Intraoperative microvascular Doppler monitoring of blood flow within a spinal dural arteriovenous fistula: a precious surgical tool. Case report.

The authors describe a case of spinal arteriovenous fistula (AVF) treated by a microvascular Doppler-assisted surgical interruption of the arterialized vein. Microvascular Doppler monitoring represents a valid, widely available, noninvasive tool that enables identification, through flow spectrum analysis, of components of this type of vascular malformation. In this case because the location of the fistula was identified prior to opening the dura only minimally invasive surgery was required. Direct recordings of the arterialized draining vein and the nidus of the fistula demonstrated a pathological spectrum caused by the arterial supply and the disturbed venous outflow in which a high-resistance flow pattern and low diastolic flow resembling an arterial-like flow velocity were observed. The fistula was obliterated by interruption of the draining vein, and Doppler measurements provided information on flow velocity changes in the medullary veins from an arterial to a venous pattern. The absence of any residual flow in the AVF confirmed successful hemodynamic treatment. Intraoperative microvascular Doppler recording during surgical closure of spinal AVF is a widely available and reliable monitoring modality that helps to produce excellent clinical results

Image-guided multisession radiosurgery of skull base meningiomas

Background: The efficacy of single-session stereotactic radiosurgery (sSRS) for the treatment of intracranial meningioma is widely recognized. However, sSRS is not always feasible in cases of large tumors and those lying close to critically radiation-sensitive structures. When surgery is not recommended, multi-session stereotactic radiosurgery (mSRS) can be applied. Even so, the efficacy and best treatment schedule of mSRS are not yet established. The aim of this study is to validate the role of mSRS in the treatment of skull base meningiomas. Methods: A retrospective analysis of patients with skull base meningiomas treated with mSRS (two to five fractions) at the University of Messina, Italy, from 2008 to 2018, was conducted. Results: 156 patients met the inclusion criteria. The median follow-up period was 36.2 \ub1 29.3 months. Progression-free survival at 2-, 5-, and 10-years was 95%, 90%, and 80.8%, respectively. There were no new visual or motor deficits, nor cranial nerves impairments, excluding trigeminal neuralgia, which was reported by 5.7% of patients. One patient reported carotid occlusion and one developed brain edema. Conclusion: Multisession radiosurgery is an effective approach for skull base meningiomas. The long-term control is comparable to that obtained with conventionally-fractionated radiotherapy, while the toxicity rate is very limited

Expression of telomeric repeat binding factor-1 in astroglial brain tumors

OBJECTIVE: In human somatic cells, telomeres shorten with successive cell divisions, resulting in progressive genomic instability, altered gene expression, and cell death. Recently, telomere-specific deoxyribonucleic acid-binding proteins, such as telomeric repeat binding factor-1 (TRF1), have been proposed as candidates for the role of molecules regulating telomerase activity, and they have been suggested to play key roles in the maintenance of telomere function. The present study was designed to assess TRF1 expression in human astroglial brain tumors and to speculate on the clinical implications of its expression. METHODS: Twenty flash-frozen surgical specimens obtained from adult patients who underwent craniotomy for microsurgical tumor resection, histologically verified as World Health Organization Grade II to IV astrocytomas, were used. Expression of TRF1 in astrocytomas of different grades was studied by means of both immunohistochemical and Western blotting analysis. The correlation between the extent of TRF1 expression and histological grading, performance status, and length of survival of patients underwent statistical analyses. RESULTS: TRF1 was expressed in all tumor samples. The level of its expression was variable, decreasing from low-grade through high-grade astrocytomas (P 0.0032). TRF1 expression correlated with the patient’s length of survival (P 0.001) and performance status (P 0.001) and proved to be an independent indicator of length of survival. CONCLUSION: Our findings suggest that the loss of TRF1 expression capability, as a result of down-regulation of TRF1 expression in malignant gliomas cells, may play a role in the malignant progression of astroglial brain tumors

Venous preservation

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Venous preservation–guided resection: a changing paradigm in parasagittal meningioma surgery

