Francesca Graziano

Neuroprotective effect of erythropoietin and darbepoetin alfa after experimental intracerebral hemorrhage.

OBJECTIVEIntracerebral hemorrhage (ICH) is a devastating clinical syndrome for which no truly efficacious therapy has yet been identified. In preclinical studies, erythropoietin (EPO) and its long-lasting analog, darbepoetin alfa, have been demonstrated to be neuroprotective in several models of neuronal insult. The objectives of this study were to analyze whether the systemic administration of recombinant human EPO (rHuEPO) and its long-lasting derivative darbepoetin alfa expedited functional recovery and brain damage in a rat model of ICH. METHODSExperimental ICH was induced in rats by injecting autologous blood into the right striatum under stereotactic guidance. Subsequently, animals underwent placebo treatment, daily injections of rHuEPO, or weekly injections of darbepoetin alfa. Animals were killed 14 days after injury. RESULTSBoth rHuEPO and darbepoetin alfa were effective in reducing neurological impairment after injury, as assessed by the neurological tasks performed. rHuEPO- and darbepoetin alfa–treated animals exhibited a restricted brain injury with nearly normal parenchymal architecture. In contrast, the saline-treated group exhibited extensive cerebral cytoarchitectural disruption and edema. The number of surviving NeuN-positive neurons was significantly higher in the rats treated with rHuEPO and darbepoetin alfa compared with those that received saline (P < 0.05). CONCLUSIONThese results demonstrate that weekly administered darbepoetin alfa confers behavioral and histological neuroprotection after ICH in rats similar to that of daily EPO administration. Administration of EPO and its long-lasting recombinant forms affords significant neuroprotection in an ICH model and may hold promise for future clinical applications.

May Autologue Fibrin Glue Alone Enhance Ossification? An Unexpected Spinal Fusion

LETTER: We have read and appreciated the report by Elder et al 1 on fusion rates in anterior cervical discectomy and anterior cervical disc fusion with cerebrospinal fluid (CSF) leakage is to be considered the first study about clinical outcomes and effects of CSF leakage in cervical fusion procedures. In addition, this report has aroused interest on the way fibrin sealant can be used to prevent even the smallest dural lacerations. In fact, fibrin glue, alone or associated to dural substitute or muscle flap, is commonly used in spinal surgery to repair durotomy and/or to prevent CSF leakage in case of adherences, dissection of the posterior longitudinal ligament in anterior approaches, or dissection of ligamentum flavum in posterior approaches.

WhatsAPP in neurosurgery: the best practice is in our hands

Dear Editor, It is our pleasure to report our successful experience with the use of an innovative communication tool: WhatsApp (WhatsApp Inc., 2013). In recent years, smartphones have become essential tools in medicine since they can assist the physician in patient care and monitoring and during the rehabilitation process. They can also make communication faster and facilitate the diagnosis, teaching, research and references. Among the innumerable communication apps available today, WhatsApp has become widely popular thanks to its costeffectiveness [1–5]. In this regard, in our Neurosurgical Center at the University Hospital of Palermo in Italy, we have adopted WhatsApp to share patient information, digital images and clinical suggestions to facilitate the spread of the most correct surgical and clinical practice. In our department, each neurosurgeon has a smartphone provided with WhatsApp, and three chat groups are usually constantly active: the first is named BNCH Palermo^ (NCH stands for neurosurgery) and used by young and senior consultants. The second is named BNCH fellows^ and used by students, researchers and honorary doctors normally involved in our surgical, medical and mainly scientific activities. This second group has been used as a means through which research projects, scientific articles and didactic images are sent. This has guaranteed an immediate and uniform distribution of information. Furthermore, since our department has a specific agreement with the Neuroendovascular Department of the University Hospital of Messina, Sicily, a multidisciplinary team including a neurosurgeon and two neurointerventional radiologists is dedicated to evaluating each neurovascular case. Therefore, a third chat group was created and named BNCH Palermo/NeuroRad Messina^ (NeuroRad stands for neuroradiology). Each chat group has been constantly active. Each time a case required a thorough discussion, a brief presentation of the onset of clinical symptoms and the patients main past and familial medical history was sent. Radiological images, comprising both pictures of the CT, MRI and DSA scans and whole videos of the specific examinations, were sent through the chat group, taking care to obscure personal patient details. Working as a neurosurgeon means being available at all times, managing unstable patients, together with performing surgery and running clinics. Because of the unpredictable nature of this work, the need for safe and fast communication among physicians emerges. Sometimes neurosurgical pathologies can be ambiguous and challenging to manage [2, 3]. In these cases, senior consultants may provide extremely important support to the decision-making process. They can cooperate with residents or junior consultants who have less experience to help themmake the most appropriate decision. In this regard, few reports are available in the literature about the use ofWhatsApp as an interhospital communication device. It has already been employed among emergency, orthopedic and plastic surgeons with great benefit. Their experience has been extremely satisfying since the app has facilitated communication and permitted a constant overviewing of activities. Junior doctors independence has also been improved at minimal risk to patient safety, recording communications for audit and training purposes [2, 3]. To sum up, WhatsApp offers a cost-effective, user-friendly and hassle-free solution over the conventional practice of * F. Graziano franeurosurgery@libero.it

