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

RET/PTC3 translocation in a rare hemorrhagic brain metastasis of papillary thyroid cancer post Chernobyl radiation affects vessels ultrastructure

Abstract Background Slow progression and good prognosis are the usual characteristics of papillary thyroid carcinoma (PTC). The presence of brain metastases (0.4–1.2%) is suggestive of a worse prognosis. RET/PTC rearrangements were particularly prevalent in PTCs developed after Chernobyl nuclear accident. Case description A 50-year-old woman born in Slovakia, exposed to radiation resulting from the accident at the Chernobyl nuclear power plant, affected since 2017 by papillary thyroid cancer and in therapy at our hospital, experimented cerebral hemorrhagic metastasis. Biopsy analyses revealed a RET/PTC3 rearrangement, so our aim was to find possible morphological relation between hemorrhagic metastasis and RET/PTC3 translocation. Results Immunohistochemical analysis showed diffuse and intense positivity for VEGF in endothelial cells of the neoplasm’ vascular network. Transmission electron microscopy images showed vessels with unorganized pattern and uneven diameters. In particular, metastasis endothelial cells (MECs) showed irregular shape and size, thickened cytoplasm and swelling of endoplasmic reticulum. MECs organized in irregular monolayers or multiple layers, surrounded by a thickened but unstructured extracellular matrix. Absence of strong junctional complexes among MECs resulted in a further weakened vessels wall. Conclusion RET/PTC3 translocation causes VEGF overexpression via STAT3 signaling cascade and the increased amount of VEGF adds to the greater amount of VEGFRs expressed by MECs. Our ultrastructural investigation show that this condition creates a massive growth of altered vessels prone to bleeding. The clinical significance of our study consists in alert oncologist and surgeons on possible arising of hemorrhagic brain metastases in patients with PTC and RET/PTC3 translocation exposed to ionizing radiation as people living in areas caught up in Chernobyl or Fukushima disasters

How future surgery will benefit from SARS-COV-2-related measures: a SPIGC survey conveying the perspective of Italian surgeons

COVID-19 negatively affected surgical activity, but the potential benefits resulting from adopted measures remain unclear. The aim of this study was to evaluate the change in surgical activity and potential benefit from COVID-19 measures in perspective of Italian surgeons on behalf of SPIGC. A nationwide online survey on surgical practice before, during, and after COVID-19 pandemic was conducted in March-April 2022 (NCT:05323851). Effects of COVID-19 hospital-related measures on surgical patients' management and personal professional development across surgical specialties were explored. Data on demographics, pre-operative/peri-operative/post-operative management, and professional development were collected. Outcomes were matched with the corresponding volume. Four hundred and seventy-three respondents were included in final analysis across 14 surgical specialties. Since SARS-CoV-2 pandemic, application of telematic consultations (4.1% vs. 21.6%; p < 0.0001) and diagnostic evaluations (16.4% vs. 42.2%; p < 0.0001) increased. Elective surgical activities significantly reduced and surgeons opted more frequently for conservative management with a possible indication for elective (26.3% vs. 35.7%; p < 0.0001) or urgent (20.4% vs. 38.5%; p < 0.0001) surgery. All new COVID-related measures are perceived to be maintained in the future. Surgeons' personal education online increased from 12.6% (pre-COVID) to 86.6% (post-COVID; p < 0.0001). Online educational activities are considered a beneficial effect from COVID pandemic (56.4%). COVID-19 had a great impact on surgical specialties, with significant reduction of operation volume. However, some forced changes turned out to be benefits. Isolation measures pushed the use of telemedicine and telemetric devices for outpatient practice and favored communication for educational purposes and surgeon-patient/family communication. From the Italian surgeons' perspective, COVID-related measures will continue to influence future surgical clinical practice

Giant cell ependymoma of cervicomedullary junction. a case report of a long-term survivor and literature review

Background: Ependymoma accounts for 3%–9% of all neuroepithelial tumors. Giant cell ependymoma (GCE) is a rare and distinct variant, with only 22 cases described in the literature. The 2007 World Health Organization classification first acknowledged this rare subtype. The cytologic features of GCE include the presence of pleomorphic giant cells with several cellular atypias, which at intraoperative frozen diagnosis may appear to be high-grade glial lesions. Despite its apparently malignant histology, GCE seems to be a neoplasm with a relatively good prognosis. Extended tumor removal is the gold standard without adjuvant treatment. Case Description: We describe the first case, to our knowledge, of GCE situated at the cervicomedullary junction in a 62-year-old patient. Surgery was performed with combined intraoperative monitoring of motor evoked potentials and somatosensory evoked potentials. Intraoperative frozen diagnosis revealed a high-grade glial neoplasm; however, gross total resection was achieved. The definitive diagnosis was GCE. At follow-up evaluation 11 years after surgery, the patient did not present with any tumor recurrence. Conclusions: As the intraoperative diagnosis can be misleading, whenever a cleavage plane is recognized, it is essential to perform a gross total resection with the aid of intraoperative neurophysiologic monitoring, to improve prognosis and neurologic outcome. Data reported in the literature show that prognosis is mainly influenced by grade of resection

