Opening New Window in Upper Clival Region: Results from Anatomic Study.

Considering its position located anteriorly to the brainstem, the retrosellar area, in particular the upper clival region and the interpeduncular cistern, is one of the most difficult regions to surgically approach. To date, many different operative solutions have been described, given that this region is attainable by both lateral and median approaches. Lateral routes include the frontolateral, subtemporal, and frontotemporozygomatic approaches with relative variants that have been extensively reported. Among the lateral approaches, the frontotemporozygomatic one is considered particularly useful because it allows better visualization of the retrosellar and suprasellar areas minimizing the…

Avoiding lumbar segmental arteries injury in oblique lateral interbody fusion procedure

Lumbar interbody fusion is performed to treat several spinal disorders and involves the insertion of a structural graft into an intervertebral disk space to promote bony arthrodesis. Although the posterior approach to the lumbar spine was long the most frequently adopted surgical strategy to perform fusion, anterior approaches, first introduced in 1906, have recently blossomed. Patient expectations and increasing demands for shorter hospital stay and early recovery have led to more innovative surgical techniques to reduce iatrogenic injury and postoperative morbidity. Depending on the level to be treated, several approaches have been developed, each dealing with peculiar anatomic obstacles:…

Surgical management of ruptured small cerebral aneurysm: Outcome and surgical notes

Background Management of small aneurysms often poses a therapeutic dilemma and surgical treatment or coiling can be considered as therapeutic choices. In the present study, we reviewed our series of ruptured small cerebral aneurysm treated surgically. Methods A total of 53 consecutive patients with ruptured small aneurysm were surgically treated between January 2008 and July 2014. Data were retrospectively collected. Procedure-related death and complications were systematically reviewed. Clinical outcomes were assessed using the Modified Ranking Scale. Neuroradiological follow-up was performed to assess aneurysmal occlusion and recanalization rate. Results The mean aneurysm size was 2 mm ± …

Treatment algorithm for spontaneous spinal infections: A review of the literature

Background: Primary spinal infections are rare pathologies with an estimated incidence of 5% of all osteomyelitis. The diagnosis can be challenging and this might result in a late identification. The etiological diagnosis is the primary concern to determine the most appropriate treatment. The aim of this review article was to identify the importance of a methodological attitude toward accurate and prompt diagnosis using an algorithm to aid on spinal infection management. Methods: A search was done on spinal infection in some databases including PubMed, ISI Web of Knowledge, Google Scholar, Ebsco, Embasco, and Scopus. Results: Literature reveals that on the basis of a clinical suspicion, the…

DEGENERATIVE CERVICAL MYELOPATHY: REVIEW OF SURGICAL OUTCOME PREDICTORS AND NEED FOR MULTIMODAL APPROACH

Degenerative cervical myelopathy is the most common cause of spinal cord injury in the elderly population in the developed world, and it significantly affects the quality of life of patients and their caregivers. Surgery remains the only treatment option able to halt disease progression and provide neurological recovery for most patients. Although it has remained challenging to predict exactly who will experience improvement after surgery, increasingly it has been shown that clinical, imaging, and electrophysiological factors can predict, with relatively good capacity, those more likely to benefit. Clinically, the baseline neurological impairment appears to be strongly related to the outcom…

Is Aspirin a Worthy Candidate in Preventing Intracranial Aneurysm Rupture?

Subarachnoid hemorrhage (SAH) usually occurs with a thunderclap headache or the worst headache of a patient's life, leading to a neurologic emergency. Among cases of nontraumatic SAH, 80%–85% are caused by ruptured intracranial aneurysms (IAs) and comprise 3% of all strokes in high-income countries In the years 2000–2008, the incidence of SAH was 4–7 per 100,000 person-years in high-income and low-to middle-income countries. Outcome after aneurysmal SAH depends on several factors, including severity of the initial hemorrhage, rebleeding, perioperative medical management, and timing and technical success for vascular malformation exclusion from the cerebral circulation. It has been estimated…

"Only Spinal Fixation" as Surgical Treatment of Cervical Myelopathy Related to Ossified Posterior Longitudinal Ligament: Review of 52 Cases.

Background Ossification of the posterior longitudinal ligament (OPLL) is a hyperostotic condition resulting in a progressive narrowing of the spinal canal and subsequent neurologic deficits. Although systemic and local factors in combination with genetic abnormality have been considered in its etiopathogenesis, OPLL remains a poorly understood pathology. Surgical management of OPLL and the choice of the most appropriate treatment are still controversial issues. Here the authors report a series of OPLL-affected patients treated by “only-fixation” technique. Methods Between June 2012 and June 2019, 52 patients having OPLL were treated by a surgical strategy involving only spinal fixation with…

Utilizzo di un nuovo sistema di coagulazione bipolare nella chirurgia dei meningiomi. Nota tecnica

Cerebral aneurysm

Changing paradigm in mild traumatic brain injury research

Analisi di anomalie ormonali subcliniche in un cluster di pazienti con trauma cranico moderato e con rilievo incidentale di empty sella.

Does Optimal Volume Fraction in Percutaneous Vertebroplasty Prevent Cement Leakage?

Lumbar facet joint stabilization for symptomatic spinal degenerative disease: A systematic review of the literature

Objective: Lumbar spinal degenerative disease (LSDD), unresponsive to conservative therapy, is commonly treated by surgical decompression and interbody fusion. Since facet joint incompetence has been suggested as responsible for the entire phenomenon of spinal degeneration, facet stabilization can be considered as an alternative technique to treat symptomatic spinal degenerative disease. The purpose of this study was to systematically review the literature for studies utilizing lumbar facet joint fixation techniques for LSDD to assess their safety and efficacy. Methods: A systematic literature review was performed following the preferred reporting items for systematic reviews and meta-analy…

Erythropoietin and subarachnoid hemorrhage.

Isolated Pediatric Intramedullary Schwannoma: Case Report and Review of Literature

Background: Intramedullary (IM) schwannomas are rare entities representing 0.3%−1% of intramedullary tumors and 1.1% of spinal schwannomas. Beside many theories proposed, their rare occurrence might be related to the absence of Schwann cells in the spinal cord. Pediatric IM schwannomas are uncommon, and in the absence of neurofibromatosis they are extremely rare. To date, few cases have been reported in the literature. Case Description: We describe the case of an 8-year-old female affected by a progressive paraparesis. Neuroradiologic investigations showed an oval-shaped mass at the level of T10-T11. The patient underwent surgery, performed under neurophysiologic monitoring. The patient was…

Cyberknife radiosurgery for cranial plasma cell tumor

Cranial and intracranial involvement by myelomatous disease is relatively uncommon. Furthermore, systemic manifestations of multiple myeloma are present in the majority of these cases at the time of symptom onset. The authors report the case of a patient with serial appearance of multiple intracranial plasma cell tumor localizations as the first manifestations of a multiple myeloma. The patient was treated with CyberKnife radiosurgery for a lesion localized at the clivus and sella turcica with complete local control. With such a technique, based on high-dose conformality, the tumor was centered with an ablative dose of radiation and, at the same time, with a low dose spreading to the surrou…

Extent of resection and survival in glioblastoma multiforme

Brown and colleagues1 reported the results of a systematic review of the literature aimed in determining whether greater extent of resection (EOR) is associated with improved 1- and 2-year overall survival and 6-month and 1-year progression-free survival in patients affected by glioblastoma multiforme. The analysis revealed 37 studies suitable for inclusion. The authors found that gross total resection (GTR) for glioblastoma multiforme reduces 1- and 2-year mortality, thus supporting GTR over subtotal resection and biopsy.

Trattamento endovascolare degli aneurismi giganti intracranici a colletto stretto mediante stent autoespandibili. Nostra esperienza

Current Concepts and Perspectives on Brain Arteriovenous Malformations: A Review of Pathogenesis and Multidisciplinary Treatment.

Brain arteriovenous malformations (bAVMs) are unusual vascular pathologies characterized by the abnormal aggregation of dilated arteries and veins in the brain parenchyma and for which the absence of a normal vascular structure and capillary bed leads to direct connections between arteries and veins. Although bAVMs have long been believed to be congenital anomalies that develop during the prenatal period, current studies show that inflammation is associated with AVM genesis, growth, and rupture. Interventional treatment options include microsurgery, stereotactic radiosurgery, and endovascular embolization, and management often comprises a multidisciplinary combination of these modalities. T…

Multi-spectral Pattern of Clinical Presentation and the Resultant Outcome in Central Nervous System Tuberculosis: A Single Center Study on the Ubiquitous Pathogen

Central nervous system (CNS) tuberculosis (TB) is a great medical masquerader having a multi-spectral pattern of clinical presentation, thereby complicating early diagnosis and appropriate management. This review article describes clinical presentation of CNS TB in a group of 47 patients, who were managed in the Nobel Medical College and Teaching Hospital in Biratnagar, Nepal during the last 2 years. We evaluated demographic profile, mode of management, and clinical outcome in these patients. The findings were that intracranial TB was present in 27 (57.5%) patients and the spinal involvement was in 20 (42.5%) patients. The most frequent presentation of the former was TB meningitis with hydr…

Microwave Ablation for Metastatic Spinal Tumors

Early Onset of Guillain–Barré Syndrome Following Lumbar Disc Herniation Surgery: An Unexpected Clinical Evolution

Letter: Guillain–Barré syndrome (GBS), is a neurologic complication rarely reported following a spinal surgery procedure.1, 2, 3, 4, 5, 6 GBS is a potentially fatal, immune-mediated disease of the peripheral nerves and nerve roots that is usually triggered by infections. It is the most common cause of acute flaccid paralysis, with an annual global incidence of approximately 1–2 per 100,000 person-years.7 Although the clinical presentation of the disease is heterogeneous, patients typically present with weakness and sensory signs in the legs that progress to the arms and cranial muscles. Disease progression can be rapid in approximately 20% of patients with respiratory failure requiring mech…

Clinical analysis following lumbar interspinous devices implant: where we are and where we go

Objectives:We present our experience with patients treated with interspinous devices who are affected by neurogenic intermittent claudication (NIC) or lumbar disc herniation (LDH) where the interspinous system has been inserted following microdiscectomy.Study design:Retrospective study.Methods:This study included patients (n=100) with NIC secondary to lumbar spinal stenosis (group 1), and patients (n=100) with LDH (group 2) in whom the interspinous device has been implanted following radicular decompression in a period spanning 6 years. The latter have been compared with a homogenous group of patients (n=100) where no interspinous system has been implanted following microdiscectomy (group 3…

Landmarks for vertebral artery repositioning in bulbar compression syndrome: anatomic and microsurgical nuances

Abstract OBJECTIVE: The purpose of this study was to better elucidate the anatomic relationship between the vertebral artery (VA) along with its perforating vessels and the brainstem to develop anatomic guidelines that would be helpful when decompressing medulla oblongata compressed by the VA. METHODS: Microanatomy dissection was performed in six formalin-fixed cadaveric heads. The VA, posteroinferior cerebellar artery (PICA), anteroinferior cerebellar artery (AICA), and lower brainstem perforators were examined under magnification using a surgical microscope. The outer diameters of the VA, PICA, and AICA were measured. The distance between the VA, lying within the lateral cerebellomedullar…

Role of i-CT, i-US, and Neuromonitoring in Surgical Management of Brain Cavernous Malformations and Arteriovenous Malformations: A Case Series.

OBJECTIVE: We retrospectively reviewed the institutional experience in patients who underwent microsurgical resection of cavernous malformations (CMs) or arteriovenous malformations (AVMs) using a multimodal intraoperative protocol including neuronavigation, intraoperative ultrasound (i-US), computed tomography (i-CT), and neuromonitoring.METHODS: Twenty-four patients (14 male), with a mean age of 47.5 years (range 27 - 73), have been included: 20 of them suffered from CMs and 4 suffered from AVMs.Neuromonitoring was used in 18 cases, when lesions were located in eloquent areas; 2 patients underwent awake craniotomy. First, an i-CT scan with and without contrast was acquired after patient p…

Anaesthetic-related neuroprotection: intravenous or inhalational agents?

