Cesare Zoia

Low-Cost Fluorescein Detection System for High-Grade Glioma Surgery

BACKGROUND Intraoperative fluorescein detection has been used in the fields of vascular and oncologic neurosurgery since 1948. Modifications of the optics in order to enhance the fluorescence contrast under microscopic view have been developed by many authors. The industries, during the past 10 years, provided commercial high-cost optimized apparatuses. Reviewing the literature, we found that the prototypical techniques were definitely inexpensive but lacked reliability, reproducibility, and standard legal norms. METHODS We describe the developing of a fluorescein detection system that could be economic, simple, effective, and law abiding. RESULTS We employed a commercial violet-blue filter designed for fluorescein excitation in endoscopic procedures and used commercial photographic yellow optical filters for fluorescence detection. All the instrumentation is cleared for clinical use, and its cost is up to 200 times lower than commercial apparatuses. CONCLUSION Our results show a good distinction of fluorescein-stained structures, with overall acceptable operating light conditions.

Are antiplatelet and anticoagulants drugs a risk factor for bleeding in mild traumatic brain injury

OBJECTIVE Facing mild traumatic brain injury, clinicians must decide whether to perform a computed tomography (CT) scan to detect a potential intracranial hemorrhage. Many useful guidelines have been developed for the general population, but there is no general consensus about the best practice to adopt when dealing with patients on antiplatelet or anticoagulation drugs. The relatively recent introduction of new anticoagulants and second-generation antiplatelet drugs poses new challenges in this field. There are no data in the literature about the relative risk of intracranial bleeding in such categories. METHODS We enrolled 2773 consecutive patients presenting at our emergency department with mild traumatic brain injury as chief complaint and evaluated the results of their head CT scans, stratifying their anticoagulation and/or antiplatelet drug regime. RESULTS Of these patients, 1608 matched the criteria for head CT scan and had a Glasgow Coma Scale (GCS) score of 15; 517 were on antiplatelet drugs, whereas 213 were on anticoagulants. The risk of developing intracranial bleeding was significantly higher for patients on antiplatelet drugs, whereas the risk of anticoagulated patients overlapped with that of the general population. The trend for second-generation drugs was of higher risk of bleeding only for antiplatelets. CONCLUSIONS Patients with a GCS score of 15 on long-term anticoagulation therapy seem to be at no higher risk for intracranial hemorrhage than are nonanticoagulated patients. On the contrary, patients with a GCS score of 15 on antiplatelet therapy seem to be more prone to developing intracranial bleeding than are the general population, with a trend to be more at risk when it comes to second-generation drugs.

Poor man's fluorescence and equipment.

Dear Editor, We have read with great interest the debate on the use of fluorescein during high-grade glioma surgery. Three consecutive letters to the editor outlined two factions: those against, and those in favor of the use of fluorescein, which has been labeled as the Bpoor man’s fluorescence^ [2, 3, 5, 7]. We strongly agree with Brawanski et al. in stating that any technical innovation potentially increasing our surgical skills should be welcomed [3]. Nevertheless, we partially disagree in stating that the difference between 5-ALA and fluorescein is not really a problem of poor man–rich man fluorescence. Moreover, we maintain that much research and trials still need to be performed in order to fully evaluate and compare these two methods and we leave to more experienced surgeons the specific analyses of their respective benefits and liabilities. Still, we deem that cost issues are not to be overlooked. Albeit with some conflicts of interests, Slof et al. and Esteves et al. have actually demonstrated the costeffectiveness of 5-ALA, whose cost of a single dose is reported to be around 1,000 euros [4, 6]. Still, their models only make vague references to the cost of the instrumentation needed not giving a real picture of the cost of this new technology. To our knowledge, at least in Europe, there are two companies currently with dedicated fluorescence filters for both 5-ALA and fluorescein (Karl Zeiss, Oberkochen, Germany, and Leica Microsystems,Wetzlar, Germany). Although these companies are both to be commended for their efforts in the development of such systems, new technologies come with a price to be paid. In particular, both systems reportedly need a cuttingedge microscope and an accessory module, implying that the encompassing total cost easily exceeds a few hundred thousand euros. All the centers involved in the debate are wellrenowned, high-volume centers which strive to perform pioneering techniques on the basis of costly, resourcedemanding equipment, whose implementation is often immediate; but what about the rest of the world, i.e., the low-volume settings or, more relevantly, the developing countries, which struggle in providing medical care? In a spending-review setting involving many aspects of the health system worldwide, we have developed a method of providing a low-cost fluorescein detection system. Other pioneering works reported their custom settings but the novelty of this approach is the fact that it employs low-cost, already widespread surgical technologies. Briefly, we employed a blue filter designed for fluorescein detection in endoscopic procedures connected to a xenon light source and fixed the light cable to a standard retractor blade applied to the head holder. As for fluorescence detection, we purchased commercial yellow optical filters (for less than 50 euros), which have been modified to fit in the microscope oculars: no structural change has been made to the microscope and the system can be easily mounted and easily removed during the operation. The endoscopic technology is already widespread in neurosurgical centers and, as a reference, in our region the commercial system employed amounts to less than 1,000 euros. Relying on this Bpoor man’s technology ,̂ we are currently recruiting patients for a phase II trial (BGLOWOMA: Glioma I, Daniele Bongetta, certify that this manuscript is a unique submission and is not being considered for publication, in part or in full, with any other source in any medium.

