Fistole rinoliquorali spontanee: verso un moderno algoritmo diagnostico-terapeutico.

Introduzione: Le fistole rinoliquorali spontanee sono un eterogeneo gruppo di fistole a cui afferiscono tutti i casi di fistola rinoliquorale per le quali non \ue8 stata possibile identificare un meccanismo eziopatogenetico. Permane tuttavia il dubbio da parte di molti autori che in tale gruppo confluiscano fistole rinoliquorali causate da patologie non correttamente diagnosticate. Sebbene siano state effettuate numerose ricerche per meglio identificare l\u2019eziologia e la patogenesi delle fistole rinoliquorali spontanee non si \ue8 ancora giunti a formulare un algoritmo diagnostico-terapeutico condiviso. Tale tipologia di fistole, dai dati ricavati dalla analisi della letteratura, \ue8 gravata da un maggiore tasso di recidiva rispetto alle fistole a eziologia nota probabilmente proprio poiche' il fattore eziopatogenetico rimane spesso misconosciuto e conseguentemente non trattato. Materiali e Metodi: Il presente studio, attraverso una valutazione retrospettiva della casistica (2002-2013) delle Cliniche Otorinolaringoiatrica e Neurochirurgica dell\u2019Ospedale del Circolo e Fondazione Macchi-Universit\ue0 degli Studi dell\u2019Insubria di Varese, analizza una popolazione di 103 pazienti sottoposti a intervento chirurgico di riparazione di fistola rinoliquorale spontanea. Scopo di questa tesi \ue8 arrivare alla stesura di un algoritmo diagnostico-terapeutico per le fistole rinoliquorali spontanee e in particolare identificare le indagini diagnostiche opportune per una diagnosi precoce delle fistole rinoliquorali spontanee e validare l\u2019approccio endoscopico endonasale come tecnica chirurgica di scelta nel trattamento delle fistole rinoliquorali spontanee. Discussione: L' algoritmo diagnostico da noi utilizzato ha permesso una rapida diagnosi ed una precisa localizzazione della fistola, e di conseguenza la pianificazione dell\u2019intervento chirurgico pi\uf9 adeguato per il paziente. L\u2019approccio endoscopico endonasale ha inoltre soppiantato nella maggior parte dei casi gli approcci intracranici ed extracranici non endoscopici, relegando quest\u2019ultima tecnica al solo intervento combinato endoscopico-lembo osteoplastico frontale per il trattamento delle fistole rinoliquorali spontanee della parete posteriore del seno frontale. I vantaggi della chirurgia endoscopica consistono soprattutto in una minore invasivit\ue0, che consente di evitare le principali complicanze dell\u2019approccio intracranico come la lesione del bulbo olfattorio con conseguentemente anosmia, l\u2019edema cerebrale. Conclusioni: L\u2019utilizzo di un valido algoritmo diagnostico-terapeutico ha infatti permesso una corretta e tempestiva diagnosi, una precisa localizzazione del difetto e un trattamento chirurgico ottimale. La possibilit\ue0 di scegliere fra le varie tecniche d\u2019approccio e di effettuare il tipo di chiusura ottimale, a seconda delle caratteristiche anatomopatologiche della fistola, risulta determinate per ottenere una bassa percentuale di recidive. Una maggiore comprensione della fisiopatologia delle fistole rinoliquorali spontanee potrebbe portare a un corretto inquadramento e a una adeguata classificazione di tale patologia poich\ue9 riconoscerne i meccanismi causali consentirebbe un miglioramento della loro gestione e permetterebbe di intraprendere, quando necessario, il trattamento pi\uf9 adeguato

Fistole rinoliquorali spontanee: verso un moderno algoritmo diagnostico-terapeutico.

