Haemostatic technique in malignant gliomas

Introduction. Haemostasis in brain surgery is mandatory to avoid postoperative re-bleeding and a poor outcome. Postoperative intra-cavity haemorrhage is a frequent complication, especially in surgery of malignant gliomas because of the fragility of pathological vessels. Material and methods. In this technical note, we describe our ‘compression’ technique used to achieve haemostasis in adult patients who underwent surgery for supratentorial malignant gliomas (GBM) at our Institute from January 2019 to January 2022. Peri-operative work-up included clinical status, laboratory data and contrast brain CT, performed at 24 hours after surgery, or earlier for patients with neurological worsening. Results. A total of 82 patients was included in this study, 46 males (57%) and 36 females (43%). A post-operative intra-cavity haemorrhage was documented by postoperative CT-scan in 3/82 patients (3.65%), and the mean surgical time was 3.66 hours. No late bleeding was observed 48 hours after surgery. Conclusions. We have documented the good results of our technique to achieve haemostasis in patients operated for malignant glioma (GBM). The technique described in this study seems to be safe and useful to avoid post-operative bleeding in the surgery of cerebral GBM

Evaluation of prognostic preoperative factors in patients undergoing surgery for spinal metastases: Results in a consecutive series of 81 cases

Background: Surgical treatment of spinal metastases should be tailored to provide pain control, neurological deficit improvement, and vertebral stability with low operative morbidity and mortality. The aim of this study was to analyze the predictive value of some preoperative factors on overall survival in patients undergoing surgery for spinal metastases. Methods: We retrospectively analyzed a consecutive series of 81 patients who underwent surgery for spinal metastases from 2015 and 2021 in the Clinic of Neurosurgery of Ancona (Italy). Data regarding patients’ baseline characteristics, preoperative Karnofsky Performance Status Score (KPS), and Frankel classification grading system, histology of primary tumor, Tokuhashi revised and Tomita scores, Spine Instability Neoplastic Score, and Epidural Spinal Cord Compression Classification were collected. We also evaluated the interval time between the diagnosis of the primary tumor and the onset of spinal metastasis, the type of surgery, the administration of adjuvant therapy, postoperative pain and Frankel grade, and complications after surgery. The relationship between patients’ overall survival and predictive preoperative factors was analyzed by the Kaplan–Meier method. For the univariate and multivariate analysis, the log-rank test and Cox regression model were used. P ≤ 0.05 was considered as statistically significant. Results: After surgery, the median survival time was 13 months. In our series, the histology of the primary tumor (P < 0.001), the Tomita (P < 0.001) and the Tokuhashi revised scores (P < 0.001), the preoperative KPS (P < 0.001), the adjuvant therapy (P < 0.001), the postoperative Frankel grade (P < 0.001), and the postoperative pain improvement (P < 0.001) were significantly related to overall survival in the univariate analysis. In the multivariate analysis, the Tomita (P < 0.001), Tokuhashi revised scores (P < 0.001), and the adjuvant therapy were confirmed as independent prognostic factors. Conclusion: These data suggest that patients with limited extension of primitive tumor and responsive to the adjuvant therapy are the best candidates for surgery with better outcome

Haemostatic technique in malignant gliomas

Introduction: Haemostasis in brain surgery is mandatory to avoid postoperative re-bleeding and a poor outcome. Postoperative intra-cavity haemorrhage is a frequent complication, especially in surgery of malignant gliomas because of the fragility of pathological vessels. Material and methods: In this technical note, we describe our 'compression' technique used to achieve haemostasis in adult patients who underwent surgery for supratentorial malignant gliomas (GBM) at our Institute from January 2019 to January 2022. Peri-operative work-up included clinical status, laboratory data and contrast brain CT, performed at 24 hours after surgery, or earlier for patients with neurological worsening. Results: A total of 82 patients was included in this study, 46 males (57%) and 36 females (43%). A post-operative intra-cavity haemorrhage was documented by postoperative CT-scan in 3/82 patients (3.65%), and the mean surgical time was 3.66 hours. No late bleeding was observed 48 hours after surgery. Conclusions: We have documented the good results of our technique to achieve haemostasis in patients operated for malignant glioma (GBM). The technique described in this study seems to be safe and useful to avoid post-operative bleeding in the surgery of cerebral GBM

Combined endoscopic transforaminal-transchoroidal approach for the treatment of third ventricle colloid cysts

