The reconstructive role of TachoSil in neurosurgery

Hemorrhages, cerebrospinal fluid (CSF) fistula and infections are the most challenging post-operative complications in Neurosurgery [1–5]. Fibrin sealant agents have been developed with the aim to provide efficient hemostasis and safe dural closure [3,6–14]. In this study we report our initial experience using TachoSil® (haemostatic surgical patch; Nycomed, Linz, Austria) in achieving hemostasis and CSF leakage repair during cranio-cerebral procedures [15–18]. We describe and show the unique features of this fibrin sealant, pioneered with stunning success in many surgical procedures known to be at high risk of peri- and postoperative bleeding (i.e. nephrectomies, pulmonary lobectomies, ballistic injuries, arthroplasties, coronary bypass graftings), but still not widely exploited at its best in the field of Neurosurgery

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

Basal cell carcinoma (BCC) is a non melanocytic skin cancer that arises from basal cells, affecting commonly fair-skinned human beings. Although the tumor is well known for local recurrences, extension into the intracranial space is reported. A case of a giant BCC of the scalp invading the middle and posterior third of the superior sagittal sinus (SSS) is reported. A 70-year-old male with a basal cell carcinoma history presented with a massive bleeding from the SSS invaded by the tumor. Since the patient refused surgery the bleeding was managed through direct compression by applying a thrombin-based hemostatic agents and sterile dressings. This procedure was performed daily in order to stimulate the spontaneous thrombosis of the dural sinus and development of collateral circle. BCC invading the SSS is rarely reported. A technical description of this case is provided. This case underscores the importance of early and appropriate treatment for high risk BCC, and whenever surgical procedure is not suitable appropriate conservative treatment may be efficacious

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

Background: Skull reconstructive surgery is critical to prevent cerebrospinal fluid (CSF) fistulas and infections, and to ensure good aesthetic results in meningiomas surgery. Methods: A 65-year-old woman was surgically treated for a bilateral parasagittal meningioma with complete superior sagittal sinus (SSS) involvement, and an intra-extracranial extension, determining a significant cranial defect at the vertex. A Simpson I resection was achieved. Postoperatively a considerable and not conservatively repairable CSF leak was detected. Surgical revision of the wound with repair of the fistula and complex reconstructive operation was performed including a combination of techniques and devices such as autologous fibrin glue and reparation of the extracranial planes by an autologous vascularized vastus lateralis pedicled muscle flap. Results: No postoperative complications, infections or new neurological deficits were detected, and the CSF leak definitively ceased after surgery; the aesthetic results were satisfactory. Conclusions: Reparation of CSF fistulas that arise after meningioma surgery can require a complex reconstructive surgery of the superficial layers; when cranioplasty is not feasible or indicated, a meticulous reconstruction of the extracranial soft tissues is possible also by using vascularized autologous distal muscular tissue, with close interdisciplinary cooperation

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 successfully operated. Conclusion: CNS cryptococcoma is a rare entity, and in immunocompetent patients, its diagnosis can be challenging. The pathophysiology of lesion-related seizure is discussed along with a review of the pertinent literature

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-analyses statement, with no limits in terms of date of publication. Demographic data, inclusion criteria, clinical and radiological outcome, frequency of adverse events (AEs), and follow-up time were evaluated. Results: A total of 19 studies were included with a total of 1577 patients. The techniques used for facet arthrodesis were Goel intra-articular spacers in 21 patients (5.3%), Facet Wedge in 198 patients (15.8%), facet screws fixation techniques in 1062 patients (52.6%), and facet joints arthroplasty in 296 patients (26.3%). Clinical outcomes were assessed through the evaluation of pain relief and improvement in functional outcome. Radiological outcomes were assessed by the evaluation of proper positioning of instrumentation, solid bony fusion rate, and preservation of disk height. AE's mainly observed were pseudoarthrosis, reoperation, instrumentation displacement/malpositioning/migration, neurological impairment, deep vein thrombosis, and infections. The mean follow-up time ranged from 6 months to 11.7 years. Conclusion: Our data demonstrate that facet joint arthrodesis appears to be effective in managing LSDD. These findings, however, are limited by the small sample size of patients. Accordingly, larger series are needed before formal recommendations can be made

