cases, older patients with congenital or acquired spinal stenosis or patients with failed back surgery syndrome. Spinal cord stimulation has been introduced as an effective therapeutic option for those patients who have previously been operated without significant clinical benefits, or for all those patients who are ineligible for traditional surgery. Methods: We report our experience with ten patients treated with spinal cord stimulation plus medication and physical therapy between November 2014 and September 2015. Inclusion criteria were: previous surgical treatments for lumbar stenosis and metameric in…

A Strange Case of Downward Displacement of a Deep Brain Stimulation Electrode 10 Years Following Implantation: The Gliding Movement of Snakes Theory.

Background Despite the best efforts to ensure stereotactic precision, deep brain stimulation (DBS) electrodes can wander from their intended position after implantation. We report a case of downward electrode migration 10 years following successful implantation in a patient with Parkinson disease. Methods A 53-year-old man with Parkinson disease underwent bilateral implantation of DBS electrodes connected to a subclavicular 2-channel pulse generator. The generator was replaced 7 years later, and a computed tomography (CT) scan confirmed the correct position of both leads. The patient developed a gradual worsening affecting his right side 3 years later, 10 years after the original implantati…

Chirurgia trans-cranica mediante ultrasuoni focalizzati ad alta intensità su guida rm: esperienza preliminare a 1,5T (primi 2 casi trattati)

Scopo del Lavoro Presentiamo i risultati preliminari ottenuti con la prima istallazione italiana di un’apparecchiatura per la neurochirurgia funzionale mediante ultrasuoni focalizzati ad alta intensità su guida RM (trans-cranial MRI-guided Focused Ultrasound Surgery, tcMRgFUS); si tratta tra l’altro della prima apparecchiatura tcMRgFUS al mondo mai installata su uno scanner RM da 1,5T. Tale apparecchiatura è attualmente certificata (CE ed FDA) per trattamenti di neurochirurgia funzionale in pazienti con tremore essenziale (Essential Tremor, ET), Parkinson idiopatico (Parkinson Disease, PD) unilaterale prevalentemente tremorigeno e dolore neuropatico (Neuropathic Pain, NP). Materiali e Metod…

Complex reconstructive surgery following removal of extra-intracranial meningiomas, including the use of autologous fibrin glue and a pedicled muscle flap

Abstract Background Skull reconstructive surgery is critical to prevent cerebrospinal fluid (CSF) fistulas and infections, and to ensure good aesthetic results in meningiomas surgery. Methods A 65-year-old woman was surgically treated for a bilateral parasagittal meningioma with complete superior sagittal sinus (SSS) involvement, and an intra-extracranial extension, determining a significant cranial defect at the vertex. A Simpson I resection was achieved. Postoperatively a considerable and not conservatively repairable CSF leak was detected. Surgical revision of the wound with repair of the fistula and complex reconstructive operation was performed including a combination of techniques and…

Trans-cranial MRI-guided Focused Ultrasound Surgery (tcMRgFUS): preliminary Italian (and world-first) experience at 1,5 Tesla (first 5 patient treated)

Preliminary experience with a transcranial magnetic resonance-guided focused ultrasound surgery system integrated with a 1.5-T MRI unit in a series of patients with essential tremor and Parkinson's disease.

OBJECTIVETranscranial magnetic resonance–guided focused ultrasound surgery (tcMRgFUS) is one of the emerging noninvasive technologies for the treatment of neurological disorders such as essential tremor (ET), idiopathic asymmetrical tremor-dominant Parkinson’s disease (PD), and neuropathic pain. In this clinical series the authors present the preliminary results achieved with the world’s first tcMRgFUS system integrated with a 1.5-T MRI unit.METHODSThe authors describe the results of tcMRgFUS in a sample of patients with ET and with PD who underwent the procedure during the period from January 2015 to September 2017. A monolateral ventralis intermedius nucleus (VIM) thalamic ablation was pe…

A new concept to treat lumbar spine stenosis in a mini invasive way.

Restoring Neurological Physiology: The Innovative Role of High-Energy MR-Guided Focused Ultrasound (HIMRgFUS). Preliminary Data from a New Method of Lesioning Surgery

Background Tremor is a disabling condition, common to several neurodegenerative diseases. Lesioning procedures and deep brain stimulation, respectively, of the ventralis intermedius nucleus for intentional tremor, and of the subthalamic nucleus for parkinsonian resting tremor, have been introduced in clinical practice for patients refractory to medical treatment. The combination of high-energy focused ultra-sound (HIFUS) with sophisticated magnetic resonance (MR) instrumentation, together with accurate knowledge of the stereotactic brain coordinates, represents a revolution in neuromodulation. Methods At the Neurosurgical Clinic and the Radiology Department of the University of Palermo,, tw…

White cord syndrome after non-contiguous double-level anterior cervical decompression and fusion (ACDF): A “no reflow phenomenon”?

Abstract Study design Case report and review of literature. Objective To report a rare complication of anterior cervical decompression and fusion (ACDF) in a patient with severe cervical cord compression and review of relevant literature. Introduction The white cord syndrome is a very rare condition characterized by an ischemic-edematous lesion of the spinal cord following a surgical procedure, lacking intra o perioperative surgical or anesthesiological complications. Case report A 64-years old male affected by a severe cervical stenosis at multiple levels, with voluminous C3–C4 and C5–C6 disc herniations associated to T2-hyperintense myelomalacic area at C3–C4 level was admitted to our Uni…

Never say never again: A bone graft infection due to a hornet sting, thirty-nine years after cranioplasty

Background: Cranioplasty (CP) is a widespread surgical procedure aimed to restore skull integrity and physiological cerebral hemodynamics, to improve neurological functions and to protect the underlying brain after a life-saving decompressive craniectomy (DC). Nevertheless, CP is still burdened by surgical complications, among which early or late graft infections are the most common outcome-threatening ones. Case Description: We report the case of 48-year-old man admitted to our neurosurgical unit because of a painful right frontal swelling and 1-week purulent discharge from a cutaneous fistula. He had been undergone frontal CP because of severe traumatic brain injury (TBI) when he was 9-ye…

Delayed chronic intracranial subdural hematoma complicating resection of a tanycytic thoracic ependymoma

Background To demonstrate that the diagnosis of an intracranial subdural hematoma should be considered for patients presenting with acute or delayed symptoms of intracranial pathology following resection of a spinal tumor. Case description We present a case of a 57-year-old woman found to have a chronic subdural hematoma 1 month following resection of a thoracic extramedullary ependymoma. Evacuation of the hematoma through a burr hole relieved the presenting symptoms and signs. Resolution of the hematoma was confirmed with a computed tomography (CT) scan. Conclusion Headache and other symptoms not referable to spinal pathology should be regarded as a warning sign of an intracranial subdural…