Repair of a spinal pseudomeningocele in a delayed postsurgical cerebrospinal fluid leak using titanium U-clips: Technical note

Introduction: Chronic cerebrospinal fluid leak (CCFL) represents a possible event following spine surgery, with an incidence rate ranging from 5 to 18%. In literature have been reported few modification techniques that involved the use of titanium U-clips with the aim to reduce dural traumatism during its closure but only after non-accidental durotomy. Case illustration: We report the case of a 47-year-old female with history of L5-S1 microsurgical discectomy. After one year the patient was admitted to our unit because she presented progressive skin swelling in the lumbar region, intermittent headache and recurrent episodes of lipothymia. One-year MRI showed a voluminous subcutaneous cerebrospinal fluid (CSF)-like intensity collection in the T2-weighted sequences and communicating with the right L5-S1 interlaminar space. A second surgery revealed pseudomeningocele and a 5 mm dural defect is identified. At first, a tobacco pouch was created, and a suture with Prolene 6–0, a non-absorbable, synthetic monofilament, is made on the previously dissected tissue. In a second step, 2 medium/short non-penetrating titanium U-clips are applied with a multi-clip applier. There was no sign of recurrent pseudomeningocele in the 2-year follow-up. Conclusion: The authors presented a novel use of titanium U-clips to manage an insidious and complex case of pseudomeningocele in a CCFL. U-clips represent a safe and effective tool in CCFL repair

Fronto-orbito-ethmoidal intradiploic meningiomas: A case study with systematic review

Background: Primary intradiploic meningiomas, extra-axial tumors arising primarily in the skull, are rare. The authors reported a complex case of intradiploic intraosseous metaplastic meningioma of the left medial wall and orbital roof with the left frontal sinus invasion and left ethmoidal body bone substitution. The authors also conducted a systematic review concerning diagnosis and management of patients affected by purely calvarial intradiploic meningiomas along with a focus on fronto-orbito-ethmoidal ones. Methods: A literature search was conducted using PubMed and Scopus databases according to preferred reporting items for systematic reviews and meta-analysis statement and with the following Mesh terms: Intradiploic, intraosseous, calvarial, and meningioma. Eligibility criteria were limited by the nature of existing literature on intradiploic meningiomas, consisting of only case series, and case reports. Results: A total of 128 published studies were identified through our search. 41 studies were included in this systematic review, 59 patients with a female/male ratio of 1.2/1. The mean age of the patients is of 47.69 years (range 3-84 years). Only seven out of 59 patients (11.9%) presented a complex intradiploic meningioma located in fronto-orbito-ethmoidal region like our case. In almost all patients, a gross-total resection was performed (96.6%) and only in two patients (3.4%) a subtotal resection was achieved. Conclusion: The authors shared this successfully treated case to add to the overall clinical experience in the management of this rare subtype tumor, with the hope that more studies are conducted to further address the mechanism of intradiploic meningiomas development

Fluorescein-guided surgery for intradural spinal tumors: A single-center experience

•Gross total removal has a pivotal role in surgical treatment of intradural spinal tumors.•Sodium fluorescein prevents vascular injuries also preserving pial vessels in posterior myelotomy.•Fluorescence before the durotomy helps to distinguishing tumor from healthy tissue in intradural lesions.•Intraoperative fluorescence is safe and effective, also preserving functional anatomy in tumor removal

Giant cystic brain metastasis from ovarian papillary serous adenocarcinoma: Case report and review of the literature

Background: Ovarian brain metastases represent a very rare occurrence and without treatment, prognosis is very poor, with a median survival of one month. We present a unique case of a patient affected by a giant cystic intracerebral metastasis (>7 cm) secondary to an ovarian papillary serous adenocarcinoma, along with a review of the literature regarding large cystic ovarian metastases and their management. Case description: A 49-years-old female patient was admitted to our institution because she presented progressive headache and altered consciousness. Brain computed tomography (CT) scan and magnetic resonance imaging (MRI) revealed the presence of a giant left frontal intracerebral cystic lesion. The patient underwent a surgical removal of an ovarian high-grade papillary serous adenocarcinoma three years before. We performed a left frontal craniotomy and microsurgical removal of the brain lesion, achieving a safe macroscopic total resection, thanks to intraoperative neurophysiological monitoring (IONM). The post-operative period was uneventful with a complete recovery. Post-operative brain MRI showed a complete removal of the lesion. Conclusions: The presence of a giant cystic metastasis with symptoms of intracranial hypertension needs a radical and safe surgical removal, along with the management of a multidisciplinary oncologic group. Keywords: Brain metastasis, Ovarian carcinoma, Cystic, Gian

New tools in percutaneous minimally invasive chronic subdural hematomas evacuation

