clinical outcome of patients over 90 years of age treated for chronic subdural hematoma

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Posterior Titanium Screw Fixation without Debridement of Infected Tissue for the Treatment of Thoracolumbar Spontaneous Pyogenic Spondylodiscitis

Study DesignRetrospective study.PurposeThe aim of our study was to analyze the safety and effectiveness of posterior pedicle screw fixation for treatment of pyogenic spondylodiscitis (PSD) without formal debridement of the infected tissue.Overview of LiteraturePosterior titanium screw fixation without formal debridement of the infected tissue and anterior column reconstruction for the treatment of PSD is still controversial.MethodsFrom March 2008 to June 2013, 18 patients with PSD underwent posterior titanium fixation with or without decompression, according to their neurological deficit. Postero-lateral fusion with allograft transplantation alone or bone graft with both the allogenic bone and the autologous bone was also performed. The outcome was assessed using the visual analogue scale (VAS) for pain and the Frankel grading system for neurological status. Normalization both of C-reactive protein (CRP) and erythrocyte sedimentation rate was adopted as criterion for discontinuation of antibiotic therapy and infection healing. Segmental instability and fusion were also analyzed.ResultsAt the mean follow-up time of 30.16 months (range, 24–53 months), resolution of spinal infection was achieved in all patients. The mean CRP before surgery was 14.32±7.9 mg/dL, and at the final follow-up, the mean CRP decreased to 0.5±0.33 mg/dL (p <0.005). Follow-up computed tomography scan at 12 months after surgery revealed solid fusion in all patients. The VAS before surgery was 9.16±1.29 and at the final follow-up, it improved to 1.38±2.03, which was statistically significant (p <0.05). Eleven patients out of eighteen (61.11%) with initial neurological impairment had an average improvement of 1.27 grades at the final follow-up documented with the Frankel grading system.ConclusionsPosterior screw fixation with titanium instrumentation was safe and effective in terms of stability and restoration of neurological impairment. Fixation also rapidly reduced back pain

Surgical treatment and predictive factors for atypical meningiomas: a multicentric experience

INTRODUCTION: Atypical meningiomas (AMs) are characterized by a high rate of recurrence and a lesser Overall Survival (OS), compared to grade I meningioma. Nowadays, it is still controversial which are the predictive parameters for OS and the Recurrence free survival (RFS). METHODS: Data regarding age, gender, localization of the tumor, pre-operative symptoms, tumor localization, size, Simpson grade, postoperative complications, the extent of the resection (EOR), the number of mitoses, the proliferation index (MIB1), the brain invasion, the post-operative Radiotherapy (RT) treatment and clinical outcome (Karnofsky performance status, KPS, post-operatively and long-time follow-up) were evaluated. In addition, data regarding the recurrence rate, the mortality, OS and RFS at 1-year, 3-year and 5-year follow-up were collected. The median follow-up was 76 months, all patients had at least 3-year follow-up. RESULTS: Between 2007 and 2017, 73 patients underwent a surgical procedure for AMs (WHO grade II) in Ospedali Riuniti Center of Ancona and Sestre Milosrdnice University Hospital Centre. A preoperative KPS> 80 resulted to be related to a better OS, also at the one-month follow-up, six-month and one-year follow-up KPS. The post-operative complications did not modify the OS and the RFS. A Gross total removal (GTR, Simpson grade I, II) was achieved in the 80,8% of patients. The RFS was statistically influenced by the EOR (p=0,002). A MIB-1>8 was a negative predictive factor for recurrence at univariate and multivariate analysis (p=0,001, p=0,021). RT was statistically related to a worse outcome. The incidence of recurrence was 38%. The RFS was 98,6% at 1-year follow-up, 81,1% at 3-year and, only 57,5% at 5-year follow-up. All patients were alive after 1-year follow-up. The OS at 3-year follow-up was 90, 5% and 78,8 % at 5-year follow-up. CONCLUSIONS: Despite some limitations, our study demonstrate that an aggressive surgical treatment, achieving a GTR is a positive predictive parameter for the RFS, as well as a good clinical outcome (KPS > 80) is related to a longer overall survival

Managing ventriculoperitoneal shunt exposure in adult patients: surgical options and implant removal prevention