In designing the anaesthetic plan for patients undergoing surgery, the choice of anaesthetic agent may often appear irrelevant and the best results obtained by the use of a technique or a drug with which the anaesthesia care provider is familiar. Nevertheless, in those surgical procedures (cardiopulmonary bypass, carotid surgery and cerebral aneurysm surgery) and clinical situations (subarachnoid haemorrhage, stroke, brain trauma and postcardiac arrest resuscitation) where protecting the CNS is a priority, the choice of anaesthetic drug assumes a fundamental role. Treating patients with a neuroprotective agent may be a consideration in improving overall neurological outcome. Therefore, a cl…

Erythropoietin and its lost receptor

Erythropoietin and Its Double Receptors.

Concept of Spectrobiopsy Facing Gliomas: Rational and Future Perspectives Related to Target Therapy

Gliomas represent the most common primary intracranial tumors with an estimated incidence of 31% of all central nervous system neoplasms. Lesions originated from glial cells are extremely heterogeneous, ranging from low grade to high grade with different clinical and biological malignancy. Glioblastoma multiforme (GBM) is the most aggressive and frequent primary malignant tumor of the central nervous system in adults. Even though in the past decades considerable efforts have been made in the therapeutic management of this type of tumor,2 the prognosis after diagnosis of GBM remains extremely poor, reaching a median overall survival of 12–18 months. In 2016 the World Health Organization clas…

The role of erythropoietin in aneurysmal subarachnoid hemorrhage: from bench to bed side.

Malignant teratoma in Klippel-Feil syndrome: a case report and review of the literature

Introduction: Klippel-Feil syndrome is characterized by a congenital fusion of cervical vertebrae. Intracranial teratomas are nongerminomatous germ cell tumors and they account for 0.3 to 0.9% of all intracranial tumors. Teratomas with malignant transformation refer to lesions which give rise to malignant cancer of somatic type. The association between tumors of dermoid origin and Klippel-Feil malformation is extremely rare. Only 23 other cases have so far been reported, and only one case of dermoid tumor with areas of dedifferentiation on squamous cell carcinoma has been described. Case presentation: We report the case of a 72-year-old white man with a 2-year history of gait and balance di…

Down with the erythropoietin. Long live the erythropoietin!

In recent years the use of erythropoietin has exploded, and the anaemia of patients with chronic renal failure has been practically resolved with the administration of rHuEpo (recombinant human, Erythropoietin). However, as a result of an intense commercial campaign, strong therapies with this growth hormone, prescribed to achieve surprising sporting performances, got athletes to run the risk of thrombosis and vascular accidents because of red blood cells increase. Erythropoietin represents a significant subject of research. In fact, besides the ability of stimulating erythrocyte production, it has many pleiotropic effects. Several studies allow the assertion that EPO, in different concentr…

The Ipsilateral Interhemispheric Transprecuneal Approach to the Atrium: Technical Considerations and Clinical Outcome on a Series of 7 Patients

Surgical removal of tumors of the atrium is challenging due to their deep location, vascularization, and to their complex three-dimensional relationships with the highly functional white matter fibers of the region. To assess the feasibility and the effectiveness of the ipsilateral interhemispheric transprecuneus approach (IITA) for tumors involving the atrium and the posterior third of the temporal horn, a retrospective chart review of all patients who had undergone a surgical treatment for intraventricular tumors between January 2008 and January 2017 was performed, and the step-by-step approach is described. Ten patients affected by lesions of the atrium of the lateral ventricle underwent…

Ossified spinal meningiomas: Clinical and surgical features

Abstract Object Meningiomas constitute 25% of primary spinal tumors and predominantly involve the thoracic spinal cord. Although calcifications are commonly seen in intracranial meningiomas, gross calcifications are observed in only 1–5% of all spinal meningiomas. We report the clinical findings, surgical strategy and histological features of 9 patients with ossified spinal meningiomas (OSMs). Patients and methods Clinical and surgical features of 9 patients with ossified spinal meningiomas were retrospectively reviewed. Results There were 8 women and 1 man with a mean age of 59 years. In 7 patients, the lesions were localized in the thoracic segment of the spine while in 2 patients in the …

Neuroprotective role of erythropoietin in spinal cord ischemic injury: Where have we been and where are we going?

I read with great interest the study recently published by Yamanaka and colleagues,1 reporting the results of the study aimed to pharmacologically induce b common receptor (bcR) subunit upregulation before ischemia to optimize the neuroprotective effect of erythropoietin (EPO). The authors hypothesized that bcR subunit upregulation by diazoxide (DZ) before ischemia amplifies the neuroprotective effects of EPO in mice after spinal cord injury (SCI). They reported that that optimal bcR upregulation occurred at 36 hours after DZ administration, and the optimal DZ dosage for bcR induction was 20 mg/kg. Motor function at 48 hours after treatment was significantly better preserved in the DZ with …

Letter to the Editor. Idiopathic normal pressure hydrocephalus: is 1-year follow-up enough?

Minimally Invasive Surgery for Decompression in Chiari I Malformation

Chiari malformations (CMs) includes different pathologies sharing common anatomic deformities of the brainstem and cerebellum. CM type I was originally introduced by Hans Chiari and described as an “elongation of the tonsils and the medial parts of the inferior lobes of the cerebellum into cone-shaped projections which accompany the medulla oblongata into the spinal canal.” The prevalence of CM has been estimated to be between 0.1% and 0.5%, but it is possible that higher rates will be identified since the increasing the use of magnetic resonance imaging (MRI) in common clinical practice. Clinical studies have shown an equal prevalence in both sexes without particular ethnic or geographic d…

Ruolo dell’eritropoietina nei gliomi: dati sperimentali e clinici.

Use of Machine Learning and Artificial Intelligence to Drive Personalized Medicine Approaches for Spine Care

Personalized medicine is a new paradigm of healthcare in which interventions are based on individual patient characteristics rather than on “one-size-fits-all” guidelines. As epidemiological datasets continue to burgeon in size and complexity, powerful methods such as statistical machine learning and artificial intelligence (AI) become necessary to interpret and develop prognostic models from underlying data. Through such analysis, machine learning can be used to facilitate personalized medicine via its precise predictions. Additionally, other AI tools, such as natural language processing and computer vision, can play an instrumental part in personalizing the care provided to patients with …

Conservative Management for Odontoid Cervical Fractures: Halo or Rigid Cervical Collar?

Odontoid fractures are the most common fractures of the cervical spine, especially in the elderly. They account for approximately one third of cervical spine fractures, and with the aging of the world population, the incidence and clinical and social relevance of such pathology are likely to increase. Odontoid fractures may occur from high-energy mechanisms, particularly in younger patients, but low-energy trauma may be the causative factor in the geriatric population. Overall, the treatment of patients with odontoid process fractures is based on the type of the fracture, patient's health status, age, association with neurologic deficits, and personal preference of the surgeon. Relative ind…

[Letter to the Editor] Bipolar radiofrequency ablation for metastatic spinal tumors: an evolving paradigm in palliative care

I read with great interest the article by Wallace and col- laborators focusing on the combination of radiofrequency ablation (RFA) and vertebral augmentation for palliation of painful spinal metastases [1]. In a retrospective approach the authors reviewed a group of patients who underwent RFA for vertebral metastases in a period spanning almost 2 years. In a cohort of 110 patients, 72 RFA procedures were performed. Interestingly, 81 % of the metastatic lesions involved the posterior vertebral body and 45 % the pedicles. In almost all the cases, vertebral augmentation was performed following the ablation procedure.

Cisplatin-induced peripheral neuropathy: neuroprotection by erythropoietin without affecting tumour growth

This study examined the dose-dependent efficacy of erythropoietin (EPO) for preventing and/or treating cisplatin (CDDP) induced peripheral neurotoxicity (CINP), and its influence on tumour treatment and growth. Rats received eight intraperitoneal (ip) injections of 2 mg/kg CDDP twice weekly. EPO co-administered (50 or 10 microg/kg ip, three times/week) had a dose-dependent effect, partially preventing CINP, but 0.5 microg/kg ip was not effective. The neuroprotective effect lasted at least 5 weeks after the last dose of EPO and CDDP. In addition, EPO (50 microg/kg ip three times/week) after the last injection of CDDP still induced a significant recovery of CINP. In a separate experiment in r…

Letter to the Editor Regarding "Comparison of Different Hybrid Techniques for the Treatment of Multilevel Cervical Degenerative Disc Disease-Analysis of Prospectively Collected Clinical, Radiologic, and Psychological Parameters".

Calcified Spinal Meningioma: A Lurking Danger

Tumors of the spine with an intradural location have an incidence ranging from 3 to 10 per 100,000 persons per year, and intradural extramedullary tumors account for two thirds of all intraspinal neoplasms. Among these, spinal meningiomas account for 25%–46% of all spinal cord tumors. They develop from the arachnoid cells that differentiate from neural crest cells and, like cerebral meningioma, they have a slow-growing behavior. Although spinal meningiomas are not uncommon, calcified spinal meningioma is rare in spinal location. Calcified meningioma manifests with extensive matrix and tends to infiltrate the surrounding structures. It exhibits a growth pattern limited by an incompletely dev…

Remodeling Pattern of Spinal Canal after Full Endoscopic Uniportal Lumbar Endoscopic Unilateral Laminotomy for Bilateral Decompression: One Year Repetitive MRI and Clinical Follow-Up Evaluation

Objective: There is limited literature on repetitive postoperative MRI and clinical evaluation after Uniportal Lumbar Endoscopic Unilateral Laminotomy for Bilateral Decompression. Methods: Clinical visual analog scale, Oswestry Disability Index, McNab’s criteria evaluation and MRI evaluation of the axial cut spinal canal area of the upper end plate, mid disc and lower end plate were performed for patients who underwent single-level Uniportal Lumbar Endoscopic Unilateral Laminotomy for Bilateral Decompression. From the evaluation of the axial cut MRI, four types of patterns of remodeling were identified: type A: continuous expanded spinal canal, type B: restenosis with delayed expansio…

Is erythropoietin a worthy candidate for traumatic brain injury or are we heading the wrong way? [version 1; referees: 2 approved]

Traumatic brain injury (TBI) is a leading cause of death and disability in the modern society. Although primary prevention is the only strategy that can counteract the primary brain damage, numerous preclinical studies have been accumulated in order to find therapeutic strategies against the secondary damage. In this scenario erythropoietin (EPO) has been shown to be a promising candidate as neuroprotective agent. A recent clinical trial, however, has shown that EPO has not an overall effect on outcomes following TBI thus renewing old concerns.  However, the results of a prespecified sensitivity analysis indicate that the effect of EPO on mortality remains still unclear. In the light of the…

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…

Microsurgical Management of Intracranial Aneurysms After Flow Diversion Failure

Subarachnoid hemorrhage (SAH) occurring after an intracranial aneurysm rupture has an incidence of 10.5 per 100,000 person-years and accounts for about 5% of strokes. The resulting outcome depends on several factors including the severity of the initial hemorrhage, rebleeding, perioperative medical management, and the timing and technical success for aneurysm treatment. The overall mortality rates from 32%−67% with 10%–20% of patients with long-term dependence due to brain damage. It is well known that 12% of patients die before achieving medical treatment and 25% die within the first 24 hours. Again, 40%–60% mortality rate occurs within 30 days. Among the surviving patients, about one thir…

Autologous fibrin sealant (Vivostat(®)) in the neurosurgical practice: Part I: Intracranial surgical procedure.

Background: Hemorrhages, cerebrospinal fluid (CSF) fistula and infections are the most challenging postoperative complications in Neurosurgery. In this study, we report our preliminary results using a fully autologous fibrin sealant agent, the Vivostat ® system, in achieving hemostasis and CSF leakage repair during cranio‑cerebral procedures. Methods: From January 2012 to March 2014, 77 patients were studied prospectively and data were collected and analyzed. Autologous fibrin sealant, taken from patient’s blood, was prepared with the Vivostat ® system and applied on the resection bed or above the dura mater to achieve hemostasis and dural sealing. The surgical technique, time to bleeding c…

Presurgical evaluation of hemifacial spasm and spasmodic torticollis caused by a neurovascular conflict from AICA with 3T MRI integrated by 3D drive and 3D TOF image fusion: A case report and review of the literature.