Introduzione: Le fistole rinoliquorali spontanee sono un eterogeneo gruppo di fistole a cui afferiscono tutti i casi di fistola rinoliquorale per le quali non è stata possibile identificare un meccanismo eziopatogenetico. Permane tuttavia il dubbio da parte di molti autori che in tale gruppo confluiscano fistole rinoliquorali causate da patologie non correttamente diagnosticate. Sebbene siano state effettuate numerose ricerche per meglio identificare l’eziologia e la patogenesi delle fistole rinoliquorali spontanee non si è ancora giunti a formulare un algoritmo diagnostico-terapeutico condiviso. Tale tipologia di fistole, dai dati ricavati dalla analisi della letteratura, è gravata da un maggiore tasso di recidiva rispetto alle fistole a eziologia nota probabilmente proprio poiche' il fattore eziopatogenetico rimane spesso misconosciuto e conseguentemente non trattato. Materiali e Metodi: Il presente studio, attraverso una valutazione retrospettiva della casistica (2002-2013) delle Cliniche Otorinolaringoiatrica e Neurochirurgica dell’Ospedale del Circolo e Fondazione Macchi-Università degli Studi dell’Insubria di Varese, analizza una popolazione di 103 pazienti sottoposti a intervento chirurgico di riparazione di fistola rinoliquorale spontanea. Scopo di questa tesi è arrivare alla stesura di un algoritmo diagnostico-terapeutico per le fistole rinoliquorali spontanee e in particolare identificare le indagini diagnostiche opportune per una diagnosi precoce delle fistole rinoliquorali spontanee e validare l’approccio endoscopico endonasale come tecnica chirurgica di scelta nel trattamento delle fistole rinoliquorali spontanee. Discussione: L' algoritmo diagnostico da noi utilizzato ha permesso una rapida diagnosi ed una precisa localizzazione della fistola, e di conseguenza la pianificazione dell’intervento chirurgico più adeguato per il paziente. L’approccio endoscopico endonasale ha inoltre soppiantato nella maggior parte dei casi gli approcci intracranici ed extracranici non endoscopici, relegando quest’ultima tecnica al solo intervento combinato endoscopico-lembo osteoplastico frontale per il trattamento delle fistole rinoliquorali spontanee della parete posteriore del seno frontale. I vantaggi della chirurgia endoscopica consistono soprattutto in una minore invasività, che consente di evitare le principali complicanze dell’approccio intracranico come la lesione del bulbo olfattorio con conseguentemente anosmia, l’edema cerebrale. Conclusioni: L’utilizzo di un valido algoritmo diagnostico-terapeutico ha infatti permesso una corretta e tempestiva diagnosi, una precisa localizzazione del difetto e un trattamento chirurgico ottimale. La possibilità di scegliere fra le varie tecniche d’approccio e di effettuare il tipo di chiusura ottimale, a seconda delle caratteristiche anatomopatologiche della fistola, risulta determinate per ottenere una bassa percentuale di recidive. Una maggiore comprensione della fisiopatologia delle fistole rinoliquorali spontanee potrebbe portare a un corretto inquadramento e a una adeguata classificazione di tale patologia poiché riconoscerne i meccanismi causali consentirebbe un miglioramento della loro gestione e permetterebbe di intraprendere, quando necessario, il trattamento più adeguato

Identifying developmental coordination disorder: MOQ-T validity as a fast screening instrument based on teachers' ratings and its relationship with praxic and visuospatial working memory deficits.

The present study was devoted to test the validity of the Italian adaptation of the Motor Observation Questionnaire for Teachers (MOQ-T, Schoemaker, Flapper, Reinders-Messelink, & De Kloet, 2008) as a fast screening instrument, based on teachers' ratings, for detecting developmental coordination disorders symptoms and to study its relationship with praxic and visuospatial working memory deficits. In a first study on a large sample of children, we assessed the reliability and structure of the Italian adaptation of the MOQ-T. Results showed a good reliability of the questionnaire and a hierarchical structure with two first-order factors (reflecting motor and handwriting skills), which are influenced by a second-order factor (general motor function) at the top. In a second study, we looked at the external validity of the MOQ-T and found that children with symptoms of Developmental Coordination Disorder (children with high scores on the MOQ-T) also had difficulty reproducing gestures, either imitating others or in response to verbal prompts. Our results also showed that children with high MOQ-T scores had visuospatial WM impairments. The theoretical and clinical implications of these findings are discussed

Epidemiology-based evaluation of trends in treatment for ruptured intracranial aneurysms in Italy

Background: In recent years there have been significant advances in the diagnosis, management and treatment of intracranial aneurysms (IAs) in Italy. Changes in prevalence of several epigenetic risk factors in the population as well as in environmental factors may have influenced the epidemiological burden of this disease. No long-term, population-based study about the incidence of treated ruptured IAs (rIAs) in Italy has yet been reported in literature. Methods: A long-term (January 2015 - December 2020), nationwide epidemiology study was performed by using discharge data collected by the Italian National Agency for Regional Healthcare Services with a particular focus on the treatment incidence of rIAs. A sub-analysis per macro-areas (north, center, and south and islands) was also performed, including the data about regional healthcare systems organization. The prevalence of common epigenetic and environmental risk factors has been also assessed. Results: Over 6 years, the mean incidence of rIAs treatment was 2.7 x 100.000 per year (ds ± 0.1; range: 2.6-2.9). In 2020, there was a significant north-south decreasing gradient in incidence (north vs center vs south and islands: 3.4 vs 2.4 vs 1.8 x 100.000/year; all p<0.001). There were no meaningful differences between macro-areas in terms of access to emergency care and number of neurosurgical wards per population. The rate of unruptured IAs (uIAs) treatment did not show a correlation to that of ruptured ones. Minor regional differences were retrieved for high-risk hypertension as well as for alcohol abuse prevalence. Air pollutants and temperature charts showed a north-south gradient similar to that of the incidence in the treated rIAs. Conclusions: The mean incidence of treated rIAs was stable over the 2015-2020 period in Italy. A north-south decreasing gradient in rIAs treatment incidence was reported. Neither the Regional healthcare organizations nor the rate of uIAs treatment were significant factors explaining the regional differences in the incidence of rIAs treatment. Minor differences in epigenetic and environmental risk factors may be synergistically involved