Could Thalidomide Be a Treatment Option for Arteriovenous Malformations

LETTER: We read with great interest the article by Pabaney et al. 1 on the development of a de novo arteriovenous malformation (AVM) and their review of the literature. Besides their praiseworthy effort to collect and analyze all the sporadic literature reports, the authors are to be commended for trying to stress and explain the dynamic manifestation of AVMs. In this regard, they emphasize the potential role of vascular endothelial growth factor pathway activation induced by other factors or insults. In particular, in their case report, they infer that an ischemic event acted like a “second hit” to an existing genetic aberrancy. Their hypothesis is that after a stressing event, the cerebral endothelial structures may be subjected to the effect of an angiogenic niche, which could dynamically challenge the stability of the vascular architecture, leading to the development or enlargement of an AVM.

Intraregional differences of perioperative management strategy for lumbar disc herniation: is the Devil really in the details?

Background This study intends to evaluate whether regional common habits or differences in case-volume between surgeons are significative variables in the perioperative management of patients undergoing surgery for lumbar disc herniation. Methods An e-mail survey was sent to all neurosurgeons working in Lombardy, Italys most populated region. The survey consisted of 17 questions about the perioperative management of lumbar disc herniation. Results Forty-seven percent (47%) out of 206 Lombard neurosurgeons answered the survey. Although in some respects there is clear evidence in current literature on which is the best practice to adopt for an optimal management strategy, we noticed substantial differences between respondents, not only between hospitals but also between surgeons from the same hospital. Still, no differences were evident in a high vs low case-volume comparison. Conclusion We identified no regional clusterization as for practical principles in the perioperative management of lumbar disc herniation and neither was case-volume a significative variable. Other causes may be relevant in the variability between the perioperative management and the outcomes achieved by different specialists.

Fluorescein-guided intraoperative endoscopy in patients with hereditary hemorrhagic telangiectasia: first impressions

Hereditary hemorrhagic telangiectasia (HHT) is a rare genetic disease that results in mucocutaneous telangiectasias and arteriovenous visceral malformations. Nasal telangiectasias lead to recurrent epistaxis, which affects up to 96% of patients. Different morphologic classifications and methods of visualization of nasal lesions have been described in the literature. We developed a new method of intraoperative endoscopy based on the intravenous administration of fluorescein. Preliminary data of this technique are reported.