Background: Hemifacial spasm (HS) and spasmodic torticollis (ST) are well-known disorders that are caused by a neurovascular conflict. HS is characterized by irregular, involuntary muscle contractions on one side of the face due to spasms of orbicularis oris and orbicularis oculi muscles, and is usually caused by vascular compression of the VII cranial nerve. ST is an extremely painful chronic movement disorder causing the neck to involuntary turn to the side, upward and/or downward. HS is usually idiopathic but it is rarely caused by a neurovascular conflict with the XI cranial nerve. Case Description: We present a case of a 36-year-old woman with a 2-year history of left hemifacial spasm …

Innovations in the Art of Microneurosurgery for Reaching Deep-Seated Cerebral Lesions.

Deep-seated cerebral lesions have fascinated and frustrated countless surgical innovators since the dawn of the microneurosurgical era. To determine the optimal approach, the microneurosurgeon must take into account the characteristics and location of the pathological lesion as well as the operator's range of technical expertise. Increasingly, microneurosurgeons must select between multiple operative corridors that can provide access to the surgical target. Innovative trajectories have emerged for many indications that provide more flexible operative angles and superior exposure but result in longer working distances and more technically demanding maneuvers. In this article, we highlight 4 …

Spontaneous Meckel's cave hematoma: A rare cause of trigeminal neuralgia

Background: The most common etiology of classic trigeminal neuralgia (TN) is vascular compression. However, other causes must be considered. Among these, spontaneous hematoma of the Meckel′s cave (MC) causing symptomatic TN is very rare. Case Description: We present the case of a 60-year-old woman with a 2-month history of left TN and diplopia. Neuroradiological examinations revealed a well-defined hematoma in the left MC. The patient underwent surgical decompression with a progressive neurological improvement. Conclusion: Despite the number of lesions potentially affecting the MC, spontaneous hemorrhage is rare but should be taken into account in the differential diagnosis.

Age-Dependent Brain AVM Characteristics: What is the Evidence?

Derivatives of Erythropoietin That Are Tissue Protective But Not Erythropoietic

Erythropoietin (EPO) is both hematopoietic and tissue protective, putatively through interaction with different receptors. We generated receptor subtype–selective ligands allowing the separation of EPO's bioactivities at the cellular level and in animals. Carbamylated EPO (CEPO) or certain EPO mutants did not bind to the classical EPO receptor (EPOR) and did not show any hematopoietic activity in human cell signaling assays or upon chronic dosing in different animal species. Nevertheless, CEPO and various nonhematopoietic mutants were cytoprotective in vitro and conferred neuroprotection against stroke, spinal cord compression, diabetic neuropathy, and experimental autoimmune encephalomyeli…

The cholinergic system in Down's syndrome

The cholinergic system is one of the most important modulatory neurotransmitter systems in the brain. Alterations of the transmission communicators are accompanied by reduction of the cortical activity, which is associated with a learning and memory deficit. Down's syndrome is a pathological condition characterized by a high number of abnormalities that involve the brain.The cholinergic system is involved in alterations of the neurological system such as severe learning difficulties.To explain these alterations, important results are obtained from studies about murine trisomy 16 (animal model of Down's syndrome).The results obtained provide useful elements in the improvement of knowledge ab…

Hirayama disease – Early MRI diagnosis of subacute medullary ischemia: A case report

Background: Hirayama disease (HD) is a rare, benign, and self-limiting motor neuron disorder that results in selective motor impairment of the C7-T1 myotomes. It is characterized by progressive, unilateral, or bilateral asymmetric muscle atrophy of the distal upper extremities and myelopathy. Case Description: A 23-year-old male presented with bilateral atrophy of the thenar/hypothenar eminences/ interosseous muscles, plus left-hand weakness. The cervical MRI documented subacute ischemic damage of the distal cervical cord. To rule out a tumor and reduce questionable cord compression, the patient underwent a C5–C6 anterior cervical discectomy and fusion (ACDF) immediately followed by a lami…

Valutazione retrospettiva sull'uso dei sistemi interspinosi per il trattamento mini-invasivi della stenosi spinale lombare: stato dell'arte e prospettive future

Maximizing the Extent of Resection in High-Grade Glioma.

High-grade gliomas (HGGs) are devastating tumors associated with one of the worst prognoses in oncology. Glioblastoma multiforme (GBM) is the most frequently reported histologic type, with a median survival after surgery and combined treatment with chemotherapy and radiotherapy of 12–16 months. Several studies have shown that the extent of resection (EOR) of the contrast-enhancing part of the tumor improves survival in patients with HGGs, although the quest to achieve optimal oncologic outcomes must be tempered with the neurologic result following radical resection. To date, limited evidence exists on the relationship between EOR and level of clinical benefit for patients with HGGs. Brown e…

Transcranial Magnetic Resonance-Guided Focused Ultrasound Surgery for Brain Tumor Ablation: Are We Ready for This Challenging Treatment?

The treatment of high-grade gliomas (HGGs) remains a challenge for modern therapy. The prognosis for these patients has been poor. The median patient survival after diagnosis has been ∼1 year with surgery and/or radiotherapy and temozolomide.1 The need for a histological diagnosis of tumor tissue in each case and the importance of decompression in symptomatic patients are well established, and extensive surgical resection has been shown to significantly prolong survival. Several factors play a role in the prognosis of patients with HGG, including age, performance status using the Karnofsky performance scale, and the extent of resection.2, 3 At present, the standard therapy for HHG consists …

Seizure in isolated brain cryptococcoma: Case report and review of the literature

Background: Central nervous system (CNS) cryptococcosis is an invasive fungal infection predominantly seen among immunosuppressed patients causing meningitis or meningoencephalitis. Rarely, cryptococcosis can affect immunologically competent hosts with the formation of localized CNS granulomatous reaction, known as cryptococcoma. Common symptoms of CNS cryptococcoma are headaches, consciousness or mental changes, focal deficits, and cranial nerve dysfunction. Rarely, seizures are the only presenting symptom. Case Description: We report the case of an immunocompetent patient with a solitary CNS cryptococcoma presenting with a long history of non-responsive generalized seizure who has been s…

Hybrid Anterior Cervical Discectomy
and Fusion and Cervical Disc Arthroplasty: An Analysis of Short-Term Complications, Reoperations, and Readmissions

Dolichoectasia of the vertebrobasilar complex causing neural compression

Dear Editor, We have read with great interest the paper of Yuh et al.[4] reporting a case of symptomatic hydrocephalus due to vertebrobasilar dolichoectasia (VBD) compressing the brainstem. Ectatic or pathologically enlarged vertebrobasilar arteries have been reported with increasing frequency and associated with several clinical syndromes. These include an assortment of cranial nerve syndromes, transient or permanent motor deficit, cerebellar dysfunction, central sleep apnea, ischemic stroke, hypertension, and hydrocephalus as reported in the paper by Yuh et al.[4] Others and we have also described pyramidal tract signs and cranial nerve nucleus dysfunction caused by vascular compression o…

Subfrontal approaches

Among the different transcranial approaches routinely used for the management of anterior cranial base lesions, the subfrontal approach is one of the most common and versatile surgical procedures, with the unilateral or bilateral alternative, according to the lesion's extension and size. © 2010 Springer-Verlag Milan.

New Challenges for the Betterment of Spine Health

Progressive necrotic encephalopathy following tacrolimus therapy for liver transplantation.

Previously described neurologic damage induced by immunosuppressive treatments includes transient or reversible central nervous system involvement. We describe a 57-year-old man who underwent liver transplantation and was started on immunosuppressive therapy with tacrolimus (FK506). Six months later, he started complaining of a progressive motor and sensory impairment of the left side, together with cognitive impairment. Brain MRI showed an enlarging lesion of the white matter with peripheral contrast enhancement. PET study indicated severe hypometabolism in the right hemisphere and spectroscopic MRI showed a peak of choline and relative reduction of other metabolites. Findings of CSF exami…

Does Neuroprotection Still Have a Role in Injured Brain Following Aneurysmal Subarachnoid Haemorrhage?

Effetto neuroprotettivo dell'asialo-eritropoietina: evidenze sperimentali e future applicazioni cliniche.

Erythropoietin mediates tissue protection through an erythropoietin and common beta-subunit heteroreceptor

The cytokine erythropoietin (Epo) is tissue-protective in preclinical models of ischemic, traumatic, toxic, and inflammatory injuries. We have recently characterized Epo derivatives that do not bind to the Epo receptor (EpoR) yet are tissue-protective. For example, carbamylated Epo (CEpo) does not stimulate erythropoiesis, yet it prevents tissue injury in a wide variety ofin vivoandin vitromodels. These observations suggest that another receptor is responsible for the tissue-protective actions of Epo. Notably, prior investigation suggests that EpoR physically interacts with the common β receptor (βcR), the signal-transducing subunit shared by the granulocyte-macrophage colony stimulating fa…

Efficacy of Zero-Profile Device versus Plate and Cage Implant for Treatment of Symptomatic Adjacent Segment Disease After Anterior Cervical Diskectomy and Fusion

Cisternostomy for Traumatic Brain Injury: Pathophysiologic Mechanisms and Surgical Technical Notes

Objective Traumatic brain injury (TBI) is one of the major challenges in health care, representing the third most frequent cause of death. Current optimal management is based on a progressive, target-driven approach combining both medical and surgical treatment strategies. Here we describe cisternostomy, an emerging surgical treatment for the treatment of TBI. Methods Cisternostomy is a novel technique that incorporates knowledge of skull base and microvascular surgery. By opening the brain cisterns to atmospheric pressure, the technique could decrease the intracranial pressure due to a backshift of the cerebrospinal fluid (CSF) from the swollen brain to the cisterns through the Virchow-Rob…

The role of erythropoietin in aneurysmal subarachnoid haemorrhage: from bench to bedside.

Subarachnoid haemorrhage (SAH) caused by a ruptured aneurysm accounts for only 5% of strokes, but occurs at a fairly young age and carries a poor prognosis. Delayed cerebral ischaemia (DCI) is an important cause of death and dependence after aneurysmal SAH. The current mainstay of preventing DCI is nimodipine and maintenance of normovolemia, but even with this strategy DCI occurs in a considerable proportion of patients. Several drugs have been developed that have the potential to limit cerebral vasospasm and delayed ischaemic neurologic defi cit, thus improving outcome for patients. However, although numerous agents can prevent arterial narrowing and/or block the excitatory cascade of even…

Hemostasis in brain tumor surgery using the Aquamantys system

Background: Adequate hemostasis in cranial and spinal tumor surgery is of paramount importance in neurosurgical practice. Generalized ooze bleeding from the surgical walls cavity, coming from neoplastic vessels or nervous tissue, may be problematic. Recent technical advances have dramatically reduced intraoperative complications related to blood loss. Several techniques are usually employed to control hemostasis in tumor surgery, including preoperative embolization, intraoperative hypotension, electrical coagulation, and local application of fibrin sealants or hemostatic matrix, which influence coagulation. Material/Methods: Our aim in this study was to evaluate the efficacy and the safety …

Intestinal ischemia/reperfusion promotes brain damage via microglia activation: can we do something now?

