Ruptured middle cerebral artery aneurysms. retrospective study and multivariate analysis of 105 patients treated by surgical clipping

Objective of the study: We analyze in this study only patients with surgically treated ruptured aneurysms in order to identify statistical significance of each predictive factor in terms of outcome of patients with ruptured MCAAs. Materials and methods: In this retrospective study, we analyzed 105 cases of ruptured MCAAs, admitted from January 2001 to December 2015 at Neurosurgical Department of Umberto I University Hospital of Rome, Italy. Predictive factors evaluated are: Patient’s features (age, sex, co-morbidities), aneurysmal location (proximal, bifurcation or distal) and size of aneurysmal dome (small, large or giant); surgical timing (ultra-early, early, delayed), and Intracerebral Hemorrhage (ICH) volume. For each parameter we calculated mean and standard deviation, covariance and relation coefficient (through the linear regression model). Results: The clinical evaluation of patients assessed through the World Federation of Neurological Surgeons (WFSN) grading scale, that is 5 for 37 patients (35.3%), 4 for 28 patients. In 40% of cases the maximum sac diameter was between 7 mm and 12 mm, while in 67% of the cases the aneurysms concerned the bifurcation of the middle cerebral artery. ICH was associated in 57 cases (54.3%). As far as outcome is concerned, at 3 months, 32 patients (30.47%) had a favourable outcome, while 73 (69.52%) patients had not favourable outcome. To one year, 46 patients (43.8%) had favourable outcomes, while 59 patients (56.19%) had not favourable outcome. The mean outcomes as mean mRS are significantly less favourable in patients with ICH. Conclusion: In MCAAs patients, the presence of ICH strongly affects the outcome with a marked increase in mortality and morbidity. Surgical timing significantly influences the outcomes and ultra-early surgery should always be taken into account

Transdural Spread of Glioblastoma with Endonasal Growth in a Long-Term Survivor Patient: Case Report and Literature Review.

Glioblastoma (GBM) is the most aggressive primary tumor of the central nervous system (CNS) in adults. Its growth has been always described as locally invasive. This tumor rarely penetrates dura mater and invades extracranial structures. We present a case of GBM, which occurred in a 39-year-old man, with final involvement of the nasal cavity. The patient was operated four times in three years, and a personalized adjuvant chemotherapy regimen was administered in a neo-adjuvant fashion. Histopathological features of the tumor are described. To our knowledge, there are only 9 cases reported in the literature showing this growth pattern and the last case was reported in 1998

Meningiomas of the Skull Base: Chapter 12, Middle Fossa Floor Meningiomas

Little is known regarding meningiomas that primarily arise from the floor of the middle fossa as opposed to the other middle fossa meningiomas. In this chapter, we treat this relatively new entity, including primary Meckel’s cave (MC) meningiomas because they respect similar anatomical landmarks. Meningiomas of the middle cranial fossa can be approached by two distinct routes: an anterolateral approach or a lateral approach; in other words, via a pterional or a subtemporal approach. Both approaches can be further extended by means of additional osteotomies, such as the cranio-orbital zygomatic approach and the temporo-zygomatic approach. “Extended” approaches and adequate cerebrospinal fluid drainage, are helpful to achieve a “retractorless” surgical technique. It is also mandatory to achieve good surgical outcomes to preserve venous structures, as the vein of Labbè. The aim of this chapter is to treat “middle fossa floor” meningiomas as a clinical entity that is distinct from meningiomas arising from the sphenoid wing and cavernous sinus, which have been already described in other chapters of this book, and to include in authors’ classification primary MC meningiomas as well

Endonasal Endoscopic Approaches for Anterior Skull Base Meningiomas: Evaluation of Potential Benefits on Outcome Compared with Transcranial Approaches

Objective: Identify potential advantages in endonasal surgical aspiration of this kind of lesion, considering several cases from our transcranial series, which could have been treated also by endoscopic route. Study Design: Midline anterior skull base meningiomas have been traditionally treated via transcranial approaches. Recently, the endoscopic endonasal approach has been introduced for the surgical treatment of such lesions. The actual advantages of the latter approach in terms of outcome are not clear yet. Methods: We analyzed a series of 94 patients treated for olfactory groove or tuberculum sellae meningiomas during the past 13 years. We selected 25 cases who had radiological characteristics that suggest resectability by endoscopic route. Inclusion criteria for the use of expanded endoscopic endonasal approaches are: size less than 4 cm; absence of carotid encasement, or cavernous sinus invasion; no optical nerves involvement, absence of optical canal invasion; extension not above the middle orbital line; anterior limits crista galli and frontal sinus; predominant midline location. We took into consideration several parameters regarding the postoperative course of our patients. Results: Transcranial microsurgical approaches are still the first choice for treatment of midline anterior skull base meningiomas because they allow treating lesions with any characteristics. Conclusion: Transcranial route offer a greater chance of complete removal and lower risk of CSF fistula

Planum Sphenoidalis, Tuberculum, and Diaphragma Sellae Meningiomas: A Unique or Three Different Entities?