Background: Incidence of chronic subdural hematomas (cSDH) is expected to progressive rise in the next decades. There is no univocal indication of the approach to be used. Furthermore, there is no data about the efficacy of twist drill craniostomy (TDC) in hematomas with membranes. Objective: To describe our modified technique for TDC in patients affected by cSDH with membranes and in treatment with antiplatelets. Methods: We analyzed a group of 37 patients, affected by cSDH with membrane (type D laminar membrane and type G trabecular membrane according to Nakaguchi classification), treated with mushroom TDC using a modified technique. Results: After surgery the average maximum thickness of the common postoperative liquoral subdural collection decreased from 18.8 to 6.21 mm. We documented one acute subdural hematoma (2.7%), asymptomatic and not treated, and one recurrence of cSDH (2.7%) after 2 months that needed re-intervention with single burr hole. Conclusions: We presented a modified twist drill technique, characterized by the introduction of an application of a new device that optimizes both surgical results, clinical outcome and surgical procedure time. The presence of membrane type D and G does not affect the efficacy of drainage, that is negatively related to the presence of clots or acute hematoma. This modified technique is safe, fast, effective and represents a valid first line treatment of an unstable and unpredictable pathology such as cSDH. We suggest performing such technique on a larger patients' cohort to further validate its effectiveness

Primary Skull Base Chondrosarcomas: A Systematic Review

From MDPI via Jisc Publications RouterHistory: accepted 2021-11-25, pub-electronic 2021-11-26Publication status: PublishedBackground: Primary skull base chondrosarcomas (SBCs) can severely affect patients’ quality of life. Surgical-resection and radiotherapy are feasible but may cause debilitating complications. We systematically reviewed the literature on primary SBCs. Methods: PubMed, EMBASE, Scopus, Web-of-Science, and Cochrane were searched following the PRISMA guidelines to include studies of patients with primary SBCs. Clinical characteristics, management strategies, and treatment outcomes were analyzed. Results: We included 33 studies comprising 1307 patients. Primary SBCs mostly involved the middle-fossa (72.7%), infiltrating the cavernous-sinus in 42.4% of patients. Cranial-neuropathies were reported in 810 patients (62%). Surgical-resection (93.3%) was preferred over biopsy (6.6%). The most frequent open surgical approaches were frontotemporal-orbitozygomatic (17.6%) and pterional (11.9%), and 111 patients (21.3%) underwent endoscopic-endonasal resection. Post-surgical cerebrospinal-fluid leaks occurred in 36 patients (6.5%). Radiotherapy was delivered in 1018 patients (77.9%): photon-based (41.4%), proton-based (64.2%), and carbon-based (13.1%). Severe post-radiotherapy complications, mostly hypopituitarism (15.4%) and hearing loss (7.1%) were experienced by 251 patients (30.7%). Post-treatment symptom-improvement (46.7%) and reduced/stable tumor volumes (85.4%) showed no differences based on radiotherapy-protocols (p = 0.165; p = 0.062). Median follow-up was 67-months (range, 0.1−376). SBCs recurrences were reported in 211 cases (16.1%). The 5-year and 10-year progression-free survival rates were 84.3% and 67.4%, and overall survival rates were 94% and 84%. Conclusion: Surgical-resection and radiotherapy are effective treatments in primary SBCs, with acceptable complication rates and favorable local tumor control

In Memoriam: A Memoir for Our Fallen "Heroes"

This article is made available for unrestricted research re-use and secondary analysis in any form or be any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.Even though neurosurgeons exercise these enormous and versatile skills, the COVID-19 pandemic has shaken the fabrics of the global neurosurgical family, jeopardizing human lives, and forcing the entire world to be locked down. We stand on the shoulders of the giants and will not forget their examples and their teachings. We will work to the best of our ability to honor their memory. Professor Harvey Cushing said: “When to take great risks; when to withdraw in the face of unexpected difficulties; whether to force an attempted enucleation of a pathologically favorable tumor to its completion with the prospect of an operative fatality, or to abandon the procedure short of completeness with the certainty that after months or years even greater risks may have to be faced at a subsequent session—all these require surgical judgment which is a matter of long experience.” It is up to us, therefore, to keep on the noble path that we have decided to undertake, to accumulate the surgical experience that these icons have shown us, the fruit of sacrifice and obstinacy. Our tribute goes to them; we will always remember their excellent work and their brilliant careers that will continue to enlighten all of us. This memorial is intended to commemorate our colleagues who succumbed during the first 4 months

Cystic meningiomas: A complex diagnostic challenge and clinicopathological insights from a unique case presentation