Does endovascular treatment with curative intention have benefits for treating High-grade AVM versus radiosurgery? Efficacy, safety, and cost-effectiveness analysis

BACKGROUND: The treatment of high-grade arteriovenous malformations (AVMs) remains challenging. Microsurgery provides a rapid and complete occlusion compared to other options, but is associated with undesirable morbidity and mortality. The aim of this study was to compare the occlusion rates, incidence of unfavorable outcomes, and cost-effectiveness of embolization and stereotactic radiosurgery (SRS) as a curative treatment for high-grade AVMs.METHODS: A retrospective series of 57 consecutive patients with high-grade AVM treated with embolization or SRS, with the aim of achieving complete occlusion, was analyzed. Demographic, clinical, and angio-architectonic variables were collected. Both …

Management of Odontoid Cervical Fracture

Fractures of the cervical odontoid process are the most common fractures of the cervical tract, accounting for one third of all cervical spine fractures. They are more frequent in elderly patients, and with the aging of the world population, their incidence and clinical and social relevance are expected to increase in the near future. The mechanisms underlying odontoid fractures differ according to patient age, with high-energy mechanisms being the causative factor frequently encountered in younger patients and low-energy trauma commonly occurring in elderly patients. Despite rising incidence and costs, there is considerable uncertainty regarding the optimal management for these fractures, …

Erythropoietin and erythropoietin receptor expression after experimental spinal cord injury encourages therapy by exogenous erythropoietin

OBJECTIVE: Erythropoietin (EPO) is a pleiotropic cytokine originally identified for its role in erythropoiesis. Recent studies have demonstrated that EPO and its receptor (EPO-R) are expressed in the central nervous system, where EPO exerts neuroprotective functions. Because the expression of the EPO and EPO-R network is poorly investigated in the central nervous system, the aim of the present study was to investigate whether the resident EPO and EPO-R network is activated in the injured nervous system. METHODS: A well-standardized model of compressive spinal cord injury in rats was used. EPO and EPO-R expression was determined by immunohistochemical analysis at 8 hours and at 2, 8, and 14 …

La telemedicina nella implementazione delle linee guida per la gestione delle emergenze neurochirurgiche

Erythropoietin and its lost receptor [8]

Amelioration of spinal cord compressive injury by pharmacological preconditioning with erythropoietin and a nonerythropoietic erythropoietin derivative.

Object Spinal cord injury (SCI) is a devastating clinical syndrome for which no truly efficacious therapy has yet been identified. In preclinical studies, erythropoietin (EPO) and its nonerythropoietic derivatives asialoEPO and carbamylated EPO have markedly improved functional outcome when administered after compressive SCI. However, an optimum treatment paradigm is currently unknown. Because the uninjured spinal cord expresses a high density of EPO receptor (EPOR) in the basal state, signaling through these existing receptors in advance of injury (pharmacological preconditioning) might confer neuroprotection and therefore be potentially useful in situations of anticipated damage. Methods…

The Role of Erythropoietin in Neuroprotection: Therapeutic Perspectives

Nervous system diseases are very complex conditions comprising a large variety of local and systemic responses. Several therapeutic agents interfering with all or in part the biochemical steps that ultimately cause neuronal death have been demonstrated to be neuroprotective in preclinical models. However, all the agents so far investigated have inexorably failed in the phase III trials carried out. A large body of evidence suggests that the hormone erythropoietin (EPO), besides its well-known hematopoietic action, exerts beneficial effects in the central nervous system. EPO's effect has been assessed in several experimental models of brain and spinal cord injury thus becoming a serious cand…

The Role of Erythropoietin in Aneurysmal Subarachnoid Haemorrhage: From Bench to Bedside

Subarachnoid haemorrhage (SAH) caused by a ruptured aneurysm accounts for only 5 % of strokes, but occurs at a fairly young age and carries a poor prognosis. Delayed cerebral ischaemia (DCI) is an important cause of death and dependence after aneurysmal SAH. The current mainstay of preventing DCI is nimodipine and maintenance of normovolemia, but even with this strategy DCI occurs in a considerable proportion of patients.

Management of aneurysmal subarachnoid hemorrhage: State of the art and future perspectives

Background: Aneurysmal subarachnoid hemorrhage (SAH) accounts for 5% of strokes and carries a poor prognosis. It affects around 6 cases per 100,000 patient years occurring at a relatively young age. Methods: Common risk factors are the same as for stroke, and only in a minority of the cases, genetic factors can be found. The overall mortality ranges from 32% to 67%, with 10–20% of patients with long-term dependence due to brain damage. An explosive headache is the most common reported symptom, although a wide spectrum of clinical disturbances can be the presenting symptoms. Brain computed tomography (CT) allow the diagnosis of SAH. The subsequent CT angiography (CTA) or digital subtraction …

Vascular endothelial growth factor induces brain erythropoietin expression?

To investigate whether the formation of vascular endothelial growth factor (VEGF) influences erythropoietin (EPO) expression in physiological conditions, we injected into the left lateral cerebral ventricle of the Mongolian gerbil an adeno-associated virus (AAV) vector capable of expressing the 165-amino-acid isoform of VEGF (VEGF165). Twelve and 18 days after AAV vector injection, the experimental animals were sacrificed and expression of EPO was evaluated through immunohistochemical analysis of both the hippocampus and the frontal cortex. We observed that VEGF165 induces EPO expression in the hippocampal pyramidal layers and in the frontal cortex of the gerbil, particularly after the 18th…

Compressione midollare dorsale in paziente con Sindrome da immunodeficienza accquisita (AIDS)

Presurgical role of MRI tractography in a case of extensive cervicothoracic spinal ependymoma

Background: Intramedullary spinal ependymoma is a tumor, hardly characterizable with conventional magnetic resonance (MR) imaging only. MR diffusion tensor imaging (DTI) with three dimensional fiber tracking reconstructions allows the evaluation of the relationship between neoplasm and white matter fiber tracts, being a powerful tool in presurgical planning. We present DTI findings in a case of a young female with an extensive cervicothoracic spinal ependymoma. Case Description: The patient complained of a 2 month history of acute urinary retention, weakness and numbness on the lower limbs and the upper left limb. She underwent MR imaging that showed an extensive cervicothoracic spinal mass…

Best Practice. British Medical Journal .

Surgical Treatment for Traumatic Brain Injury: Is It Time for Reappraisal?

Traumatic brain injury (TBI) is a major cause of morbidity and mortality in the United States. It is estimated that each year, on average, TBIs associated with 1.1 million visits to the emergency department, 235,000 hospitalizations, and 50,000 deaths.

Familial Replicating Arachnoidal Cysts: Case Series and Review of Literature

Background: Arachnoid cysts are intra-arachnoid fluid collections covered by a thin membrane that may develop throughout the cerebrospinal axis. Although the precise causative mechanism is unknown, arachnoid cyst (AC) are now generally accepted to be developmental anomalies of arachnoid. These lesions have commonly been described in the literature; however the presence of familial arachnoid cysts is quite rare. Most genetically related AC have been documented in patients with a known genetic syndrome. The current case report describes a family with four members affected by an arachnoid cyst in the same region. Methods: In addition to reviewing the current case, a literature search was condu…

Erythropoietin in Traumatic Brain Injury: An Answer Will Come Soon

Traumatic brain injury (TBI) is a major cause of morbidity and mortality in the United States. It is estimated that each year TBIs are associated with 1.1 million emergency department visits, 235,000 hospitalizations, and 50,000 deaths (1). Despite improvements in medical interventions, there are still no neuroprotective agents available to counteract secondary or delayed damage to the traumatically injured human brain or to promote its repair. TBI encompasses heterogeneous etiologic, anatomical, and molecular patterns of injury that exhibit different propensities to cause cerebral damage. Without careful consideration of individual injuries, the results of therapeutic trials remain difficu…

Imaging neuroradiologico funzionale 3-D per l'asportazione di un angioma cavernoso in area eloquente: case report e review della letteratura

Imaging neuroradiologico

Dysphagia Prevention in Anterior Cervical Discectomy Surgery: Results from a Prospective Clinical Study

Background: Dysphagia is a common complication after anterior cervical discectomy surgery (ACDS). Recent studies have shown that reducing the endotracheal tube cuff pressure, local irrigation with methylprednisolone, and minimizing the pharynx/esophagus retraction can decrease the incidence of postoperative dysphagia after ACDS. This is the first study assessing the efficacy of all these 3 measures simultaneously. Methods: This prospective study included 35 patients (group 1) who underwent ACDS with the adoption of all the 3 preventive measures. Group 1 was compared with a homogenous group of 35 patients who underwent regular ACDS (group 2). Postoperative dysphagia and odynophagia were eval…

Sealing the Cranial Base Access After Endonasal Endoscopic Approach: Reabsorption Rate of Fat Graft in the "3FTechnique".

Commentary on: Microwave Ablation for Metastatic Spinal Tumors

An unexpected association between intracranial hypotension and split cord malformation

Management of Complex Cerebral Aneurysms

BACKGROUND: Complex intracranial aneurysms (CIAs) are challenging pathologies to treat. Characteristics making an aneurysm complex include dimension, history of previous treatment, location, absence of collateral circulation, intraluminal thrombosis, and calcification of the wall. The goal of the therapeutic process is to exclude the malformation from the cerebral circulation and both endovascular and surgical treatments are valid procedures.METHODS: Between 1990 and 2020, 170 CIAs were treated at our institution (33 ruptured, 137 unruptured). They were 3 prepetrous segment of the internal carotid artery (ICA), 14 purely intracavernous sinus, 27 intracavernous with subarachnoid extension, 6…

The many faces of erythropoietin: from erythropoiesis to a rational neuroprotective strategy

It has been more than 10 years since the discovery that erythropoietin (EPO) and its receptor are expressed by the nervous system. In that brief time, a remarkable acceleration in understanding the...

Innovation in Neurosurgery: Integration Between Cutting-Edge Devices and "Old-Fashioned" Surgical Technique.

n times of rapid scientific and technological progress, doctors must be able to pursue innovations. However, although clinical decision making can rely on new opportunities, the optimism should be tempered by equally newfangled limits, mainly of economic nature, that can bind medical management. The 3 cornerstones of medical progress are genomics, nanotechnologies, and robotics, the future of which lie in the integration among imaging, digital telemedicine, and artificial intelligence. With the aid of wireless and mobile technologies, the world of digital medicine is growing quickly. In this scenario, the simple control of vital signs no longer needs spatial relationship; the continuous con…

Neuroprotective properties of xenon and helium in an in vitro model of traumatic brain injury: one small step or one big jump?

Letter: Cerebrospinal Fluid Shunting Improves Long-Term Quality of Life in Idiopathic Normal Pressure Hydrocephalus.

Is erythropoietin a worthy candidate for traumatic brain injury or are we heading the wrong way?

Traumatic brain injury (TBI) is a leading cause of death and disability in the modern society. Although primary prevention is the only strategy that can counteract the primary brain damage, numerous preclinical studies have been accumulated in order to find therapeutic strategies against the secondary damage. In this scenario erythropoietin (EPO) has been shown to be a promising candidate as neuroprotective agent. A recent clinical trial, however, has shown that EPO has not an overall effect on outcomes following TBI thus renewing old concerns.  However, the results of a prespecified sensitivity analysis indicate that the effect of EPO on mortality remains still unclear. In the light of the…

PROGRESSIVE MULTIFOCAL LEUCOENCEPHALOPATHY DURING TACROLIMUS THERAPY FOR LIVER TRANSPLANTATION

Exploring the Virchow-Robin spaces function: A unified theory of brain diseases.

Background: Cerebrospinal fluid (CSF) transport across the central nervous system (CNS) is no longer believed to be on the conventional lines. The Virchow-Robin space (VRS) that facilitates CSF transport from the basal cisterns into the brain interstitial fluid (ISF) has gained interest in a whole new array of studies. Moreover, new line of evidence suggests that VRS may be involved in different pathological mechanisms of brain diseases. Methods: Here, we review emerging studies proving the feasible role of VRS in sleep, Alzheimer's disease, chronic traumatic encephalopathy, and traumatic brain injury (TBI). Results: In this study, we have outlined the possible role of VRS in different path…

Neuroprotection by erythropoetin and darbopoetin-alfa - Following experimental intracerebral hemorrhage

Magnetic Resonance Spectrobiopsy for Prediction of Isocitrate Dehydrogenase Mutation in Glioma

Despite the existence of multimodal therapy paradigm, high-grade gliomas (HGGs) remain devastating tumors associated with one of the worst prognoses. Glioblastoma (GBM) is the most frequent reported histologic type with a median survival, after surgery and combined treatment with chemotherapy and radiotherapy, ranging from 12 to 16 months. The poor prognosis is due to the lack of therapeutic efficacy of chemical agents and irradiation in hypoxic tumor areas. Experimental studies have investigated several molecules with the aim to counteract several downstream signaling important in tumor progression, unfortunately without conclusive results. Several studies have shown that the extent of res…

Resting-State Functional Connectome in Patients with Brain Tumors Before and After Surgical Resection

Purpose: High-grade glioma surgery has evolved around the principal belief that a safe maximal tumor resection improves symptoms, quality of life, and survival. Mapping brain function has been recently improved by resting-state functional magnetic resonance imaging (rest-fMRI), a novel imaging technique that explores networks connectivity at “rest.” Methods: This prospective study analyzed 10 patients with high-grade glioma in whom rest-fMRI connectivity was assessed both in single-subject and in group analysis before and after surgery. Seed-based functional connectivity analysis was performed with CONN toolbox. Network identification focused on 8 major functional connectivity networks. A v…

Intramedullary spinal cord tumor presenting as the initial manifestation of metastatic colon cancer: case report and review of the literature

Study design: Case reports and review of the literature. Objective: Intramedullary spinal cord metastases (ISCMs) are rare type of central nervous system (CNS) involvement of systemic malignant tumors. Since the advent of new neuroradiological techniques, their detection have become increasingly diagnosed in recent years and, although somewhat controversial, surgical treatment has been considered a valid option. Setting: Neurosurgical Clinic, Department of Clinic Neuroscience, University of Palermo, Italy. Method: The authors describe the case of a 61-year-old woman who was admitted presenting withprogres sive tetraplegia. Investigations revealed an intramedullary spinal cord lesion at the …

Does Endovascular Treatment with Curative Intention Have Benefits for Treating High-Grade Arteriovenous Malformation versus Radiosurgery? Efficacy, Safety, and Cost-Effectiveness Analysis.