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

Abstract Study design Case report and review of literature. Objective To report a rare complication of anterior cervical decompression and fusion (ACDF) in a patient with severe cervical cord compression and review of relevant literature. Introduction The white cord syndrome is a very rare condition characterized by an ischemic-edematous lesion of the spinal cord following a surgical procedure, lacking intra o perioperative surgical or anesthesiological complications. Case report A 64-years old male affected by a severe cervical stenosis at multiple levels, with voluminous C3–C4 and C5–C6 disc herniations associated to T2-hyperintense myelomalacic area at C3–C4 level was admitted to our Unit of Neurosurgery in July 2015. A double-level anterior cervical decompression and fusion (ACDF) procedure was performed without intraoperative complications and, in the immediate post-operative period, the patient developed a severe motor weakness to four limbs. The post-operative cervical spine MRI revealed an extension of the hyperintensity on the C5–C6 level. In the immediate post-operative course high doses of dexamethasone were administered, in order to treat the secondary spinal damage. The patient was, after few days, transferred to a Rehabilitation Unit where a partial improvement of the motor weakness was gradually observed. We report the second case of this complication in Literature to support the theory of a possible reperfusion injury after a double ACDF. We speculate an ethiologic mechanism similar to a long-term no-reflow phenomenon, likely during the post-ischemic period in myocardial or cerebral infarction. Conclusions Despite the pathophysiology of non-reflow phenomenon is not widely known, we suspect that an improper blood flow after the double-level discectomy could have led to the changes in medullar hemodynamics

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

The authors describe a case of spinal arteriovenous fistula (AVF) treated by a microvauscular Doppler–assisted surgical interruption of the arterialized vein. Microvascular Doppler monitoring represents a valid, widely available, non-invasive 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

Emergency endovascular treatment of petrous carotid artery false aneurysm

Introduction: The management of ruptured intracranial false aneurysms (IFAs) might be tricky as any kind of treatment modality, surgical or endovascular, is burdened with significant challenges. A case report of the endovascular treatment of IFA in emergency setting is presented to provide more understanding of its pathophysiology as well as of the best operative work-up for petrous carotid artery reconstruction. Methods: Technical notes from a left sided skull base abscess, involving and eroding the carotid canal and petrous carotid artery (PCA) resulting in an IFA are shown and analyzed. Results: Balloon-assisted low viscosity Onyx embolization seems an effective method for the emergency treatment of IFA. Indications, technical nuances, and peri- and post-procedural complications are thoroughly discussed. A flow chart for the management of IFA is also proposed. Conclusions: The combination of parent artery balloon protection and low viscosity Onyx embolization can provide an effective occlusion of the IFA while maintaining parent artery patency. Normal distal filling of the parent artery, and optimal obliteration of the IFA are easily achievable

A Difficult Case of Ventriculitis in a 40-Year-Old Woman with Acute Myeloid Leukemia

Ventriculitis and nosocomial meningitis caused by carbapenem-resistant Gram-negative and vancomycin-resistant Gram-positive bacteria represent a growing treatment challenge. A case of ventriculitis and bacteremia caused by carbapenem-resistant, KPC-producing Klebsiella pneumoniae and vancomycin-resistant Enterococcus faecium in a young woman with acute leukemia who was successfully treated with meropenem/vaborbactam (MVB), rifampicin, and linezolid is described in this paper. This case report emphasizes the importance of a multidisciplinary strategy, including infectious focus control, for the treatment of device-associated central nervous system (CNS) infections from multidrug-resistant bacteria. Considering the novel resistance patterns, more research on drug penetration into the central nervous system, as well as on the necessity of association therapies, is needed

The Use of Intraoperative Microvascular Doppler in Vascular Neurosurgery: Rationale and Results—A Systematic Review

Surgical treatment of neurovascular lesions like intracranial aneurysms, arteriovenous malformations and arteriovenous dural fistulas is still associated with high morbidity. Several recent studies are providing increasing insights into reliable tools to improve surgery and reduce complications. Inadvertent vessel compromise and incomplete occlusion of the lesion represent the most possible complications in neurovascular surgery. It is clear that direct visual examination alone does not allow to identify all instances of vessel compromise. Various modalities, including angiography, microvascular Doppler and neurophysiological studies, have been utilized for hemodynamics of flow vessels in proper clipping of the aneurysm or complete obliteration of the lesion. We intended to review the current knowledge about the intraoperative microvascular Doppler (iMDS) employment in the most updated literature, and explore the most recent implications not only in intracranial aneurysms but also in neurovascular lesions like arteriovenous malformations (AVMs) and arteriovenous dural fistulas (AVDFs). According to the PRISMA guidelines, systematic research in the most updated platform was performed in order to provide a complete overview about iMDS employment in neurovascular surgery. Twelve articles were included in the present paper and analyzed according to specific research areas. iMDS employment could represent a crucial tool to improve surgery in neurovascular lesions. The safety and effectiveness of the surgical treatment of neurovascular lesions like intracranial aneurysm and other neurovascular lesions like AVMs and AVDFs requires careful and accurate consideration regarding the assessment of anatomy and blood flow. Prognosis may depend on suboptimal or incomplete exclusion of the lesion