Neurosurgical systematic reviews and meta-analyses for a daily practice

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Surgical Techniques in Benign Extra-Axial Tumors

Extra-axial tumors are lesions, neoplastic and not, which are external to the brain parenchyma and can originate in the skull, meninges, cranial nerves, and brain appendages such as the pituitary gland. Surgery provides a diagnosis and can be the first step in the treatment. When chosen as a treatment, we should consider the access and the approach to the lesion, the adequate operative technique, and related skills, minor or major complications. Because of the benign nature of these tumors, the evaluation of the risk/benefit in submitting a patient to a surgical treatment has to be considered. We would like to give an overview about benign extra-axial tumors and surgical operative techniques and tools that can be applied to improve patient’s outcome

Letter by Rustemi et al Regarding Article, "Flow Diverters for Intracranial Aneurysms: The DIVERSION National Prospective Cohort Study"

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Innovations in the Surgery of Cerebral Aneurysms: Enhanced Visualization, Perfusion, and Function Monitoring

Surgery of cerebral aneurysms has evolved over the years. Advances regard enhanced intraoperative visualization and monitoring of both function and perfusion. Technological assistance used in oncological or skull base surgery, such as intraoperative neurophysiological monitoring (IONM) or endoscopy, now adopt to vascular surgery. Intraoperative indocyanine green video angiography (ICG-VA) and techniques for its interpretation (squeezing maneuver; entrapment sign), endoscopes, and exoscopes increase visualization. Flow evaluation by microflow probe permits perfusion monitoring; IONM allows functional monitoring. Bypasses replace flow in complex aneurysm cases. Pre-, intra-, and postoperative imaging and flow measurement techniques help in donor selection and follow-up. Despite some progression in the aneurysm clips, the principle has not changed. Innovation and even change of principle in aneurysm exclusion might be desirable. Basic research in aneurysm wall and flow dynamics might in the future change the paradigms of cerebral aneurysm treatment

The Cerebral Venous System: New Pathophysiological Theories and Diseases Related to Veins Occlusion

Cerebral physiology and pathology are still frequently missing a comprehensive explanation and a complete description, but new data and hypothesis are emerging on a daily basis. Particularly, comprehension of the cerebral venous system’s functions and functioning has undergone through the last decades a deep and extended change. Depiction of the perivascular spaces and the mechanisms of glymphatic system has given light about venous system pivotal role in the genesis of different pathologies such as multiple sclerosis, hydrocephalus, cerebral hemorrhages, and strokes. After a key point discussion about embryology, physiology, and anatomy of the cerebral venous system, an overview is provided on the main pathologies, both well-known and newly described ones, in which cerebral veins act a major pathogenic role

A workflow to generate physical 3D models of cerebral aneurysms applying open source freeware for CAD modeling and 3D printing

Objectives: 3D anatomical models are becoming a new frontier in surgery for planning and simulation on an individualized patient specific basis. Since 1999, 3D cerebral aneurysms models for neurosurgery have been proposed. The possibility of reproducing in a realistic 3D fashion the malformation with the surrounding vascular structures, provides important preoperative information for the treatment strategy. The same models can be used for training and teaching.Unfortunately stereolitography is often burdened by high costs and long times of production. These factors limit the possibility to use 3D models to plan surgeries in an easy daily fashion. Patients and methods: Our study enrolled 5 patients harboring cerebral aneurysms. DICOM data of each aneurysm were elaborated by an open source freeware to obtain CAD molds. Afterwards, the 3D models were produced using a fused deposition or a stereolitography printer. Results: Models were evaluated by Neurosurgeons in terms of quality and usefulness for surgical planning. Costs and times of production were recorded. Conclusions: Models were reliable, economically affordable and quick to produce. Keywords: Stereolitography, Cerebral aneurysms, 3D printing, Surgical planning, Aneurysm model

Eagle jugular syndrome: a morphometric computed study on styloid process orientation

Cerebral venous drainage impairment is related to a wide spectrum of pathologies, both acute or chronic. Among the most intriguing and less explained there are those caused by a long-lasting compression on internal jugular vein (IJV), mono or bilaterally. Recently, a jugular variant of the Eagle syndrome has been described,1,2 in which an elongated styloid process, coming from the mastoid tip down through the neck, compresses the IJV (more frequently J3) in its passage on the C1 anterior arch. Interestingly, those patients often complaint of typical symptoms of intracranial hypertension, such as headache (not frequent in classic Eagle syndrome), tinnitus, dizziness. They also seem to have an increased risk of perimesencephalic hemorrhages. Conceptually, it is not the styloid process length in itself to determine the compression, but rather its spatial orientation. We could therefore expect to find patients suffering from Eagle jugular syndrome who present normal or short styloid process, but in close proximity to C1. To test this hypothesis, we are developing a novel software to analyze 3-D spatial orientation of styloid process in patient with a previously diagnosed Eagle jugular syndrome compared to healthy controls. Methods We collected cervical computed tomography angiography (CTA) images from 8 patients with EJS confirmed by venous angiography at our institution, and a control group of 7 random patients, homogenous for sex and age. A blind operator created with a dedicated pre-existing software3, an editable 3-D model (.stl file) of the 3 main region of interest (ROI), namely: right styloid, left styloid, C1 anterior arch. Starting from this dataset, our software, written using the open-source package management system Anaconda4 ver. 2-2.4.0, compares all the possible couples of points between each styloid process and the C1 arch, detecting the minimum and maximum distance. Then, it provides the mean spatial orientation of the process respect the CT-axis: x-axis (from left to right), y-axis (from occiput to nose) and z-axis (cranio-caudal). Results By now we included 15 patients (8 cases, 7 controls), homogeneous for sex and age. Preliminary data (Table 1), although not statistically significant yet, seems to indicate that Eagle jugular patients effectively have a more vertical styloid process, meaning an angle between styloid and y-axis greater than controls, rather than a longer one. Conclusions Our preliminary results could confirm that spatial orientation is more important in Eagle jugular patients than styloid process length. This study is currently ongoing and we planned to enroll at least 20 subjects for each arm. At the same time, we are collecting data from patients with carotic variant of Eagle syndrome, to better characterize morphometric structure of styloid in various subset of this pathology