Colloid cysts are histologically benign lesions whose primary goal of treatment should be complete resection to avoid recurrence and sudden death. Open surgery is traditionally considered the standard approach, but, recently, the endoscopic technique has been recognized as a viable and safe alternative to microsurgery. The endoscopic approach to colloid cysts of the third ventricle is usually performed through the foramen of Monro. However, this route does not provide adequate visualization of the cyst attachment on the tela choroidea. The combined endoscopic transforaminal-transchoroidal approach (ETTA), providing exposure of the entire cyst and a better visualization of the tela choroidea, could increase the chances of achieving a complete cyst resection. Between April 2005 and February 2011, 19 patients with symptomatic colloid cyst of the third ventricle underwent an endoscopic transfrontal-transforaminal approach. Five of these patients, harboring a cyst firmly adherent to the tela choroidea or attached to the middle/posterior roof of the third ventricle, required a combined ETTA. Postoperative MRI documented a gross-total resection in all 5 cases. There were no major complications and only 1 patient experienced a transient worsening of the memory deficit. To date, no cyst recurrence has been observed. An ETTA is a minimally invasive procedure that can allow for a safe and complete resection of third ventricle colloid cysts, even in cases in which the lesions are firmly attached to the tela choroidea or located in the middle/posterior roof of the third ventricle

Mini-Craniotomy under Local Anesthesia to Treat Acute Subdural Hematoma in Deteriorating Elderly Patients

Background and Study Aims Surgical treatment for acute subdural hematomas (ASDHs) in elderly patients is still considered unsatisfactory. Series focusing on the use of conventional craniotomy or decompressive craniectomy in such patients report discouraging results. Glasgow Coma Scale (GCS) score at admission seems to be crucial in the decision-making process. Deteriorating patients with a GCS score between 9 and 11 are those who would benefit most from the surgical treatment. Unfortunately, elderly patients often present other comorbidities that greatly increase the risk of severe complications after major neurosurgical procedures under general anesthesia. The aim of the present study was to evaluate the feasibility of performing a mini-craniotomy under local anesthesia to treat ASDHs in a select group of elderly patients who were somnolent but still breathing autonomously at admission (GCS 9-11). Material and Methods Twenty-eight elderly patients (age > 75 years) with ASDH and a GCS score at surgery ranging from 9 to 11 were surgically treated under local anesthesia by a single burr-hole mini-craniotomy (transverse diameter 3-5 cm) and hematoma evacuation. At the end of the procedure, an endoscopic inspection of the surgical cavity was performed to look for residual clots that were not visible under direct vision. Results The median operation time was 65 minutes. Hematoma evacuation was complete in 22 cases, complete consciousness recovery was observed in all patients but one, and reoperation was required for two patients. Conclusion Historically, elderly patients with ASDH treated with a traditional craniotomy performed under general anesthesia have not had a good prognosis. Our preliminary experience with this less invasive surgical and anesthesiological approach suggests that somnolent but autonomously breathing elderly patients could benefit from this approach, achieving an adequate hematoma evacuation and bypassing the complications related to intubation and artificial respiratory assistance

Nonmetastatic Ewing’s Sarcoma of the Lumbar Spine in an Adult Patient

Although the spine is frequently involved in metastatic Ewing's sarcoma, primary involvement of the spine, beside sacrum, is much less frequent, especially in adult patients. Because of the low incidence of these tumors, there are currently no clinical guidelines outlining their management and a multitude of therapeutic strategies have been employed with varying success. The definitive management of Ewing's sarcoma of the spine, as in other locations, could include the combination of three main modalities: aggressive surgery, radiotherapy, and combined chemotherapy. Whenever possible, en bloc spondylectomy or extralesional resection is preferable, providing a better oncological result with a longer survival and a better preservation of the spine biomechanics. This is the lesson we learned about the case, we present here, of nonmetastatic lumbar localization by Ewing’s sarcoma in as adult patient

Piezosurgery as a further technical adjunct in minimally invasive supraorbital keyhole approach and lateral orbitotomy

One of the problems in neurosurgery is how to perform rapid and effective craniotomies that minimize the risk of injury to underlying eloquent structures. The traditional high-powered pneumatic tools and saws are efficient in terms of speed and penetration, but they can provoke bone necrosis and sometimes damage neurovascular structures. As an alternative, we evaluated the piezoelectric bone scalpel (piezosurgery), a device that potentially allows thinner and more precise bone cutting without lesioning neighboring delicate structures, even in the case of accidental contact

Surgical treatment of cervical spine trauma: Our experience and results

The objective of this study is to evaluate how the neurological outcome in patients operated for cervical spinal cord injury (SCI) is influenced by surgical timing, admission American Spinal Injury Association (ASIA) grading system, and age