ACTH-dependent Cushing's Syndrome: Diagnostic Pitfalls in Concomitant Non-secreting Pituitary Adenomas

Objectives: To describe the possible pitfalls in correctly interpreting clinical, radiological and biochemical findings in ACTH-dependent Cushing's syndrome. Methods: We describe a case of a pituitary adenoma visualized at MRI not correlated with an ACTH-dependent Cushing’s syndrome. Results: Radiological imaging and hormonal testing can be misleading in suspected pituitary ACTH-related Cushing’s syndrome. Conclusion: Correct interpretation of the initial clinical presentation can help in the proper diagnosis and treatment of ACTH-dependent Cushing’s syndrome

Systemic Sarcoidosis Unmasked by Cushing’s Disease Surgical Treatment

Diseases responsive to glucocorticoids, like sarcoidosis, are rarely masked by Cushing’s syndrome. An ACTH secreting pituitary adenoma is a possible cause of Cushing’s syndrome and its resection can make a subclinical sarcoidosis clear. Only few cases of sarcoidosis following the treatment of hypercortisolism are reported in literature. We report a case of sarcoidosis after the resection of an ACTH secreting pituitary adenoma

Unequal impact of COVID-19 on private and academic neurosurgical workforce: results of an international survey

Background: Since the COVID-19 outbreak several manuscripts regarding neurosurgical practice during this pandemic have been published. Qualitative studies on how the pandemic affected neurosurgeons, with additional focus on their practice, are still scarce. This study's objective was to investigate the impact of COVID-19 on various aspects of the professional and private life of a homogeneous group of international neurosurgeons affiliated to the European Association of Neurosurgical Societies (EANS).Methods: Neurosurgeons from Europe and abroad were invited to participate in an online survey endorsed by the Individual Membership Committee of the EANS. The survey captured a subjective snapshot of the impact of the first wave of the COVID-19 pandemic on EANS members and was advertised through its Institutional website. In addition to departmental data, personal feeling of safety, financial security, local precautions, number of surgeries performed, changes in daily routine, and other practice-related information were inquired. Differences among practice types were closely reviewed.Results: The survey was distributed between April and May 2020: 204 neurosurgeons participated. Participants were typically active EANS members (73%), consultants (57.9%), from university hospitals (64.5%). Elective surgical practice was still ongoing only for 15% of responders, whereas 18.7% of them had already transitioned to COVID-19 and emergency medical services. While 65.7% of participants thought their institutions were adequately prepared, lack of testing for SARS-CoV-2, and scarcity of personal protective equipment were still a matter of concern for most of them. Overall surgical activity dropped by 68% (cranial by 54%, spine by 71%), and even emergencies decreased by 35%. COVID-19 prompted changes in communication in 74% of departments, 44% increased telemedicine by >50%. While most neurosurgeons had concerns about personal and families' health, financial outlook appeared to be gloomy only for private practitioners.Conclusion: The lockdown imposed in many countries by the COVID-19 outbreak called for immediate modification of working routine and resulted in a dramatic decrease of elective surgical procedures. Neurosurgeons share common concerns but were not equally exposed to the personal health and financial dangers of the ongoing pandemic.Scientific Assessment and Innovation in Neurosurgical Treatment Strategie

Ultra-Early Treatment of Neurosurgical Emergencies with Endoscopic Endonasal Approach: Experience from Three Italian Referral Centers

Purpose: the aim of this multicenter study is to preliminarily assess the role of the Endoscopic Endonasal Approach (EEA) in ultra-early (i.e., within 12 h) management of selected neurosurgical emergencies in terms of clinical and radiological outcomes. Methods: 26 patients affected by sellar/parasellar pathologies with rapid progression of symptoms were managed with EEA within 12 h from diagnosis in three Italian tertiary referral Centers from January 2016 to December 2019. Both clinical and radiological data have been collected preoperatively as well as post-operatively in order to perform retrospective analysis. Results: The average time from admission to the operating room was 5.5 h (±2.3). The extent of resection was gross-total in 20 (76.9%), subtotal in 6 (23.1%) patients. One patient experienced re-bleeding after a subtotal removal of a hemorrhagic lesion. Patients with a longer time from admission (&gt;4 h) to the operatory room (OR) experienced stable impairment of the visual acuity (p = 0.033) and visual field (p = 0.029) in the post-operative setting. Conclusions: The Endoscopic Endonasal Approach represents a safe, effective technique that can be efficiently used with good results in the management of selected neurosurgical emergencies in centers with adequate experience