Key Clinical Message Meningiomas present diverse clinical and radiological characteristics, with cystic formations constituting a lesser subset but posing significant diagnostic hurdles. We explore the complexities of cystic meningiomas through a distinctive case, highlighting the challenges in diagnosis and management due to their variable presentations. A 54‐year‐old female from Bengaluru, Karnataka, initially presented with transient memory disturbances. Brain MRI revealed a sizable left frontal cystic lesion exerting a mass effect and midline shift. However, rapid neurological decline led to an urgent surgical intervention via decompressive craniectomy unveiling unique intraoperative findings and with subsequent histopathological documentation of a Grade WHO 1 cystic meningioma. Cystic meningiomas present intricate diagnostic challenges resembling other intracranial lesions. Various classification systems attempt to categorize these tumors based on their imaging and histopathological characteristics. Despite this, atypical clinical manifestations often lead to misdiagnoses, necessitating a comprehensive approach to differential diagnosis. Further research is crucial to unravel the mechanisms underlying these tumors' cystic changes for improved diagnostic accuracy and tailored therapeutic interventions

Recurrent intracranial anaplastic ependymoma with late‐onset giant scalp metastasis

Key Clinical Message Ependymomas are primary brain tumors that predominantly affect individuals between 0 and 4 years of age. Although ependymomas have a propensity for recurrence and the potential to spread within the central nervous system through cerebrospinal fluid (resulting in drop metastases), reports of extra‐neural metastatic localizations are exceedingly rare in the existing literature. This case report presents a unique and rare instance of recurrent intracranial anaplastic ependymoma with a late‐onset giant scalp metastasis. Abstract A 55‐year‐old male patient with a medical history of partial resection of an atypical supratentorial left temporal ependymoma presented with a recurrent anaplastic ependymoma, which had been managed with surgery and radiotherapy. After a 4‐year follow‐up, the patient developed a subcutaneous mass in the left parietal region of the scalp. A multidisciplinary team of neurosurgeons and plastic surgeons performed a surgical procedure, which included en bloc removal of the scalp lesion, resection of 1 cm of unaffected skin, and craniotomy to address an osteolytic area in the parietal skull bone. Skin autografts were used for reconstruction. Histological examination confirmed metastasis of anaplastic ependymoma in the scalp. After a delay in starting chemotherapy due to concerns related to the COVID‐19 pandemic, the patient eventually initiated chemotherapy, leading to disease stability at a short‐term follow‐up. Scalp metastases from ependymoma are rarely reported in the literature. Management of such cases necessitates aggressive surgical resection, followed by adjuvant chemotherapy and radiotherapy. A multidisciplinary approach is recommended to ensure effective and targeted therapy, with a focus on preserving aesthetics, particularly in pediatric cases

Primary Intraosseous Osteolytic Meningioma with Aggressive Clinical Behaviour: Clinico-Pathologic Correlation and Proposed New Clinical Classification

(1) Introduction: Primary intraosseous osteolytic meningiomas (PIOM) are non-dural-based tumors predominantly presenting an osteolytic component with or without hyperostotic reactions. They are a subset of primary extradural meningiomas (PEM). In this study, we present a peculiar case with a systematic literature review and propose a new classification considering the limitations of previous classification systems. (2) Materials and Methods: Using a systematic search protocol in Google Scholar, PubMed, and Scopus databases, we extracted all case studies on PIOM published from inception to December 2020. A 46-year-old female patient form Dhaka, Bangladesh, was also described. The search protocol was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. (3) Results: Here, we present a 46-year-old female patient with PIOM who successfully underwent bifrontal craniotomy and gross total removal (GTR) of the tumor. At 6-month follow-up, no tumor recurrence was shown. Including our new case, 55 total cases from 47 articles were included in the analysis. PIOMs were in closer frequency among males (56.4%) and females (43.6%). The most common tumor location was the frontal and parietal calvarium, most commonly in the frontal bone (29.1%). Surgical resection was the predominant modality of treatment (87.3%); only 1.8% of patients were treated with radiotherapy, and 5.4% received a combination of surgery and radiotherapy. Gross total resection (GTR) was achieved in 80% of cases. Extracranial extension was reported in 41.8% of cases, dural invasion in 47.3%, and recurrence in 7.3%. Whole-body 68 Ga-DOTATOC PET/CT has also been reported as a useful tool both for differential diagnosis, radiotherapy contouring, and follow-up. Current treatments such as hydroxyurea and bevacizumab have variable success rates. We have also suggested a new classification which would provide a simple common ground for further research in this field. (4) Conclusions: Surgical resection, especially GTR, is the treatment of choice for PIOM, with a high GTR rate and low risk of complications and mortality. More research is needed on the differential diagnosis and specific treatment of PIOM