Role of stem cells-based in facial nerve reanimation: A meta-analysis of histological and neurophysiological outcomes

BACKGROUND Treatments involving stem cell (SC) usage represent novel and potentially interesting alternatives in facial nerve reanimation. Current literature includes the use of SC in animal model studies to promote graft survival by enhancing nerve fiber growth, spreading, myelinization, in addition to limiting fibrotic degeneration after surgery. However, the effectiveness of the clinical use of SC in facial nerve reanimation has not been clarified yet.AIMTo investigate the histological, neurophysiological, and functional outcomes in facial reanimation using SC, compared to autograft.METHODSOur study is a systematic review of the literature, consistently conducted according to the preferred reporting items for systematic reviews and meta-analyses statement guidelines. The review question was: In facial nerve reanimation on rats, has the use of stem cells revealed as effective when compared to autograft, in terms of histological, neurophysiological, and functional outcomes? Random-effect meta-analysis was conducted on histological and neurophysiological data from the included comparative studies.RESULTSAfter screening 148 manuscript, five papers were included in our study. 43 subjects were included in the SC group, while 40 in the autograft group. The meta-analysis showed no significative differences between the two groups in terms of myelin thickness [CI: -0.10 (-0.20, 0.00); I-2 = 29%; P = 0.06], nerve fibers diameter [CI: 0.72 (-0.93, 3.36); I-2 = 72%; P = 0.6], compound muscle action potential amplitude [CI: 1.59 (0.59, 3.77); I-2 = 89%; P = 0.15] and latency [CI: 0.66 (-1.01, 2.32); I-2 = 67%; P = 0.44]. The mean axonal diameter was higher in the autograft group [CI: 0.94 (0.60, 1.27); I-2 = 0%; P <= 0.001].CONCLUSIONThe role of stem cells in facial reanimation is still relatively poorly studied, in animal models, and available results should not discourage their use in future studies on human subjects

The eagle jugular syndrome

The elongation of the styloid process is historically associated with two variants of the Eagle syndrome. The classic one, mainly characterized by pain and dysphagia, and the carotid variant characterized by pain and sometimes by cerebral ischemia. We observed a further variant characterized by a styloid elongation coursing adjacent to the transverse process of C1, causing significant compression of the internal jugular vein

Two-Level Corpectomy and Fusion vs. Three-Level Anterior Cervical Discectomy and Fusion without Plating: Long-Term Clinical and Radiological Outcomes in a Multicentric Retrospective Analysis

Background: Anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF) represent effective alternatives in the management of multilevel cervical spondylotic myelopathy (CSM). A consensus on which of these techniques should be used is still missing. Methods: The databases of three centers were reviewed (January 2011-December 2018) for patients with three-level CSM, who underwent three-level ACDF without plating or two-level ACCF with expandable cage (VBRC) or mesh (VBRM). Demographic data, surgical strategy, complications, and implant failure were analyzed. The Neck Disability Index (NDI), the Visual Analog Scale (VAS), and the cervical lordosis were compared between the two techniques at 3 and 12 months. Logistic regression analyses investigated independent factors influencing clinical and radiological outcomes. Results: Twenty-one and twenty-two patients were included in the ACDF and ACCF groups, respectively. The median follow-up was 18 months. ACDFs were associated with better clinical outcomes at 12 months (NDI: 8.3% vs. 19.3%, p < 0.001; VAS: 1.3 vs. 2.6, p = 0.004), but with an increased risk of loss of lordosis correction & GE; 1 & DEG; (OR = 4.5; p = 0.05). A higher complication rate in the ACDF group (33.3% vs. 9.1%; p = 0.05) was recorded, but it negatively influenced only short-term clinical outcomes. ACCFs with VBRC were associated with a higher risk of major complications but ensured better 12-month lordosis correction (p = 0.002). No significant differences in intraoperative blood loss were noted. Conclusions: Three-level ACDF without plating was associated with better clinical outcomes than two-level ACCF despite worse losses in lordosis correction, which is ideal for fragile patients without retrovertebral compressions. In multilevel CSM, the relationship between the degree of lordosis correction and clinical outcome advantages still needs to be investigated