Endoscopic transorbital eyelid approach for the removal of an extraconal cavernous venous malformation: Case report

Cavernous venous malformations (CVMs) are one of the most common benign primary orbital lesions in adults and the second most frequent cause of unilateral proptosis. Extraconal location is extremely rare, representing a favorable condition as compared to intraconal, as lesions at this level often adhere to orbital muscles and optic nerve. Herein, we report the case of a 50-year-old patient, who came to our attention because of progressive painless right axial proptosis. Magnetic resonance images were consistent with an extraconal CVM, occupying the superior temporal compartment of the orbit. Successful removal of the lesion was achieved through an endoscopic transorbital eyelid approach. The present case confirms the safety and efficacy of the endoscopic transorbital eyelid approach

Meningiomas: criteria for modern surgical indications

The contemporary management of meningiomas is the result of the continuous evolution of neurosurgical techniques, along with the refinement of dedicated instrumentations. Above all, it is the magnification of the surgical view, thanks to the microscope and the endoscope, and their advancements, which allowed the improvement of surgical outcomes, in terms of both extent of resection and morbidity rates. Because of the benign nature of the vast majority of meningiomas, complete tumor resection is curative, and it is the gold-standard treatment. However, in the case of high risk of surgical morbidity, a less aggressive surgical treatment may be justified, also upon tailored analysis of the meningiomas’ biological behavior and the improvements in postoperative strategies. The endoscopic technique plays a role, as a unique visualization tool or in combination with the microscope, in granting so-called maximum allowed resection. Considering the above, the most challenging task confronting modern meningioma surgery remains the selection of the most appropriate surgical approach, the latter greatly depending on location, anatomic tumor features, and relationships with critical neurovascular structures. Herein, we present a cogent analysis of the modern multifaceted indications for the endoscopic treatment of meningiomas, with a glimpse into the adjacent fields

The role of Vitom-3D in the management of spinal meningiomas: review of the literature and illustrative case

The favorable outcome generally associated with spinal meningioma surgery is the result of the continuing refinement of the surgical technique, the use of intraoperative neuromonitoring, and a better understanding of the tumor biological behavior. Among all the technological advancements, visualization tools are the keys to any successful surgical procedure. The operating microscope is the gold standard in all neurosurgical procedures. In recent years, high-definition exoscope systems have entered the field of neurosurgery, as another tool in the armamentarium of the contemporary neurosurgeon. After initial experiences and technical improvements, the exoscope has proven to be best suited for spinal procedures. This study aims to briefly review the exoscope journey in neurosurgery, with a special focus on spinal meningioma surgery. Benefits and limitations are analyzed and an illustrative case is reported. Spinal meningiomas removal under exoscope visualization has proven to be feasible, efficient, and safe. Indication for the use of the exoscope greatly depends on meningioma size, consistency, relationship to surrounding neurovascular structures, and the surgeon’s experience. Switching to the operating microscope, if deemed safer, should always be considered

Myeloid Diagnostic and Prognostic Markers of Immune Suppression in the Blood of Glioma Patients

Background: Although gliomas are confined to the central nervous system, their negative influence over the immune system extends to peripheral circulation. The immune suppression exerted by myeloid cells can affect both response to therapy and disease outcome. We analyzed the expansion of several myeloid parameters in the blood of low- and high-grade gliomas and assessed their relevance as biomarkers of disease and clinical outcome. Methods: Peripheral blood was obtained from 134 low- and high-grade glioma patients. CD14+, CD14+/p-STAT3+, CD14+/PD-L1+, CD15+ cells and four myeloid-derived suppressor cell (MDSC) subsets, were evaluated by flow cytometry. Arginase-1 (ARG1) quantity and activity was determined in the plasma. Multivariable logistic regression model was used to obtain a diagnostic score to discriminate glioma patients from healthy controls and between each glioma grade. A glioblastoma prognostic model was determined by multiple Cox regression using clinical and myeloid parameters. Results: Changes in myeloid parameters associated with immune suppression allowed to define a diagnostic score calculating the risk of being a glioma patient. The same parameters, together with age, permit to calculate the risk score in differentiating each glioma grade. A prognostic model for glioblastoma patients stemmed out from a Cox multiple analysis, highlighting the role of MDSC, p-STAT3, and ARG1 activity together with clinical parameters in predicting patient’s outcome. Conclusions: This work emphasizes the role of systemic immune suppression carried out by myeloid cells in gliomas. The identification of biomarkers associated with immune landscape, diagnosis, and outcome of glioblastoma patients lays the ground for their clinical use

Midline Skull Base Meningiomas: Transcranial and Endonasal Perspectives

Skull base meningiomas have always represented a challenge for neurosurgeons. Despite their histological nature, they may be associated with unfavorable outcomes due to their deep-seated location and the surrounding neurovascular structures. The state of the art of skull base meningiomas accounts for both transcranial, or high, and endonasal, or low, routes. A comprehensive review of the pertinent literature was performed to address the surgical strategies and outcomes of skull base meningioma patients treated through a transcranial approach, an endoscopic endonasal approach (EEA), or both. Three databases (PubMed, Ovid Medline, and Ovid Embase) have been searched. The review of the literature provided 328 papers reporting the surgical, oncological, and clinical results of different approaches for the treatment of skull base meningiomas. The most suitable surgical corridors for olfactory groove, tuberculum sellae, clival and petroclival and cavernous sinus meningiomas have been analyzed. The EEA was proven to be associated with a lower extent of resection rates and better clinical outcomes compared with transcranial corridors, offering the possibility of achieving the so-called maximal safe resection

Assessment of structural disconnections in gliomas: comparison of indirect and direct approaches

none14Gliomas are amongst the most common primary brain tumours in adults and are often associated with poor prognosis. Understanding the extent of white matter (WM) which is affected outside the tumoral lesion may be of paramount importance to explain cognitive deficits and the clinical progression of the disease. To this end, we explored both direct (i.e., tractography based) and indirect (i.e., atlas-based) approaches to quantifying WM structural disconnections in a cohort of 44 high- and low-grade glioma patients. While these methodologies have recently gained popularity in the context of stroke and other pathologies, to our knowledge, this is the first time they are applied in patients with brain tumours. More specifically, in this work, we present a quantitative comparison of the disconnection maps provided by the two methodologies by applying well-known metrics of spatial similarity, extension, and correlation. Given the important role the oedematous tissue plays in the physiopathology of tumours, we performed these analyses both by including and excluding it in the definition of the tumoral lesion. This was done to investigate possible differences determined by this choice. We found that direct and indirect approaches offer two distinct pictures of structural disconnections in patients affected by brain gliomas, presenting key differences in several regions of the brain. Following the outcomes of our analysis, we eventually discuss the strengths and pitfalls of these two approaches when applied in this critical field.Silvestri, Erica; Villani, Umberto; Moretto, Manuela; Colpo, Maria; Salvalaggio, Alessandro; Anglani, Mariagiulia; Castellaro, Marco; Facchini, Silvia; Monai, Elena; D'Avella, Domenico; Puppa, Alessandro Della; Cecchin, Diego; Corbetta, Maurizio; Bertoldo, AlessandraSilvestri, Erica; Villani, Umberto; Moretto, Manuela; Colpo, Maria; Salvalaggio, Alessandro; Anglani, Mariagiulia; Castellaro, Marco; Facchini, Silvia; Monai, Elena; D'Avella, Domenico; Puppa, Alessandro Della; Cecchin, Diego; Corbetta, Maurizio; Bertoldo, Alessandr