Background The treatment of high-grade arteriovenous malformations (AVMs) remains challenging. Microsurgery provides a rapid and complete occlusion compared with other options but is associated with undesirable morbidity and mortality. The aim of this study was to compare the occlusion rates, incidence of unfavorable outcomes, and cost-effectiveness of embolization and stereotactic radiosurgery (SRS) as a curative treatment for high-grade AVMs. Methods A retrospective series of 57 consecutive patients with high-grade AVM treated with embolization or SRS, with the aim of achieving complete occlusion, was analyzed. Demographic, clinical, and angioarchitectonic variables were collected. Both t…

Neuroprotective potential of erythropoietin and darbepoetin alfa in an experimental model of sciatic nerve injury. Laboratory investigation.

Object The objectives of this study were to examine whether the systemic administration of recombinant human erythropoietin (rHuEPO) and its long-lasting derivative darbepoetin alfa expedited functional recovery in a rat model of sciatic nerve injury, and to compare the effects of these agents in the model. Methods Thirty male Sprague–Dawley rats received a crush injury to the left sciatic nerve and subsequently underwent either placebo treatment, daily injections of rHuEPO, or weekly injections of darbepoetin alfa. Results Both rHuEPO and darbepoetin alfa were effective in reducing neurological impairment and improving compound muscle action potentials following nerve injury. Darbepoetin …

Changing paradigm in mild traumatic brain injury research

Traumatic brain injury (TBI) is a major cause of death and disability among young adults. Recent data show that TBI affects about 1.7 million people annually in the United States (Faul and Coronado, 2015). After TBI, the primary injury produces almost irreparable brain damage. However, recent experimental studies have shown evidence for dynamic brain repair following TBI because endogenous progenitor cells may play regenerative roles in response to injuries (McGinn and Povlishock, 2015). In surviving patients, what plays a critical role in the clinical prognosis is the subsequent secondary injury; without effective treat- ment, cascades that include glutamatergic excitotoxicity and calcium …

Regional and experiential differences in surgeon preference for the treatment of cervical facet injuries: a case study survey with the AO Spine Cervical Classification Validation Group

Abstract Purpose The management of cervical facet dislocation injuries remains controversial. The main purpose of this investigation was to identify whether a surgeon’s geographic location or years in practice influences their preferred management of traumatic cervical facet dislocation injuries. Methods A survey was sent to 272 AO Spine members across all geographic regions and with a variety of practice experience. The survey included clinical case scenarios of cervical facet dislocation injuries and asked responders to select preferences among various diagnostic and management options. Results A total of 189 complete responses were received. Over 50% of responding surgeons in each region…

Pathogenetic Mechanisms of Intratumoral Hemorrhage in Meningioma: The Role of Microvascular Differentiation

The transformation of normal cells into neoplastic cells is based on a series of gradual and progressive processes . One of the most important aspects underlying the tumorigenesis ist hat neoplastic proliferation needs mechanisms to ensure cancer development, bypass the body's protective strategies, and survive the apoptotic mechanisms. Subsequently, measures to promote replicative immortality and vascular support will be required. If cancer develops in an area offering excellent vascularization, pre-existing vascular circuits can supporti ts growth .Otherwise,tumor angiogenetic mechanisms will trigger new vascular networks, which will be necessary for tumor survival and expansion. The latt…

Anatomy and physiology of cisternostomy

Cisternostomy is defined as opening the basal cisterns to atmospheric pressure. This technique helps to reduce the intracranial pressure in severe head trauma as well as other conditions when the so-called sudden “brain swelling” troubles the surgeon. We elaborated the surgical anatomy of this procedure as well as the proposed physiology of how cisternostomy works. This novel technique may change the current trends in neurosurgery.

Spinal Cord Stimulation and Psychosomatic Conditions

No abstract

Long-term clinical and radiological outcomes following anterior cervical discectomy and fusion by zero-profile anchored cage

Objectives: The purpose of this study was to extend the results of our previous study providing a minimum of 4-year follow-up results of a prospective study following implantation of a cervical cage with an integrated fixation system. Summary of Background Data: The use of cervical intersomatic cages with an integrated fixation system for anterior cervical discectomy and fusion (ACDF) has increased rapidly in this last decade. In addition to immediate stabilization, these implants allow avoidance of anterior plating and iliac crest bone-grafting. Methods: Patients were studied prospectively, and data were collected and analyzed. Intersomatic cages with an integrated fixation system were use…

Role of Erythropoietin in Cerebral Glioma: An Innovative Target in Neuro-Oncology

Background: Erythropoietin (EPO) is a cytokine primarily involved in the regulation of erythropoiesis. In response to hypoxia–ischemia, hypoxia-inducible factor 1 induces EPO production, which, in turn, inhibits apoptosis of erythroid progenitor cells. By the same mechanism and acting through other signaling pathways, EPO exerts neuroprotective effects. Increased resistance to hypoxia and decreased apoptosis are thought to be important mechanisms for tumor progression, including malignant glioma. Because recent studies have demonstrated that EPO and its receptor (EPOR) are expressed in several tumors and can promote tumor growth, in the present study, we investigated EPO and EPOR expression…

Does Hybrid Surgery Improve Quality of Life in Multilevel Cervical Degenerative Disk Disease? Five-Year Follow-up Study.

Background: Patient satisfaction is becoming an increasing factor worthy of consideration when evaluating the surgical quality. The correlation between patient satisfaction and surgical outcomes 5 years after cervical hybrid surgery (HS), which incorporates anterior cervical decompression and fusion and cervical disk arthroplasty techniques in multilevel cervical degenerative disk disease, has not been evaluated. Methods: The aim of this study was firstly to analyze prospectively collected data from a sample of patients (n = 50) treated with cervical HS for selected cases of radiculopathy and myelopathy in order to evaluate pain levels of patients, using the Neck and Arm Pain scale as an ex…

Regressione di stato vegetativo dopo derivazione ventricolo-peritoneale e cranioplasstica in paziente con idrocefalo post-traumatico: case report e review della letteratura.

Cervical Spondylotic Myelopathy: When and Why the Cervical Corpectomy?

Background: Cervical spondylotic myelopathy (CSM) is a degenerative disease that represents the most common spinal cord disorder in adults. The best treatment option has remained controversial. We performed a prospective study to evaluate the clinical, radiographic, and neurophysiologic outcomes for anterior cervical corpectomy in the treatment of CSM. Methods: From January 2011 to January 2017, 60 patients with CSM were prospectively enrolled in the present study. The patients were divided according to the modified Japanese Orthopaedic Association scale (mJOA) score into 2 groups: group A, patients with mild to moderate CSM (mJOA score ≥13); and group B, patients with severe myelopathy (mJ…

Clinical and radiological features of hybrid surgery in multilevel cervical degenerative disc disease.

Purpose: Although several studies have established the safety and efficacy of cervical disc arthroplasty (CDA) as compared to anterior cervical discectomy and fusion (ACDF), few studies have investigated the role of hybrid surgery (HS) that incorporates ACDF and CDA techniques in multilevel cervical degenerative disc disease (MLCDDD). Methods: This prospective study enrolled patients with MLCDDD who underwent HS. Twenty consecutive patients who underwent HS were compared with patients who underwent ACDF and CDA at the same level of surgery. Patients were followed up for more than 2 years. Intraoperative parameters, clinical features and outcome scores were recorded. Radiological assessments…

Proteinuric effect of transcranial magnetic stimulation in healthy subjects and diabetic patients with stage 3-4 CKD

BackgroundMany authors have investigated the numerous connections between the nervous system and kidneys, and recent literature has indicated that these similar systems are interconnected. Recent scientific works have shown that there is similarity between the cerebral cortex 'viscera representation' and the 'motor omunculus'. We studied the connection between the brain and kidney in vivo using repetitive transcranial magnetic stimulation (rTMS). Proteinuria and albuminuria were used as markers of renal response in patients with diabetes (DP) and in a group of healthy subjects (HSs) who received rTMS for 5 consecutive days.MethodsThe study population consists of the following four groups: G…

Letter: Tissue-Glue-Coated Collagen Sponge (TachoSil) for Minor Cerebral Dural Venous Sinus Laceration: What is the Evidence?

We read with great interest the article by Gazzeri et al1 focusing on tissue-glue–coated collagen sponge (TachoSil) application to repair minor cerebral dural sinus lacerations. In their series, 57 consecutive patients were prospectively enrolled, and tears of the cerebral venous sinus were treated by TachoSil application directly to the site of the bleeding. In all patients, venous bleeding was managed initially by standard techniques for hemostasis such as compression, application of oxidized cellulose, or gelatin sponge. TachoSil application was used when standard measures failed to be effective, were excessively time- consuming or inadequate, or were considered risky. No complications r…

Brain and Cancer: The Protective Role of Erythropoietin

Erythropoietin (Epo) is a pleiotropic agent, that is to say, it can act on several cell types in different ways. An independent system Epo/Epo receptor (EpoR) was detected in brain, leading to the hypothesis that this hormone could be involved in cerebral functions. Epo/EpoR expression changes during ontogenesis, thus indicating the importance of this system in neurodevelopment. Moreover, the hypoxia-induced production of Epo in the adult brain suggests that it could exert a neurotrophic and neuroprotective effect in case of brain injury. Epo could also influence neuro- transmission, inducing neurotransmitters (NT) release. Epo therapy in anemic cancer patients is still a controversial issu…

Resting-State Functional Magnetic Resonance Imaging for Surgical Neuro-Oncology Planning: Towards a Standardization in Clinical Settings

Resting-state functional magnetic resonance imaging (rest-f-MRI) is a neuroimaging technique that has demonstrated its potential in providing new insights into brain physiology. rest-f-MRI can provide useful information in pre-surgical mapping aimed to balancing long-term survival by maximizing the extent of resection of brain neoplasms, while preserving the patient’s functional connectivity. Rest-fMRI may replace or can be complementary to task-driven fMRI (t-fMRI), particularly in patients unable to cooperate with the task paradigm, such as children or sedated, paretic, aphasic patients. Although rest-fMRI is still under standardization, this technique has been demonstrated to be feasible…

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Ruolo dell’imaging funzionale nel management delle emorragie cerebrali atipiche: proposta di un protocollo diagnostico derivato dalla sperimentazione clinica

A new computed-assisted technique for experimental sciatic nerve function analysis.

BACKGROUND: Peripheral nerve injury is a well-known experimental tool to evaluate the effect of various neurotrophic substances. Besides histological and electrophysiological techniques, nerve functional status has been assessed by means of the sciatic function index (SFI) and the static sciatic index (SSI). However, these techniques are still based on a complex and old-fashioned apparatus requiring a relatively long time of execution. This study aimed to assess a novel, rapid, computerized method for assessment of SSI in a rat model of sciatic nerve injury. MATERIAL/METHODS: Fourteen rats were used in this study. The left sciatic nerve was exposed and compressed for 2 minutes with an aneur…

Erythropoietin: a new paradigm for neuroprotection.