Objective: Demonstrate within this group the existence of distinct patterns, which could influence the type of treatment. Study Design: Planum sphenoidalis, tuberculum sellae, and diaphragma sellae meningiomas are usually considered as the same entity, known as TSM (tuberculum sellae meningiomas). TSM can origin from dura covering the planum sphenoidalis, limbus sphenoidalis, chiasmatic sulcus, tuberculum sellae, or diaphragma sellae. Methods: In the last 13 years, at our department have been treated 44 TSM. The majority of these cases have been treated by transcranial route. Most of the surgical interventions were performed by pterional approach. Data collection has been based on anatomical characteristics, radiological appearance, and clinical patterns, distinguishing some categories. Results: We suspect that some features could determine the treatment of these lesions: position of nearest vessels (hypophyseal arteries); optic nerves and chiasm position; pituitary stalk displacement; cavernous sinus invasion. Size of lesion is also important for surgical decision-making, including anteroposterior extension and laterolateral diameter. Conclusion: From our analysis, we conclude that some lesions are better approached by transcranial route, respect to diaphragma sellae meningiomas, which could be easily and safely treated by endoscopic approach

Surgical management of acute subdural hematoma: a comparison between decompressive craniectomy and craniotomy on patients treated from 2010 to the present in a single center.

BACKGROUND: Acute subdural hematoma represents an important cause of disability and mortality. Its surgical treatment takes advantage of two surgical procedures: craniotomy and decompressive craniectomy, nevertheless the effectiveness of one procedure rather than the other is still debated. This study was conducted to identify which of the surgical procedures could provide better neurological outcome after traumatic acute subdural hematoma; as a secondary endpoint, the study tries to settle pre-operative prognostic factors useful to identify the most appropriate surgical technique for every specific patient and kind of trauma. METHODS: A retrospective analysis was performed on patients who underwent craniotomy or decompressive craniectomy between January 2010 and July 2017 at the Department of Neurosurgery of Umberto I Hospital in Rome. Ninty-four patients were selected and reviewing clinical records, pre-operative and post-operative's data were collected (e.g. GCS, mechanism of trauma, CT findings, mortality rate, neurological outcome at discharge, mRS at 12 months). Data were analyzed using X2 test and the F test. The multivariate analysis was performed using a stepwise logistic regression. The analysis was carried out using SPSS software and a p value ≤ 0.05 was considered significant. RESULTS: On 94 patients 46.8% underwent decompressive craniectomy and 53.2% underwent craniotomy. The mortality rate was (53.2%); it was shown to be related to a GCS 60 years old (p = 0.0001). Decompressive craniectomy was performed most frequently for high energy trauma (p =0.006); the mean GCS at admission was 7.91 for decompressive craniectomy and 9.64 for craniotomy (p = 0.05). Patients who underwent decompressive craniectomy and survived surgery showed a better neurological outcome compared to those who underwent craniotomy (p = 0.009). The evaluation of mRS after 12 months didn't show a statistically significant difference between the two groups. CONCLUSIONS: In case of high energy trauma and GCS ≤8 different neurosurgeons decided to perform most frequently decompressive craniectomy rather than craniotomy. Furthermore, even if not related to survival rate, decompressive craniectomy showed a better neurological outcome especially in patients with GCS ≤8 at admission. In conclusion, even if prospective studies are required, these results depict the current attitude about the choice between craniotomy and decompressive craniectomy

Four-year clinical and neuroradiological follow-up of a papillary tumor of the pineal region

Papillary tumor of the pineal region (PTPR) is a rare variety of CNS neoplasms and, since its first definition in 2003, only 64 cases have been described. PTPR is a primary neoplasm morphologically characterized by papillary structure staining for cytokeratin, transthyretin, neurone-specific enolase and S-100 protein. We report on a case of about 4 years' clinical history and neuroradiological follow-up of PTPR, in a 47-year-old Indian patient, with the aim of increasing the knowledge of its natural history. We describe through CT and MRI scans the natural evolution of this neoplasm, enhancing changes and morphologic structures involved, together with the final surgical treatment and pathological details. A mean growth rate average was calculated for this kind of lesion. In conclusion, the inexorable progressive growing nature of this tumor leads us to advocate an aggressive attitude among neurosurgeons and radiotherapists, with a precocious surgical approach when the suspicion rises