Tension pneumocephalus secondary to osteoradionecrosis of the clivus

We report the case of a 36 year-old man with relapsing undifferentiated nasopharyngeal carcinoma treated with a re-irradiation Cyberknife, who subsequently developed tension pneumocephalus due to a cerebrospinal fluid leakage located at the clivus. The fistula was caused by osteonecrosis of the skull base secondary to the tumor invasion and to the sequelae of the radiotherapy. An endoscopic endonasal technique was used in order to repair the defect, with a peduncolated nasoseptal flap harvested to perform the skull base reconstruction. In this paper, we discuss the importance of identifying this possible complication related to radiotherapy in the management of neoplasm along the skull base; moreover, the role of endoscopy in the diagnosis and treatment of skull base fistulas is also described and commented.

Haemorrhagic Presentation of a Craniopharyngioma in a Pregnant Woman

Objective. Craniopharyngioma is a rare tumour, and, consequently, acute clinical presentation and diagnosis, during pregnancy, of this pathology are quite difficult to find. Only few cases are reported in the literature, and no one describes these two conditions in association. Methods. We report a particular case of craniopharyngioma presenting both of the above conditions. Results. The patient was successfully operated with endoscopic technique. Conclusions. Rare and difficult cases, created by the superposition of different clinical conditions, need multidisciplinary management, with collaboration, integration, and cooperation between different medical specialists.

Onyx Embolization Before the Surgical Treatment of Grade III Spetzler-Martin Brain Arteriovenous Malformations: Single-Center Experience and Technical Nuances

BACKGROUND Grade III Spetzler-Martin brain arteriovenous malformations (AVMs) are a specific set of AVMs with high variability in terms of site, size, angioarchitecture, flow dynamics, and involvement of eloquent areas. Surgery preceded by preoperative embolization has been reported as a useful treatment option for these lesions. The aim of this study is to report outcomes and personal experience of combined preoperative Onyx embolization and surgical resection on a consecutive series of grade III brain AVMs. METHODS Between 2005 and 2017, 27 grade III AVMs were treated by means of a staged Onyx embolization and subsequent surgical treatment. Site and size of the AVMs, embolization, and surgical specifics as well as complications and outcomes were retrospectively reviewed. RESULTS All AVMs were supratentorial, 13 of which were hemorrhagic. Mean nidal volume was 19.5 mL. Average embolization sessions were 1.6. Mean embolization-related obliteration rate and morbidity were 28.8% and 3.7%, respectively. Surgery was performed within 3.7 days on average. In our experience, Onyx embolization made the nidus excision easier, facilitated the hemostasis, and contributed to the early identification of the lesion in cases of small or racemose nidus. The surgical obliteration rate was 92.6%. A good overall outcome (modified Rankin Scale score 0-2) was achieved in 70.4% of patients. CONCLUSIONS In our experience, preoperative Onyx embolization helped the surgical management of grade III Spetzler-Martin brain AVMs. Careful evaluation of the angioarchitecture, a tailored strategy in the embolization process, and full cooperation within the neurosurgical-neuroendovascular team are mandatory.

Outcome of elderly patients undergoing intracranial meningioma resection: a single center experience

BACKGROUND Higher life expectancy and higher mean age in general population created growing interest in medical and surgical management of meningiomas in elderly. It is well known that, due to possible complications, pre-operative status and comorbidities, expecially in aged people, should be carefully considerated in the decision-making process. We described our experience with this kind of patients and analized the influence of complications on the outcome. METHODS We conducted a monocentric retrospective study to evaluate outcome and complications in elderly patients that underwent intracranial meningioma surgery in our center in a ten year period. Between January 2005 and December 2014, 107 patients - older than 70 years old - were operated for an intracranial meningioma. We excluded patients operated for a recurrent meningioma. We use the Dindo classification modified by Poon to describe complications and the Karnofsky Performance Status Scale and Glasgow Outcome Scale to evaluate the outcome at discharge and after a 6 months period. RESULTS 84 patients did not have postoperative complications, 10 patients had mild postoperative complications, while 13 patients suffered severe postoperative complications. As a group, patients with mild complications presented, six months after surgery, an average Karnofsky Performance Status better than preoperative one. CONCLUSIONS Even though the fragility is considered an important risk factor, surgery for symptomatic intracranial meningiomas should be considered also in elderly patients. The presence of early postoperative mild complications do not seem to worsen the average 6 months- KSP score.