Posttraumatic chronic cranial osteomyelitis due to a superficial wound - A clinical and neuroradiological case report

Background: Osteomyelitis is a progressive infection of bone and bone marrow by microorganisms, resulting in inflammatory destruction of bone, bone necrosis, and new bone formation. Skull involvement is a rare occurrence which mainly affects children with chronic inflammatory diseases of paranasal sinusitis, or malignant otitis. In adults, cranial vault osteomyelitis can occur after cranial surgery or head trauma. Case Description: We describe an unusual case of chronic cranial osteomyelitis occurred 3 months following a mild traumatic brain injury. The causative mechanisms along with the diagnostic modalities are discussed. Conclusion: Focal cranial vault osteomyelitis, in the absence of …

Unusual recurrence of trigeminal neuralgia after microvascular decompression by muscle interposal.

Summary Background Patients with trigeminal neuralgia (TN) and persistent or recurrent facial pain after microvascular decompression (MVD) typically undergo less invasive procedures in the hope of providing pain relief. However, re-operation should be considered in selected patients. Case Report A 48-year-old woman presented with recurrent trigeminal neuralgia (TN) 3 years following microvascular decompression (MVD). The patient underwent brain magnetic resonance angiography (MRA), which did not reveal neurovascular compression; therefore surgical re-exploration was carried out. During the operation, the fifth cranial nerve was seen without impingement from any blood vessels; however, a ver…

Spinal cord compression in HIV infection

Prevention of lumbar reherniation by the intraoperative use of a radiofrequency bipolar device: A case-control study.

Objective: The most common complication after lumbar discectomy is reherniation. Although many studies have investigated factors that may increase the reherniation risk, few are agreed upon all. It has been suggested that limited nucleus removal is associated with higher reherniation risk, while more aggressive nucleus removal can result in increased disc degeneration. Here, we assessed the efficacy of a coblation-assisted microdiscectomy in adult patients undergoing single-level disc surgery. Methods: We prospectively compared the reherniation rate in 75 patients (Group 1) undergoing single-level lumbar disc surgery completed with the radiofrequency bipolar system Aquamantys® (Medtronic, M…

Spontaneous spinal discitis and spondylodiscitis: Clinicotherapeutic remarks

Spinal infections are rare (their incidence is estimated in about the 5% of all osteomyelitis) and severe pathologies. They are usually identified with different names, as disk space infection, spondylodiscitis, and vertebral osteomyelitis. Spondylodiscitis is the most frequent among spinal infections. The etiology might be due to bacteria, fungi, and parasites and might affect many anatomical structures. The reported incidence is increased in the last years.[1,2] The disease can be classified according to the involved anatomical structure: Vertebral osteomyelitis Discitis and spondylodiscitis Spinal canal infections Adjacent soft tissue infections. In adult patients, the terms osteomyeliti…

Resting-State Functional Magnetic Resonance Imaging for Brain Tumor Surgical Planning: Feasibility in Clinical Setting.

The aim of this study was to introduce resting-state functional magnetic resonance imaging (rest-fMRI) capability for brain tumor surgical planning. rest-fMRI is an emerging functional neuroimaging technique potentially able to provide new insights into brain physiology and to provide useful information regarding brain tumors in preoperative and postoperative settings. rest-fMRI evaluates low-frequency fluctuations in the blood oxygen level–dependent signal while the subject is at rest during magnetic resonance imaging examination. Multiple resting-state networks have been identified, including the somatosensory, language, and visual networks, which are of primary importance for surgical pl…

Imaging features of perineural and perivascular spread in rapidly progressive rhino-orbital-cerebral mucormycosis: A case report and brief review of the literature

Background: Rhinocerebral mucormycosis (ROCM) is an opportunistic fungal infection originating from the paranasal sinuses with extension to the brain. A delayed diagnosis can rapidly result in a poor prognosis. ROCM commonly affects patients with diabetes or immunocompromised states with a variable progression. Case Description: We report the case of a 59-year old patient with an untreated diabetes who developed a ROCM with rapidly progressive neurological symptoms. From the onset of sinus pain, nasal congestion, he rapidly developed facial swelling and masticatory dysfunction. The patient underwent sinus surgery which allowed Rhizopus oryzae to be isolated. Accordingly, a systemic therapy…

Vascular and pulmonary embolisms following percutaneous vertebroplasty.

Surgery versus Conservative Treatment for Symptomatic Lumbar Disk Herniation: A Never-Ending Story.

Natural Course, Clinical Profile, and Treatment Strategies for Cerebral Cavernous Malformations

A large body of evidence has suggested that the natural biology for symptomatic cerebral cavernous malformations (CCMs) is dynamic. These lesions exhibit a temporal clustering epiphenomenon and usually manifest with multispectral clinical patterns, the most relevant being hemorrhagic and seizurogenic events. Most patients with cerebral cavernous malformations are asymptomatic, and the lesions are detected as incidentalomas. However, association with the CCM3 gene, Zabramski type I and II lesions, and brainstem location have the propensity to increase the bleeding events. The rebleeding risk is 20%/year per lesion, which supports the need for surgical strategies for brainstem cavernous malfo…

Regenerative Medicine: Does Erythropoietin have a Role?

Regenerative Medicine, a recent new medical domain, aims to develop new therapies through the stimulation of natural regenerative processes also in human beings. In this field, Erythropoietin (EPO) represents a significant subject of research. Several studies allow the assertion that EPO, in different concentrations, has protective effects mainly on the central nervous system, cardiovascular system and renal tissue. This action is carried out through one of few regenerative activities of human beings: angiogenesis. This mechanism, which involves endothelial stem cells and VEGF (Vascular Endothelial Growth Factor), has been experimentally demonstrated with Recombinant human erythropoietin (r…

Neurosurgical Practice at the Time of COVID-19

Avoiding Complications in Aneurysm Ligation: Operative Tips and Tricks

Preventing possible complications during brain aneurysm surgery is mandatory to ensure a better outcome for patients. Currently, it is possible to rely on some technologic innovations such as motor evoked potential, endoscope-assisted surgery, dye with indocyanine green, and video angiography capable of supporting the surgeon's work. The innovation process has mainly assisted the endovascular technique compared with surgery. The latter, apart from some new technical expedients, always requires anatomic knowledge and optimal technical preparation. A careful patient selection, adequate surgical exposure, use of microsurgical techniques in expert hands, and meticulous postoperative management …

Red Flag for Cauda Equina Syndrome in Symptomatic Lumbar Disc Herniation

Role of Hemodynamic Forces in Unruptured Intracranial Aneurysms: An Overview of a Complex Scenario.

Background An understanding of the natural history of unruptured intracranial aneurysms (IAs) has always played a critical role in presurgical or endovascular planning, to avoid possibly fatal events. Size, shape, morphology, and location are known risk factors for rupture of an aneurysm, but morphologic parameters alone may not be sufficient to perform proper rupture risk stratification. Methods We performed a systematic PubMed search and focused on hemodynamics forces that may influence aneurysmal initiation, growth, and rupture. Results We included 223 studies describing several hemodynamic parameters related to aneurysm natural history. In these studies, different modalities of aneurysm…

Anterior cervical discectomy and fusion with ROI-C peek cage: cervical alignment and patient outcomes

OBJECTIVE: The intersomatic cage ROI-C one is a new promising system in anterior cervical discectomy with subsequent fusion. METHODS: Patients were studied prospectively. ROI-C cages were used in consecutive 32 patients. Intraoperative parameters, clinical features and dysphagia scores were recorded. Radiographs evaluated the height of intervertebral space, the cervical Cobb angle and implant positioning. Data were collected on the last day of hospital stay, at 6 weeks, at 3, 6, 12 and 24 months. RESULTS: A total of 32 cages were implanted. One patient had transient dysphagia. The intervertebral height and the cervical Cobb angle were significantly improved at 24 months follow-up (P < 0.05)…

Preliminary experience with lumbar facet distraction and fixation as treatment for lumbar spinal stenosis

Objectives: To assess the properties of facet fixation with the Facet Wedge system in patients affected by lumbar spinal stenosis (LSS). Summary of Background Data: Implant of intra-articular spacers is an emerging technique for lumbar degenerative disease. Methods: This study included forty patients (Group 1) with symptomatic LSS in whom intra-articular spacers have been implanted along with microdecompression (MD) of the neural structures. Group 1 has been compared with a homogeneous group of patients with LSS treated with MD without intra-articular spacers implant (Group 2). Clinical findings have been observed preoperatively and 3, 6, 12 months postoperatively using dedicated questionna…

"July Effect" on Care for Aneurysmal Subarachnoid Hemorrhage.

Subarachnoid hemorrhage (SAH) following a ruptured intracranial aneurysm accounts for about 5% of strokes, with an incidence of 10.5 per 100,000 person years (about 27,000 patients per year). Outcome after aneurysmal SAH depends on several factors, including the severity of the initial hemorrhage, rebleeding, perioperative medical management, and the timing and technical success for aneurysm exclusion from the cerebral circulation.The overall mortality rates range from 32% to 67% with 10%–20% of patients with long-term dependence due to brain damage. In this regard, 12% of patients die before medical treatment can be given and 25% die within the first 24 hours. A further 40%–60% mortality r…

Appraisal of Burden of Caregivers to Chronically Rehabilitated Patients with Spinal Cord Injuries in a Tertiary Neurological Center in Nepal

The care of a patient with a spinal cord injury is part of healthcare systems. It causes a substantial physical and emotional drain on the caretakers who often are in short supply and thus may lack adequate training, preparation, and support. Long hours of assisting a chronically handicapped patient with activities of daily living and exercises decrease the rehabilitator's quality of life and take a psychological toll that increases a risk of burnout syndrome. The present study found a significant caregiving burden among care providers of chronically dependent patients with spinal cord injuries. Additionally, financial drain escalates the issue in this rather neglected health and quality of…

ERYTHROPOIETIN FOR THE TREATMENT OF SUBARACHNOID HEMORRAGE: A FEASIBLE INGREDIENT FOR A SUCCESS MEDICAL RECIPE

Subarachnoid hemorrhage (SAH) following aneurysm bleeding accounts for 6% to 8% of all cerebrovascular accidents. Although an aneurysm can be effectively managed by surgery or endovascular therapy, delayed cerebral ischemia is diagnosed in a high percentage of patients resulting in significant morbidity and mortality. Cerebral vasospasm occurs in more than half of all patients after aneurysm rupture and is recognized as the leading cause of delayed cerebral ischemia after SAH. Hemodynamic strategies and endovascular procedures may be considered for the treatment of cerebral vasospasm. In recent years, the mechanisms contributing to the development of vasospasm, abnormal reactivity of cerebr…

A Novel Pathophysiological Mechanism Contributing to Trigeminal Neuralgia

Trigeminal neuralgia (TN) is a form of neuropathic pain that affects the fifth cranial nerve, the most widely distributed nerve in the head. Although TN has been associated with a variety of pathological conditions, neurovascular compression on the trigeminal nerve, as it exits the brain stem, is the most frequent reported cause. This compression provides a progressive demyelination of the nerve and a subsequent aberrant neural transmission. Although several studies have clarified some physiopathological mechanisms underlying TN, the molecular basis remains vague. Very recently the substitution of methionine 136 by valine (MET126Val) in sodium channel Nav1.6 in a case study of typical TN ha…

Tecniche avanzate di imaging neuroradiologico applicate al planning preoperatorio delle procedure neurochirurgiche e alla didattica: un anno di esperienza in un singolo centro.

An unusual internal carotid artery compression as a possible cause of Eagle syndrome – A novel hypothesis and an innovative surgical technique

Background: Eagle syndrome (ES) is a rare symptomatic condition generally caused by an elongated styloid process (SP) or calcification of the stylohyoid complex. On the diagnosis is made, its treatment remains subjective since the indications for surgical intervention are still not standardized. Although styloidectomy is the surgical treatment of choice, no consensus exists regarding the transcervical or/and transoral route. Here, we report our experience in a patient with bilateral internal carotid artery (ICA) dissection caused by ES, who underwent innovative surgical technique. Case Description: A 53-year-old man, with the right-sided middle cerebral artery acute stroke, underwent compu…

Enfisema sottocutano cervico-facciale e pneumomediastino dopo chirurgia cervicale con approccio anteriore: management diagnosticoterapeutico di una grave complicanza.