The Efficacy of a Multidisciplinary Approach and Diagnostic–Therapeutic Algorithm for Vertebral Metastases with Spinal Cord Compression

Background and Objectives: Metastatic spinal cord compression represents a substantial risk to patients, given its potential for spinal cord and/or nerve root compression, which can result in severe morbidity. This study aims to evaluate the effectiveness of a diagnostic–therapeutic algorithm developed at our hospital to mitigate the devastating consequences of spinal cord compression in patients with vertebral metastases. Materials and Methods: The algorithm, implemented in our practice in January 2022, is based on collective clinical experience and involves collaboration between emergency room physicians, oncologists, spine surgeons, neuroradiologists, radiation oncologists, and oncologists. To minimize potential confounding effects from the COVID-19 pandemic, data from the years 2019 and 2021 (pre-protocol) were collected and compared with data from the years 2022 and 2023 (post-protocol), excluding the year 2020. Results: From January 2022 to December 2023, 488 oncological patients were assessed, with 45 presenting with urgency due to suspected spinal cord compression. Out of these, 44 patients underwent surgical procedures, with 25 performed in emergency settings and 19 cases in elective settings. Comparatively, in 2019 and 2021, 419 oncological patients were evaluated, with 28 presenting with urgency for suspected spinal cord compression. Of these, 17 underwent surgical procedures, with 10 performed in emergency scenarios and 7 in elective scenarios. Comparing the pre-protocol period (years 2019 and 2021) to the post-protocol period (years 2022 and 2023), intrahospital consultations (commonly patients neurologically compromised) for spine metastasis decreased (105 vs. 82), while outpatient consultations increased remarkably (59 vs. 124). Discussion: Accurate interpretation of symptoms within the context of metastatic involvement is crucial for patients with a history of malignancy, whether presenting in the emergency room or oncology department. Even in the absence of a cancer history, careful interpretation of pain characteristics and clinical signs is crucial for diagnosing vertebral metastasis with incipient or current spinal cord compression. Early surgical or radiation intervention is emphasized as it provides the best chance to prevent deficits or improve neurological status. Preliminary findings suggest a notable increase in both the number of patients diagnosed with suspected spinal cord compression and the proportion undergoing surgical intervention following the implementation of the multidisciplinary protocol. The reduced number of intrahospital consultations (commonly patients neurologically compromised) and the increased number of visits of outpatients with vertebral metastases indicate a heightened awareness of the issue, leading to earlier identification and intervention before neurological worsening necessitating hospitalization. Conclusions: A comprehensive treatment planning approach is essential, and our multidisciplinary algorithm is a valuable tool for optimizing patient outcomes. The protocol shows potential in improving timely management of spinal cord compression in oncological patients. Further analysis of the factors driving these changes is warranted. Limitations: This study has limitations, including potential biases from the retrospective nature of data collection and the exclusion of 2020 data due to COVID-19 impact. To enhance the robustness of our results, long-term studies are required. Moreover, the single-center study design may limit the validity of the findings. Further multicenter studies would be beneficial for validating our results and exploring underlying factors in detail

Casemix, management, and mortality of patients receiving emergency neurosurgery for traumatic brain injury in the global neurotrauma outcomes study: a prospective observational cohort study

Abstract Background: Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development. Methods: We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital's 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)-a composite of life expectancy, education, and income measures-into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation. Findings: Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24-51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34-69) and the youngest in the low HDI tier (median 28 years, IQR 20-38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6-32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55-5·2) and high HDI tier (2·26, 1·23-4·15), but not the low HDI tier (1·66, 0·61-4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17-2·49). Interpretation: Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practice

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 second recurrence; and (3) incidence of recurrence and clinical outcome. Data were analyzed with the Pearson's Chi-square test for its significance. Results: In 582 cases (59.4%), a discectomy was performed, while in 381 (40.6%), a herniectomy was undertaken. In 16 cases, a procedure marked as “other” was performed. Among all patients, 110 (11.2%) had a recurrence. Recurrent LDH was observed in 55 patients following discectomy (9.45%), in 45 following herniectomy (11.8%), and in 10 (62.5%) following other surgery. Our data showed that 90.5% of discectomies and 88.2% of the herniectomies had a good clinical outcome, whereas other surgeries presented a recurrence rate of 62.5% (Pearson's χ2 0.05). A significant statistical correlation emerged between the use of other techniques and the incidence for the second recurrences (P < 0.05). Conclusions: The recurrence of an LDH is one of the most feared complications following surgery. Although the standard discectomy has been considered more protective toward the recurrence compared to herniectomy, our data suggest that there is no significant correlation between the surgical technique and the risk of LDH recurrence