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

Post-Treatment Edema after Meningioma Radiosurgery is a Predictable Complication

Symptomatic post-treatment edema (PTE) causing seizures, focal deficits, and intracranial hypertension is a rather common complication of meningioma radiosurgery. Factors associated to the occurrence of PTE still needs to be clarified. We retrospectively analyzed our patients' data to identify factors associated with the development of symptomatic PTE. Supposed risk factors were systematically analyzed. Between July 2007 and March 2014, 245 meningiomas in 229 patients were treated by a single fraction or multisession radiosurgery (2-5 fractions) or hypofractionated stereotactic radiotherapy (6-15 fractions) using the CyberKnife system (Accuray Inc., Sunnyvale, CA) at the University Hospital of Messina, Italy. Local tumor control was achieved in 200 of 212 patients with World Health Organization (WHO) Grade I meningiomas (94%) at a mean follow-up of 62 months. Symptomatic PTE on MRI was diagnosed in 19 patients (8.3%) causing seizure (n=17, 89%), aggravating headache (n=12, 63%), or focal deficits (n=13, 68%). Four variables were found to be associated with the likelihood of edema development, including tumor volume > 4.5 mL, non-basal tumor location, tight brain/tumor interface, and atypical histology. Nonetheless, when multivariate logistic regression analysis was performed, only tumor volume and brain-tumor interface turned out to be independent predictors of PTE development. Our results suggest that the factor associated with the risk of developing PTE is associated to characteristics of meningioma rather than to the treatment modality used. Accordingly, an appropriate patient selection is the way to achieve safe treatment and long-term disease control

Ultra-Mutation in IDH Wild-Type Glioblastomas of Patients Younger than 55 Years is Associated with Defective Mismatch Repair, Microsatellite Instability, and Giant Cell Enrichment

Glioblastomas (GBMs) are classified into isocitrate dehydrogenase (IDH) mutants and IDH wild-types (IDH-wt). This study aimed at identifying the mutational assets of IDH-wt GBMs in patients aged 18-54 years for which limited data are available

Lamina terminalis fenestration

Chohan et al.3 (Chohan MO, Carlson AP, Hart BL, et al: Lack of functional patency of the lamina terminalis after fenestration following clipping of anterior circulation aneurysms. Clinical article. J Neurosurg 119:629–633, September 2013). In their study, the authors injected, on postoperative Day 1 following clipping of anterior circulation aneurysms, an iodine-based contrast agent intraventricularly to assess, with CT imaging, the flow into the basal cisterns through a fenestrated lamina terminalis. They concluded that fenestration of the lamina terminalis (FLT) did not result in functional patency of the lamina terminalis when performed as part of surgical clipping for ruptured aneurysms. We have some remarks and criticisms regarding this article, which leads to clear-cut conclusions

Transcallosal approach to third ventricle tumors: how I do it

Background The transcallosal approach provides a direct corridor to the lesions lying in the third ventricle with distinct advantages over alternative routes, such as the pos- sibility to use multiple corridors for tumor resection. Method Here we present a personal perspective of the sur- gery of tumors of the anterior portion of the third ventricle using this approach. Conclusions This approach requires the ability to move around many neurovascular, cortical, and white matter structures. Knowledge of regional anatomy and adherence to principles of microsurgery are basic requirements to obtain a favorable outcome

Nitric oxide in the injured spinal cord: Synthases cross-talk, oxidative stress and inflammation

Nitric oxide (NO) is a unique informational molecule involved in a variety of physiological processes in the central nervous system (CNS). It has been demonstrated that it can exert both protective and detrimental effects in several disease states of the CNS, including spinal cord injury (SCI). The effects of NO on the spinal cord depend on several factors such as: concentration of produced NO, activity of different synthase isoforrns, cellular source of production and time of release. Basically, it has been shown that low NO concentrations may play a role in physiologic processes, whereas large amounts of NO may be detrimental by increasing oxidative stress. However, this does not explain all the discrepancies evidenced studying the effects of NO in SCI models. The analysis of the different synthase isoforms, of their temporal profile of activation and cellular source has shed light on this topic. Two post-injury time intervals can be defined with reference to the NO production: immediately after injury and several hours-to-days later. The initial immediate peak of NO production after injury is due to the up-regulation of the neuronal NO synthase (nNOS) in resident spinal cord cells. The late peak is due primarily to the activity of inducible NOS (iNOS) produced by inflammatory infiltrating cells. High NO levels produced by up-regulated nNOS and NOS are neurotoxic; the down-regulation of nNOS corresponds temporally to the expression of NOS. On the bases of those evidence, therapeutic approaches should be aimed: (1) to reduce the NO-elicited damage by inhibition of specific synthases according to the temporal profile of activation; (2) by maintaining physiologic amount of NO to keep the induction of iNOS expression suppressed and avoiding ischemia/reperfusion injuries; (3) by using scavengers of oxygen and nitrogen reactive species or using inhibitors of the specific kinases. (C) 2007 Elsevier B.V. All rights reserved