Object. Surgical treatment of parasagittal meningiomas is challenging. Preserving the venous outflow is the key point, but this may preclude radical resection. Different surgical strategies have been proposed. To contribute to the debate on the optimal strategy for treating these tumors, a single-institutional, single-surgeon series of patients with parasagittal meningiomas was analyzed and the available literature reviewed. Methods. Clinical charts of patients with parasagittal meningioma, managed at the University of Messina be- tween 1988 and 2008, were retrospectively reviewed. A microsurgical resection, the goal of which was to preserve the venous outflow, was performed. Only if the superior sagittal sinus (SSS) was angiographically occluded, but if alternative venous outflow was clearly recognized, was the tumor resected, together with the sinus without further flow restoration. A MEDLINE review of the literature published between 1955 and 2011 was performed. Results. Long-term follow-up (mean 80 months) data obtained in 67 patients with meningiomas involving the SSS were analyzed. The recurrence rate was 10.4%; the morbidity and mortality rates were 10.4% and 4.5%, re- spectively. The authors identified in the literature 19 relevant studies on this issue, and based on their review of the literature, there is no evidence that aggressive management offers an advantage in terms of recurrence rate. Conclusions. Analysis of the data obtained in the 67 patients confirmed good outcome and long-term tumor control following a surgical strategy aimed to preserve venous outflow. These findings and the results of the authors’ analysis of the literature emphasize that the goal of radical tumor resection should be balanced by an awareness of the increased surgical risk attendant on aggressive management of the SSS and bridging veins

Telemedicine-assisted treatment of patients with intracerebral hemorrhage

Object. Telemedicine provides a new approach to improve stroke care in community settings, delivering acute stroke expertise to hospitals in rural areas. Given the controversies in many aspects of the treatment of intracerebral hemorrhage (ICH) and the lack of guidelines, a prompt neurosurgical second opinion may facilitate the treatment of patients with ICH. Here, the authors’ 8-year experience with the use of telemedicine in the management of ICH is reported. Methods. The medical records of patients with ICH treated through a telemedicine system in the district of Messina, Italy, between June 2003 and June 2011 were retrospectively reviewed. Neuroradiological and clinical data for patients were transmitted through a high-technology “hub-and-spoke” telemedicine network. Neurosurgical teleconsulting (at the hub) was available for 7 peripheral hospitals (spokes) serving about 700,000 people. The authors analyzed 1) the time between peripheral hospital admission and the specialized second opinion consultation, 2) primary and secondary transfers to the authors’ neurosurgery department, and 3) the treatments (surgical or medical) of patients transferred to the hub. Results. The telemedicine network was used to treat more than 2800 patients, 733 with ICH. A neurosurgical consultation was provided in 38 minutes versus 160 minutes for a consultation without telemedicine. One hundred seventy-six (24%) of 733 patients were primarily transferred to the hub. Ninety-five patients (13%) underwent surgical treatment. The remaining 81 patients (11%) underwent neurointensive care. Eight (1.4%) of 557 patients treated at the spokes needed a secondary transfer for surgical treatment because of a worsening clinical condition and/or CT findings. Considering secondary and inappropriate transfers, the interpretation of data was correct in 96.5% of cases. Conclusions. Telemedicine allowed rapid visualization of neuroradiological and clinical data, providing neurosurgical expertise to community hospitals on demand and within minutes. It allowed the treatment of patients at peripheral hospitals and optimized resources. A small percentage of patients treated at the peripheral hospitals had secondary deterioration. Telemedicine allowed fast patient transfer when necessary and provided improved accuracy in patient car

Does early decompression improve neurological outcome of spinal cord injured patients? Appraisal of the literature using a meta-analytical approach

Study design: Definitive and unequivocal evidence to support the practice of early or late surgery is still lacking in clinical studies. Accordingly, meta-analysis is one of the few methods that offer a rational, statistical approach to management decision. A review of the clinical literature on spinal cord injury with emphasis on the role of early surgical decompression and a meta-analysis of results was performed. Objectives: To determine whether neurological outcome is improved in traumatic spinal cord-injured patients who had surgery within 24 h as compared with those who had late surgery or conservative treatment. Methods: A Medline search covering the period 1966\u20132000, supplemented with manual search, was used to locate studies containing information on indication, rationale and timing of surgical decompression after spinal cord injuries. The analysis included a total of 1687 eligible patients. Results: Statistically, early decompression resulted in better outcome compared with both conservative (P<0.001) and late management (P<0.001). Nevertheless, analysis of homogeneity showed that only data regarding patients with incomplete neurological deficits who had early surgery were reliable. Conclusions: Although statistically the percentage of patients with incomplete neurological deficits improving after early decompression appear 89.7% (95% confidence interval: 83.9, 95.5%), to be better than with the other modes of treatment when taking into consideration the material available for analysis and the various other factors including clinical limitations; early surgical decompression can only be considered as practice option for all groups of patients