Impact of Health Care−Associated Infection in Patients with Aneurysmal Subarachnoid Hemorrhage

In the era of antibiotics, nosocomial infections are still uncontrollable and represent a problem with a problematic solution. The terms nosocomial and health care−associated infections are both used for disease, absent at the time of admission, acquired by patients under medical care in the hospital or other health care facilities. Recently, the term health care−associated infection (HAI) has been introduced for the type of infection caused by a prolonged hospital stay, and it accounts for a significant risk factor for severe health issues leading to death. HAIs can occur during health care delivery for other diseases and even after patient discharge. Invasive devices such as catheters and…

Raro caso di intolleranza al sistema di stimolazione spinale: Ruolo delle condizioni psicosomatiche.

Intracranial venous sinus thrombosis as unusual presentation of Bing-Neel syndrome: case illustration.

A 42-year-old woman presented with progressive blurred vision, vertigo, and headache. MRI showed bilateral intraocular protrusion of the optic nerve head and right transverse sinus thrombosis . Low-molecular-weight heparin was administered without symptom relief. Additional MRI showed left frontoparietal arachnoid space obliteration by pathological tissue, and infiltration of the sagittal and right transverse sinuses. After Gd administration, we observed diffuse enhancement of the dura in the left cerebral hemisphere and subdural and epicranial soft-tissue infiltration . A biopsy of the extra-axial tissue was performed. Histological examination showed a neoplasm composed of large cells with…

Vasospasm in Aneurysmal Subarachnoid Hemorrhage: An Evolving Knowledge

During the last decade, accumulating experimental and clinical evidence has demonstrated that the presence of delayed vasospasm of the major cerebral vessels may just be a contributing factor but not necessarily the principal determinant of delayed cerebral ischemia and delayed ischemic neurologic deficit. Cerebral infarction can occur when vasospasm is not angiographically detected in the territorial artery, and poor outcome in aSAH seems to be directly dependent on infarction but independent of vasospasm . There is increasing evidence that other contributing factors may be involved in the development of delayed cerebral ischemia, and their characterization and treatment could improve the …

Erythropoietin for Subarachnoid Hemorrhage: Is There a Reason for Hope?

I b S a r a S ubarachnoid hemorrhage (SAH) associated with a ruptured cerebral aneurysm remains a source of significant morbidity and mortality, not only from the initial hemorrhage but lso from the delayed complications, such as cerebral vasospasm ften severe enough to induce irreversible changes in cerebral erfusion. Several drugs have been developed that have the otential to limit cerebral vasospasm and delayed ischemic eurologic deficit, thus improving outcome for patients. Howver, although numerous agents that can prevent arterial narrowng and/or block the excitatory cascade of events leading to schemic neuronal death in experimental conditions, there is still o pharmacologic agent tha…

Emerging Therapeutic Strategies for Traumatic Spinal Cord Injury

Spinal cord injury (SCI) is a debilitating neurologic condition with tremendous socioeconomic impact on affected individuals and the health care system. The treatment of SCI principally includes surgical treatment and marginal pharmacologic and rehabilitation therapies targeting secondary events with minor clinical improvements. This unsuccessful result mainly reflects the complexity of SCI pathophysiology and the diverse biochemical and physiologic changes that occur in the injured spinal cord. Once the nervous system is injured, cascades of cellular and molecular events are triggered at varying times. Although the cascade of tissue reactions and cell injury develops over a period of days …

Resection of Brainstem Cavernous Malformations: Pearls and Pitfalls for Minimizing Complications

BACKGROUND: Surgical management of brainstem cavernous malformations (CMs) is a controversial topic in the field of neurosurgery. These lesions have a propensity to hemorrhage, thereby disrupting surrounding brainstem eloquence.METHODS: This article provides the personal reflections are senior author and a narrative literature review on resection of brainstem CMs.RESULTS: Here we discuss the indications for microsurgery, microsurgical techniques and nuances, and perioperative management considerations necessary to minimize complications during resection of brainstem CMs, which are lesions of venous origin.CONCLUSIONS: The natural history of the lesion, risk of future hemorrhage, and potenti…

The impact of preoperative neurological symptom severity on postoperative outcomes in cervical spondylotic myelopathy

Study Design: The study design is a retrospective cohort study.Objective: To compare patient-reported outcomes between patients with mild versus moderate-to-severe myelopathy following surgery for cervical spondylotic myelopathy (CSM).Summary of Background Data: Recent studies have demonstrated that decompression for CSM leads to improved quality of life when measured by patient-reported outcomes. However, it is unknown if preoperative myelopathy classification is predictive of superior postoperative improvements.Materials and Methods: A retrospective review of patients treated surgically for CSM at a single institution from 2014 to 2015 was performed. Preoperative myelopathy severity was c…

Perfusion computed tomography of intracranial meningiomas: In vivo correlation of cerebral blood volume and vascular permeability

Background A noninvasive method to predict the grade of a meningioma would be desirable since it would anticipate information about tumour nature, recurrence and improve tumour management and outcomes. The aim of the present study was to assess the ability of perfusion computed tomography (PCT) technique in predicting the meningioma grade before surgery. Data from PCT, such as cerebral blood volume (CBV) and permeability surface (PS), were correlated with immunohistolopathological information. Methods Twenty-three patients with a diagnosis of intracranial meningioma underwent PCT for pre-surgical evaluation of CBV and PS. During surgery, samples from the centre and periphery of the tumour w…

Revision Surgery for Primary Spinal Tumor: Too Little Too Late

Primary tumors of the spine are rare and represent less than 8% of all bone tumors.1 Because of their low prevalence, they are often misdiagnosed and consequently managed improperly. Unlike metastatic spine tumors, some primary tumors can be cured. Spine tumors are classified according to their histology. How- ever, patient age and anatomic location add relevant information on the biological behavior of the tumor. In children, the most frequent spinal tumors are malignant and are represented by neuroblastoma and sarcoma. In adults, the most common spinal tumors are multiple myeloma, osteosarcoma, histiocytosis, chordoma, and hemangioma. These tumors often develop in the anterior vertebral b…

Thoracic spinal cord cavernous angioma: a case report and review of the literature

Introduction: Cavernous angiomas of the spinal cord are rare vascular malformations, which account for approximately 5 to 12 percent of spinal cord vascular lesions. They usually originate in the vertebrae, with occasional extension into the extradural space, and intramedullary cavernomas, even if reported in the literature, are very rare. Case presentation: We report the case of a 34-year-old Caucasian woman affected by a thoracic intramedullary cavernous angioma. Our patient complained of 10-day history of acute dorsal pain, progressive weakness of both lower extremities, worse on the right side, a ‘pins and needles’ sensation in the abdominal region and bladder dysfunction. Magnetic reso…

The ARUBA Study: What Is the evidence?

Innovative Educational Pathways in Spine Surgery: Advanced Virtual Reality–Based Training

Background Over the past few years, a reorganization of the educational pathways has been promoted with the purpose of optimizing the acquisition of competences and their assessment, so as to reduce the risks to both health care professionals and end users. Virtual reality (VR) has been repeatedly tested, initially as a positive reinforcement for more traditional educational pathways and, more recently, as their potential substitute. The aim of this study was to demonstrate the potentiality of VR simulation training in spine surgery. Methods The VR simulator reproduced the lateral lumbar access to the spine. The simulation included a tutorial, the preoperative settings, and the surgical ses…

Ruolo dell'eritropoietina e del suo recettore nella degenerazione discale.

Erythropoietin: not just about erythropoiesis.

Letter to the Editor Regarding “Small Aneurysms with Low PHASES Scores Account for a Majority of Subarachnoid Hemorrhage Cases”

Artroplastica cervicale con sistema Prodisc-C: nostra esperienza.

Financial Aspects of Cervical Disc Arthroplasty: A Narrative Review of Recent Literature

Recently, there has been significant interest in understanding the cost-effectiveness of treatments in spine surgery as health care systems in the United States move toward value-based care and alternative payment models. Previous studies have shown comparable outcomes of cervical disc arthroplasty (CDA) and anterior cervical discectomy fusion; however, there is a lack of consensus on the cost-effectiveness of CDA to support full adoption. Evidence of the limitations of these cost-analysis studies also exists in the literature, including industry funding, potential selection bias, and varying methods of calculating value. The goal of this narrative review is to provide an overview of the co…

Anterior cervical discectomy and fusion is more effective than cervical arthroplasty in relieving atypical symptoms in patients with cervical spondylosis

Background and purpose Patients with cervical spondylosis often present with concurrent 'atypical symptoms' of unknown etiology that have been associated with cervical spondylotic disease, including dizziness, headache, nausea, tinnitus, blurred vision, palpitations, and memory and gastrointestinal disturbances. Few studies have addressed whether surgical intervention to treat classic symptoms of cervical spondylosis can also effectively alleviate atypical symptoms. Accordingly, the purpose of this study is to compare the ability of cervical arthroplasty (CA) and anterior cervical discectomy and fusion (ACDF) to alleviate atypical symptoms associated with cervical spondylosis. Materials and…

PNET diffuso encefalo-spinale che mima una Neurofibromatosi di tipo 2: case report.PNET diffuso encefalo-spinale che mima una Neurofibromatosi di tipo 2: case report.

Neuroprotection by erythropoietin administration after experimental traumatic brain injury.

A large body of evidence indicates that the hormone erythropoietin (EPO) exerts beneficial effects in the central nervous system (CNS). To date, EPO's effect has been assessed in several experimental models of brain and spinal cord injury. This study was conducted to validate whether treatment with recombinant human EPO (rHuEPO) would limit the extent of injury following experimental TBI. Experimental TBI was induced in rats by a cryogenic injury model. rHuEPO or placebo was injected intraperitoneally immediately after the injury and then every 8 h until 2 or 14 days. Forty-eight hours after injury brain water content, an indicator of brain edema, was measured with the wet-dry method and bl…

When Neuroprotection Becomes a Potential Ally of High-Grade Glioma.

Despite the use of multimodal treatment regimens, high-grade gliomas (HHGs) are tumors invariably associated with a poor prognosis. The median patient survival after diagnosis is approximately 1 year, through surgery/radiation and chemotherapy treatments.To date, traditional approaches fail to treat efficiently HHGs because surgery does not completely remove the tumor without damaging the brain, radiation therapy cannot be used beyond a certain threshold dose, and chemotherapy has shown limited efficacy and toxic effects. Notwithstanding many attempts at improving outcome using novel agents, the treatment of this disease has not improved in more than a decade. Although scientific and techno…

Giant olfactory groove meningiomas: extent of frontal lobes damage and long-term outcome after the pterional approach.

The treatment of giant olfactory groove meningiomas (OGMs; maximum diameter ≥ 6 cm) poses special problems and represents a surgical challenge. We discuss the long-term results in a series of 18 patients with giant OGMs and report our experience on a global strategy encompassing the pterional approach to manage the lesion and an extended transbasal approach to treat recurrences.Between February 1991 and December 2007, 18 patients with giant OGMs were surgically managed via a pterional craniotomy. Postoperative follow-up imaging was obtained at one, six, and 12 months and then yearly. In preoperative images, data from tumor volume were assessed. The volume of the residual right frontal poren…

Reoperations After First Lumbar Disk Herniation Surgery with or without Implantation of Mechanical Annular Closure Device

Lumbar diskectomy is a widely performed surgical procedure in patients affected by lumbar disk herniation (LDH). Such a surgical procedure is considered to be safe and able to provide a consistent symptomatic relief in most patients. However, perioperative complications have been reported, ranging from 13% to 15%, and pose a considerable financial burden among patients, hospitals, and national health care agencies. The most common perioperative complication following lumbar diskectomy for disk herniation is the recurrence. Although the recurrence rate of LDH has been reported to be 5%−15%, its exact incidence may be underestimated. Recurrent lumbar disk herniation (rLDH) is defined as disk …

AN UNESPECTED ASSOCIATION BETWEEN INTRACRANIAL HYPOTENSION AND SPLIT CORD MALFORMATION

From erythropoietin to a rationale neuroprotective therapeutic strategy and beyond

Neuroprotective effect of erythropoietin and darbepoetin alfa after experimental intracerebral hemorrhage.