Background: Ventriculoperitoneal shunt exposure is rare. Small series reporting on managing this complication mainly focus on the pediatric population, where wound breaks over cerebrospinal fluid (CSF) chambers are observed most frequently. However, case series on adult patients are missing. Methods: Between June 2004 and December 2019, 18 patients underwent ventriculoperitoneal shunt revision due to implant exposure. Pertinent data were retrospectively collected from the hospital database. Their full clinical history, laboratory values, neuroradiological imaging, pre-treatment CSF characteristics, photographic and video material, and surgery types were reviewed. Results: The ventricular catheter was exposed in eight patients (the frontal region in six and the occipital region in two), the valve chamber at the retroauricular region in six, the shunt tube in seven (at the neck in four, the supraclavicular region in two, and the abdominal incision in one). Multiple exposure sites were found in two cases. Two patients with CSF infections benefitted from system removal and temporary external ventricular drainage until infection control was achieved. The remaining 16 patients underwent on-ward revision (wound curettage, skin mobilisation, and re-suture over the exposed part of the shunt), which was effective in 14 patients, but further revision was required in two patients. Conclusions: While rare, ventriculoperitoneal shunt exposure is a serious complication. In our experience, a prompt and accurate on-ward revision could save the implant in most patients without CSF infections

Calvarial bone cavernous hemangioma with intradural invasion: An unusual aggressive course—Case report and literature review

Introduction: Cavernous hemangioma of the skull is a rare pathological diagnosis, accounting for 0.2% of bone tumors and 7% of skull tumors. Usually calvarial bone cavernous hemangioma are associated with a benign clinical course and, despite their enlargement and subsequent erosion of the surrounding bone, the inner table of the skull remains intact and the lesion is completely extracranial. Presentation of a case: The authors present the unique case of a huge left frontal bone cavernous malformation with intradural extension and brain compression determining a right hemiparesis. Discussion: Calvarial cavernous hemangiomas are benign tumors. They arise from vessels in the diploic space and tend to involve the outer table of the skull with relative sparing of the inner table. More extensive involvement of the inner table and extradural space is very unusual and few cases are reported in literature. To the best of our knowledge, intradural invasion of calvarial hemangioma has not been previously reported. Conclusion: Our case highlights the possibility of an aggressive course of this rare benign pathology

P13.10 * SURGICAL TREATMENT FOR GLIOBLASTOMA MULTIFORME: OUTCOME AND ANALYSIS OF PROGNOSTIC FACTORS ESPECIALLY ORIENTED TO THE EXTENT OF SURGICAL RESECTION

INTRODUCTION: The prognosis of Glioblastoma Multiforme (GBM) remains poor despite recent therapeutic advances. The surgical treatment of GBM (supported by functional imaging, neuronavigation and electrophysiological monitoring) remains a fundamental step. The methylation of the enzyme O6-methylguanine-DNA methyltransefrase (MGMT) seems to improve the effectiveness of alkylating agents on this tumour, but other factors can influence the survival. An evaluation of all prognostic factors is essential to individuate subgroups of patients for a better selection of different treatment modalities. Our study confirms the prognostic values of both new recognized factors (MGMT presence, IDH1, news schedule of TM2 etc.) and the well-recognized prognostic factors particularly to the extent of surgical removal with the help of new technologies and in the era where people is asking more and more a better quality of life. METHODS: We retrospectively analysed 172 operated patients (115 males and 57 females), 55 of which located in eloquent areas, between March 2008 and December 2012. For each patient age, sex, preoperative clinical evaluation (Karnofsky score, KPS), tumour location, extent of surgical removal, genetic and epigenetic profile (MGMT, IDH1,etc) and postoperative treatments were recorded. We used Kaplan Meier method for the univariate analysis and the Cox regression for the multivariate one. Surgical strategy was always planned for a total tumour resection, when allowed by the intrinsic characteristics of the tumour using the so called “extracapsular “ technique. RESULTS: Overall median survival time after surgery was 10 months. At univariate analysis the gross total removal (p<0,0001), a postoperative KPS>70 (p<0,0001) and radiotherapy (p<0,0001) improve survivals. Deep structures involved or multifocal lesions (p<0,0001) resulted as negative factors in term of the quod vitam prognosis, whereas lesions arising in insula, deep structures or in primary motor cortex worse the quod valitudinem prognosis (persistent deficit after three months of follow-up). Unexpectedly we noticed that the eloquent area involved doesn't influenced the extent of tumour resection. At multivariate analysis only the extent of tumour removal (p<0,0001), the postoperative KPS (p = 0,011) and the postoperative treatments undergone (p<0,0001) has been confirmed as able to influence the prognosis. CONCLUSIONS: A complete surgical removal, a good post-operative KPS and a postoperative radio-chemotherapy according to Stupp protocol were conditions for a longer survival. To obtain a complete tumour removal minimizing at the same time postoperative deficits it's mandatory to use the most complete pre-operative planning and intra-operative monitoring, using the newest functional mapping technologies, and whenever possible planning an “extracapsular” tumour resection strategy