Telo-velar approach to fourth-ventricle tumours: how I do it

Background The telo-velar approach is an alternative to cerebellar splitting to gain access to the fourth ventricle through the so-called cerebello-medullary fissure (CMF). Method In this approach, the CMF is exposed and access to the ventricle is obtained by incising the tela chorioidea and inferior medullary velum. This approach enables the explora- tion of the entire ventricle cavity from the obex to the aqueduct. Conclusions The exposure of the fourth ventricle is satisfac- tory and the floor of the fourth ventricle can be visualised early and protected. The extent of resection and outcome are satis- factory in most patients, including those with large tumours or lesions attached to the lateral or superolateral recesses of the ventricle. The deep rostral tumour attachment is the main lim- itation of the telo-velar approac

Nanoparticles drug-delivery systems and antiangiogenic approaches in the treatment of gliomas

The prognosis of patients with cerebral gliomas remains noticeably poor. Total surgical resection is almost unachievable due to considerable infiltrative ability of glial cells. Furthermore, adjuvant treatments are burdened by considerable limitations. Angiogenesis is the mechanism by which new blood vessels are formed from preexisting ones, thus supporting neoplasm progression. Gliomas are characterized by extensive microvascular proliferation. The extent of neovascularization in brain tumor correlates directly with the biological aggressiveness, degree of malignancy, and clinical recurrence of the tumor. Although a plethora of molecules can act as inducers of angiogenesis, the major growth factors include members of the vascular endothelium growth factor family. The new therapeutic approaches envisage the identification of specific biomarkers involved in this process and try to inhibit them, thus slowing down the neoplastic progression. Nanoparticles (NPs) show the ability to pass the blood–brain barrier, and moreover, when suitably modified, they can bind to specific overexpressed receptors in the glial cells. As carriers, they are able to protect the therapeutic agent and allow their sustained release. In this review, we describe some NP delivery systems which target specific biomarkers to intervene in the process of angiogenesis

Telovelar Approach to Fourth Ventricle Tumors: Highlights and Limitations

Fourth ventricle tumors have been traditionally approached by opening the cerebellar vermis. The "telovelar" approach is an alternative approach performed through the cerebellomedullary fissure to gain access to the fourth ventricle, avoiding neural tissue damage. We describe our experience with this approach and predictive factors for the extent of resection (EOR) and for outcomes. METHODS: We retrospectively analyzed the data of patients who underwent resection of fourth ventricle lesions using a bilateral telovelar approach between June 1998 and June 2013. We evaluated EOR, clinical outcomes, complication rates, and postoperative cerebellar dysfunction. Univariate and multivariate analyses were performed to identify the predictive factors for EOR and outcomes. RESULTS: Forty-five patients were included in this series. Complete resection was obtained in 40 patients (88.9%). One patient (2.2%) had lower cranial nerve palsy and died 2 months after surgery. Two patients (4.5%) had persistent deficits of the sixth cranial nerve. Two patients (4.5%) developed shunt dependency. Brainstem attachment, tumor size >4 cm, and location in the rostral one third of the ventricle were associated with a higher rate of subtotal resection and neurological worsening. Cerebellar mutism did not occur in any patient. CONCLUSIONS: Exposure of the fourth ventricle was satisfactory in all of the patients, and the floor of the fourth ventricle could be visualized early and be protected. EOR and outcomes were satisfactory in 90% of patients, including those harboring large tumors or lesions attached to the lateral or superolateral recesses of the ventricle. Deep rostral tumor attachment was the main limitation of the telovelar approach