OBJECTIVE: Intracerebral hemorrhage (ICH) is a devastating clinical syndrome for which no truly efficacious therapy has yet been identified. In preclinical studies, erythropoietin (EPO) and its long-lasting analog, darbepoetin alfa, have been demonstrated to be neuroprotective in several models of neuronal insult. The objectives of this study were to analyze whether the systemic administration of recombinant human EPO (rHuEPO) and its long-lasting derivative darbepoetin alfa expedited functional recovery and brain damage in a rat model of ICH. METHODS: Experimental ICH was induced in rats by injecting autologous blood into the right striatum under stereotactic guidance. Subsequently, animal…

Cavernous malformation of the optic chiasm: An uncommon location

Background: Cavernous malformations (CMs) of the optic chiasm are rare lesions often presenting with acute chiasmal syndrome or a progressive visual loss. The case of a 48-year-old female with an intrachiasmatic CM is presented. Case Description: The patient presented with an insidious history of progressive visual loss. Magnetic resonance imaging (MRI) showed a CM in the suprasellar region. The patient was operated via a right pterional approach with a complete lesion removal. The postoperative course was uneventful. Early postoperative ophthalmological examination revealed minimal improvement of the vision in the left eye. Conclusion: The clinical, neuroradiological, and intraoperative fi…

Ruolo del complesso EPO/EPO-R nella oncogenesi cerebrale.

Cisternostomy: A Timely Intervention in Moderate to Severe Traumatic Brain Injuries: Rationale, Indications, and Prospects.

Traumatic brain injury (TBI) represents a major public health concern worldwide, with no significant change in its epidemiology over the last 30 years. After TBI, the primary injury induces irreversible brain damage, which is untreatable. The subsequent secondary injury plays a critical role in the clinical prognosis because without effective treatment it will provide additional tissue damage. The resulting scenario is the rise in intracranial pressure (ICP) with the development of progressive neurological deficits. Current optimal management is based on a progressive, target-driven approach combining both medical and surgical treatment strategies among which is decompressive hemicraniectom…

Artrodesi cervicale anteriore con sistema ROI-C. Valutazione clinica preliminare.

Role of hybrid construct in cervical spondylosis.

Recurrent lumbar disc herniation: Is there a correlation with the surgical technique? A multivariate analysis

Purpose: The recurrence of a lumbar disc herniation (LDH) is a common cause of poor outcome following lumbar discectomy. The aim of this study was to assess a potential relationship between the incidence of recurrent LDH and the surgical technique used. Furthermore, we tried to define the best surgical technique for the treatment of recurrent LDH to limit subsequent recurrences. Materials and Methods: A retrospective study was conducted on 979 consecutive patients treated for LDH. A multivariate analysis tried to identify a possible correlation between (1) the surgical technique used to treat the primary LDH and its recurrence; (2) technique used to treat the recurrence of LDH and the secon…

The Quest for Predictors of Shunt-Dependent Chronic Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage: Toward a Tailored Approach for Permanent Shunt-Dependency Following Aneurysmal Subarachnoid Hemorrhage

Lesione secondaria intramidollare del tratto cervicale come prima manifestazione di adenocarcinoma del colon: case report e review della letteratura

Mast cells in canine mammary gland tumour: number, distribution and EPOR positivity.

Erythropoietin (EPO)-mediated mitogenic and anti-apoptotic effects involve all the cells expressing functional receptors for EPO (EPOR), as demonstrated by in vitro and in vivo studies. EPO shows pleiotropic effects and acts as an endogenous mediator of adaptive tissue response to metabolic stress protecting tissues from different injuries. Recently, the EPO/EPOR complex has been identified in several neoplastic cell lines and solid tumours. In this study, the authors investigated the mast cells (MCs) number, distribution and their immunoreactivity for EPOR in normal, dysplastic and neoplastic canine mammary gland. The results showed that MCs were more numerous in displastic glands compared…

Multimodal Intraoperative Neuromonitoring in Aneurysm Surgery

Following aneurysmal subarachnoid hemorrhage, the primary goal of treatment is to exclude the vascular malformation from the intracranial circulation, while preserving the parent artery. In unruptured aneurysms, the decision whether to treat or observe the malformation is made on a case-by-case basis. In this regard, the ISUIA (International Study of Unruptured Intracranial Aneurysms) investigators suggested that aneurysm size and location were independent predictors for aneurysm rupture.1 ISUIA examined 1692 patients with cerebral aneurysms with a mean follow-up time of 4.1 years. Rupture rates differed depending on size and location, ranging from 0% in aneurysms &lt;7 mm located in the in…

BENEFICIAL EFFECT OF PROBIOTICS ADMINISTRATION IN INFLAMMATORY BOWEL DISEASE AND RELATED SPONDYLOARTHROPATHY: A PROSPECTIVE STUDY

Background: Therapeutic treatment for inflammatory bowel disease (IBD) may follow different approaches, systemic as well as local, especially when the target is the osteoarticular apparatus. Although some clinical trials have suggested benefits from probiotics administration in IBD, there is still a great deal of controversy on their use. The aim of this study was to further investigate the effects of probiotics in patients with IBD and related spondyloarthropathy. Material/Methods: Fifty-nine patients affected by IBD with extra-intestinal involvement where evaluated from 2006 to 2010. Twenty-eight patients received administration of a standard therapy with mesalazine and 31 where treated w…

Comment on “Controversies about Interspinous Process Devices in the Treatment of Degenerative Lumbar Spine Diseases: Past, Present, and Future”

Overview of Minimally Invasive Spine Surgery

Minimally invasive spine surgery (MISS) has continued to evolve over the past few decades, with significant advancements in technology and technical skills. From endonasal cervical approaches to extreme lateral lumbar interbody fusions, MISS has showcased its usefulness across all practice areas of the spine, with unique points of access to avoid pertinent neurovascular structures. Adult spine deformity has also recognized the importance of minimally invasive techniques in its ability to limit complications and to provide adequate sagittal alignment correction and improvements in patients' functional status. Although MISS has continued to make significant progress clinically, consideration …

Utilizzo di eritropoietina umana ricombinante nell’emorragia subaracnoidea sperimentale

Innovation in Neurosurgery: The Concept of Cognitive Mapping

In recent years, advances in cortical-subcortical mapping, intraoperative neurophysiology, and neuropsychology have increased the ability to remove intrinsic brain tumors, expanding indications and maximizing the extent of resection. This has provided a significant improvement in progression-free survival, time of malignant transformation (in low-grade gliomas), and overall survival. Although current techniques enable preservation of language and motor functions during surgery, the maintenance of a complex set of functions defined with the term cognition is not always achievable. Cognition is defined as every neural process underlying a high human function and includes motor haptic and visu…

The erythropoietin and regenerative medicine: a lesson from fish

Background Erythropoietin (EPO), the main haematopoietic growth factor for the proliferation and differentiation of erythroid progenitor cells, is also known for its angiogenic and regenerative properties. Materials and methods In this study, we aimed to test the regenerative effects of EPO administration in an experimental model of Sea bass (Dicentrarchus labrax) subjected to amputation of the caudal fin. Results Erythropoietin-treated fishes (3000 UI of human recombinant EPO-alpha immediately after cutting and after 15 days) showed an increased growth rate of their fins compared with those untreated (ANOVA variance: P :0 AE01 vs. P :0 AE04). By analysing fin length at established times (1…

Neuroprotection by erythropoietin and darbopoietin-alfa following experimental intracerebral hemorrhage

Erythropoietin and erythropoietin receptor expression in low and high-grade glioma

A rare case of solitary brain Langerhans cell histiocytosis with intratumoral hemorrhage in a patient affected by Turner syndrome

Background: Langerhans cell histiocytosis (LCH) is a rare disease involving clonal proliferation of cells with characteristics similar to bone marrow-derived Langerhans cells. The case of a young woman, affected by Turner syndrome and a solitary intraparenchymal LCH associated with an osteolytic lesion of the overlying skull, is presented. Case Description: The patient, with an insidious history of headache and a growing soft mass in the left frontal region, presented with a sudden generalized tonic-clonic epileptic seizure. Neuroradiological investigations showed an osteolytic lesion of the left frontal bone and an underlying brain lesion associated with recent signs of bleeding. The patie…

Diagnostic potential of the diffusion tensor tractography with fractional anisotropy in the diagnosis and treatment of cervical spondylotic and posttraumatic myelopathy

Background: Diffusion tensor imaging (DTI) is a magnetic resonance imaging (MRI)-based methodology widely used for the evaluation of microstructural integrity of the central nervous system (CNS), particularly of brain white matter fibers and bundles. Methods: The most common parameters evaluated in a DTI study are the fractional anisotropy (FA) and mean diffusivity (MD). Combining FA and MD analyses is commonly used in the evaluation of various types of brain pathologies, such as brain tumors, where a combined analysis allows an accurate tumor characterization. Results: Recent studies have shown that FA and MD could be of value in non-oncologic spinal pathology. In this regard, it has been …

Introducing the concept of “CSF-shift edema” in traumatic brain injury

Brain edema after severe traumatic brain injury (TBI) plays an important role in the outcome and survival of injured patients. It is also one of the main targets in the therapeutic approach in the current clinical practice. To date, the pathophysiology of traumatic brain swelling is complex and, being that it is thought to be mainly cytotoxic and vasogenic in origin, not yet entirely understood. However, based on new understandings of the hydrodynamic aspects of cerebrospinal fluid (CSF), an additional mechanism of brain swelling can be considered. An increase in pressure into the subarachnoid space, secondary to traumatic subarachnoid hemorrhage, would result in a rapid shift of CSF from t…

An overview of new pharmacological treatments for cerebrovascular dysfunction after experimental subarachnoid hemorrhage

Cerebral vasospasm and the resulting cerebral ischemia occurring after subarachnoid hemorrhage (SAH) are still responsible for the considerable morbidity and mortality in patients affected by cerebral aneurysms. Mechanisms contributing to the development of vasospasm, abnormal reactivity of cerebral arteries and cerebral ischemia after SAH have been intensively investigated in recent years. It has been suggested that the pathogenesis of vasospasm is related to a number of pathological processes, including endothelial damage, smooth muscle cell contraction resulting from spasmogenic substances generated during lyses of subarachnoid blood clots, changes in vascular responsiveness and inflamma…

Ruolo dell'eritropoietina nel trattamento del vasospasmo cerebrale: stato dell'arte. SINCH

Typical trigeminal neuralgia by an atypical compression: case report and review of the literature.

Aim Trigeminal neuralgia is a disabling form of facial pain that causes a considerable discomfort and a marked reduction in the quality of life. Although neurovascular compression is often associated with trigeminal neuralgia, other intracranial pathologies can result in compression along the nerve. Case description The authors report a case of a patient suffering from a typical left trigeminal neuralgia affecting both the second and the third branches. Neuroradiological examinations showed the presence of an arachnoid cyst located in the left temporal lobe, contiguous with the Meckel's cave, eroding the greater wing of the sphenoid bone. Following a meticulous decision-making process the p…

Long-Term Efficacy of Shunt Therapy in Idiopathic Normal Pressure Hydrocephalus.

Background: Idiopathic normal pressure hydrocephalus (iNPH) is one of the very few treatable types of dementia. Shunt therapy has been shown to be effective in improving symptoms. However, the long-term results of cerebrospinal fluid diversion are variable. The aim of this retrospective study was to investigate long-term outcomes of patients with idiopathic normal pressure hydrocephalus treated with ventriculoperitoneal shunt by using programmable valves. Methods: Symptoms before treatment were recorded. Clinical symptoms and outcome after ventriculoperitoneal shunt were assessed based on changes in gait, urinary incontinence, and cognitive dysfunction at yearly follow-up spanning at least …

Preconditioning with a Non-erythropoietic Erythropoietin Ameliorates Spinal Cord Compressive Injury

Impianto di dispositivo interspinoso (X Stop) per il trattamento della stenosi del canale lombare; analisi della nostra esperienza.