Surgical management of medial tentorial meningioma: falcotentorial and torcular

Falcotentorial meningiomas (FTM) stand out for their rarity, inconsistent definition, and surgical complexity. It is appropriate to deal with them in the context of medial tentorial meningiomas (MTM)

Recurrent atypical meningiomas: combining surgery and radiosurgery in one effective multimodal treatment

OBJECTIVE: Owing to their rarity and proteiform pathologic features, the clinical behavior of atypical meningiomas is not yet well characterized. Though the extent of resection is believed to be a key determinant of prognosis, limited data exist regarding optimal management of patients with recurrent disease. METHODS: In this 20-year retrospective case series, we reviewed the medical records of 46 patients with recurrent atypical meningiomas (185 lesions, 89 of which were local, 78 marginal, and 18 distant recurrences); treatment was radiosurgery (n = 60), surgery (n = 56), or both (n = 8). The median follow-up period was 53 months. Outcome measures were length of overall survival and disease-free intervals and prognostic factors for survival. RESULTS: Overall, the median progression-free survival was 26 months at the first recurrence and 100 months thereafter (the sum of the later intervals). Multivariate analysis showed that no treatment-related factors influenced prognosis, whereas recurrence at the skull base was a significant tumor-related factor limiting further treatment. Irrespective of treatment type, the recurrence-free interval was increasingly shorter during the clinical course, with a higher occurrence of marginal and distant lesions migrating to the midline and to the skull base. In sporadic cases, disease-free intervals were longer after wide craniotomy, tumor and dural resection with tumor-free margin. CONCLUSIONS: The disease-free interval was substantially similar after surgery and radiosurgery for treating recurrent disease in patients with atypical meningiomas. Surgery is the mainstay for prolonging survival, while radiosurgery can be an adjuvant strategy to gain time for clinical observation and planning aggressive surgical treatment

Surgical management of lateral tentorial meningiomas

OBJECTIVE: Tentorial meningiomas represent an heterogeneous group of tumors. Most of the published series deal with either a small number of patients or consider different locations as a whole, making indications for treatment and prognosis difficult to be drawn.We analysed the surgical management of the lateral tentorial meningiomas, a homogenous and rare sub-group.METHODS: 52 later tentorial meningiomas were operated between 1990 and 2010. Clinical, radiological features and surgical management of these patients were reviewed. Tumors were further subcategorized in posterior/intermediate and in supra/infratentorial subgroups. Surgical outcome, long-term results and prognostic factors are described.RESULTS: Mean age was 57 years(41 female,11 male). Mean tumor size was 46 mm; most had an infratentorial location(36vs16). Prevailing presenting symptoms were headache(n=28), vertigo/gait disturbances(n=25), confusion and visual disturbances(n=16). The infratentorial group presented with poorer clinical condition before as well as after operation. Extent of tumor resection was Simpson I in 10 patients, II in 26, III in 6 and IV in 10. Subtotal resection was statistically correlated with sinus invasion and tumor size. There was no surgical mortality. Permanent complications occurred in 3 patients. At latest follow-up(mean: 119 months)42/46 resumed their normal daily activity. Six cases recurred and remained stable after radiosurgery.CONCLUSION: Lateral tentorial meningomas are an homogeneous entity characterized by simple surgical approaches and favourable outcome(no mortality and low overall morbidity).Infratentorial location was more frequent and characterized by poorer outcome.The limiting factors for surgical removal were tumor size and sinus invasion. The latter point strengths the rationale for their classification into posterior and intermediate

Combined transcranial Doppler sonography and rCBF measurements in the early stage of subarachnoid hemorrhage

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Language assessment in multilingualism and awake neurosurgery

: Multilingualism has become a worldwide phenomenon that poses critical issues about the language assessment in patients undergoing awake neurosurgery in eloquent brain areas. The accuracy and sensitivity of multilingual perioperative language assessment procedures is crucial for a number of reasons: they should be appropriate to detect deficits in each of the languages spoken by the patient; they should be suitable to identify language-specific cortical regions; they should ensure that each of the languages of a multilingual patient is tested at an adequate and comparable level of difficulty. In clinical practice, a patient-tailored approach is generally preferred. This is a necessary compromise since it is impossible to predict all the possible language combinations spoken by individuals and thus the availability of standardized testing batteries is a potentially unattainable goal. On the other hand, this leads to high inconsistency in how different neurosurgical teams manage the linguistic features that determine similarity or distance between the languages spoken by the patient and that may constrain the neuroanatomical substrate of each language. The manuscript reviews the perioperative language assessment methodologies adopted in awake surgery studies on multilingual patients with brain tumor published from 1991 to 2021 and addresses the following issues: (1) The language selected for the general neuropsychological assessment of the patient. (2) The procedures adopted to assess the dimensions that may constrain language organization in multilingual speakers: age and type of acquisition, exposure, proficiency, and use of the different languages. (3) The type of preoperative language assessment used for all the languages spoken by the patient. (4) The linguistic tasks selected in the intraoperative setting. The reviewed data show a great heterogeneity in the perioperative clinical workup with multilingual patients. The only exception is the task used during language mapping, as the picture naming task is highly preferred. The review highlights that an objective and accurate description of both the linguistic profile of multilingual patients and the specific properties of the languages under scrutiny can profitably support clinical management and decision making in multilingual awake neurosurgery settings

The value of hemodynamic measurements in the early stage of subarachnoid hemorrhage

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Direct surgery for brainstem tumors

Updating a previous report, the authors offer a review of 45 patients between age 2 and 63 treated by direct surgical excision for brainstem tumours of various description. Since 1986 all candidate patients were examined by NMR imaging in addition to CT scanning, sometimes with the further addition of digital-subtraction vertebral angiography. By Epstein and McLeary's criteria, 24 of the tumours were focal, 12 were cervicomedullary and 9 were diffuse. The most frequent histological diagnosis was glioma (36 cases between low-grade astrocytoma, anaplastic astrocytoma and glioblastoma); the balance was provided by cavernoma (6 cases), haemangioblastoma (2 cases), and lipoma (2 cases). Gross total resection was achieved in 28 patients, namely all those with ependymoma or vascular tumours and 14 of 17 with low-grade astrocytoma. Resection was subtotal in 16 cases and confined to a generous biopsy in one. There was no operative mortality, but 2 deaths occurred in the early postoperative period. At discharge, neurological status was unchanged or improved in 35 cases. At 3-month follow-up examination, 12 patients were improved, 27 were unchanged and 3 were worsened. By January 1990 (6 to 72 months postoperatively) 27 of the first 40 patients treated were alive: 13 had resumed normal life, 6 were self-sufficient and 8 were disabled. The authors conclude that present-day microsurgical resection of intra-axial brainstem tumours is associated with low mortality and morbidity and affords favourable results for which they credit high-quality NMR imaging, efficient microsurgery, adequate anesthesia, and competent postoperative intensive care

The role of hemodynamic assessment in the management of cerebral AVMs

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