Preliminary experience with a transcranial magnetic resonance-guided focused ultrasound surgery system integrated with a 1.5-T MRI unit in a series of patients with essential tremor and Parkinson's disease

OBJECTIVE Transcranial magnetic resonance-guided focused ultrasound surgery (tcMRgFUS) is one of the emerging noninvasive technologies for the treatment of neurological disorders such as essential tremor (ET), idiopathic asymmetrical tremor-dominant Parkinsons disease (PD), and neuropathic pain. In this clinical series the authors present the preliminary results achieved with the worlds first tcMRgFUS system integrated with a 1.5-T MRI unit. METHODS The authors describe the results of tcMRgFUS in a sample of patients with ET and with PD who underwent the procedure during the period from January 2015 to September 2017. A monolateral ventralis intermedius nucleus (VIM) thalamic ablation was performed in both ET and PD patients. In all the tcMRgFUS treatments, a 1.5-T MRI scanner was used for both planning and monitoring the procedure. RESULTS During the study period, a total of 26 patients underwent tcMRgFUS thalamic ablation for different movement disorders. Among these patients, 18 were diagnosed with ET and 4 were affected by PD. All patients with PD were treated using tcMRgFUS thalamic ablation and all completed the procedure. Among the 18 patients with ET, 13 successfully underwent tcMRgFUS, 4 aborted the procedure during ultrasound delivery, and 1 did not undergo the tcMRgFUS procedure after stereotactic frame placement. Two patients with ET were not included in the results because of the short follow-up duration at the time of this study. A monolateral VIM thalamic ablation in both ET and PD patients was performed. All the enrolled patients were evaluated before the treatment and 2 days after, with a clinical control of the treatment effectiveness using the graphic items of the Fahn-Tolosa-Marin tremor rating scale. A global reevaluation was performed 3 months (17/22 patients) and 6 months (11/22 patients) after the treatment; the reevaluation consisted of clinical questionnaires, neurological tests, and video recordings of the tests. All the ET and PD treated patients who completed the procedure showed an immediate amelioration of tremor severity, with no intra- or posttreatment severe permanent side effects. CONCLUSIONS Although this study reports on a small number of patients with a short follow-up duration, the tcMRgFUS procedure using a 1.5-T MRI unit resulted in a safe and effective treatment option for motor symptoms in patients with ET and PD. To the best of the authors knowledge, this is the first clinical series in which thalamotomy was performed using tcMRgFUS integrated with a 1.5-T magnet.

Reconstruction of Vertebral Body After Radiofrequency Ablation and Augmentation in Dorsolumbar Metastatic Vertebral Fracture: Analysis of Clinical and Radiological Outcome in a Clinical Series of 18 Patients

BACKGROUNDnPainful spinal metastases usually occur in malignant neoplastic disease. Treatment for bone metastases has been largely conservative, and it includes the use of high doses of analgesics, radiotherapy, chemotherapy, hormone therapy, and bisphosphonates; however, results are sometimes transient and ineffective. In the presence of neurological involvement a surgical strategy should be considered. Recently, percutaneous procedures such as radiofrequency ablation, vertebroplasty, and kyphoplasty have been introduced as palliative techniques to treat painful vertebral metastases [3, 11, 25].nnnMETHODSnIn our study we combined the use of radiofrequency ablation with vertebroplasty in the treatment of dorsolumbar metastatic vertebral fractures in order to examine the relationship between restoration of the vertebral structure and decrease in pain. From January 2014 to March 2015 we retrospectively analyzed 18 patients with malignant vertebral lesions who underwent radiofrequency ablation with vertebroplasty followed by cementoplasty, with posterior transpedicle fixation on levels near the lesions. The parameters examined were: demographics, pain relief, and the distribution of polymethylmethacrylate (PMMA) determined by the mean Saliou filling score; all complications were recorded.nnnFINDINGSnThe mean age of the patients was 55.72 years (range 34-69); average operative time was 60.4 min (range, 51-72). The average pain index score (visual analog score; VAS) decreased significantly from 8.05 at baseline to 3.0 (p < 0.05) after 6 months. The Saliou filling score revealed a distribution of PMMA in the vertebral body that was satisfactory (12-18) in eight patients, mediocre (6-12) in seven patients, and inadequate (0-6) in the remaining three patients. In two vertebrae, minimal asymptomatic cement leakage occurred in the lateral recess without neurological damage. No pulmonary embolism and no visceral or neural damage was recorded.nnnCONCLUSIONnRadiofrequency ablation combined with vertebroplasty seems to achieve rapid and lasting improvement in clinical symptoms in patients with malignant vertebral lesions. There was wide diffusion of PMMA in the vertebral body, with a mean cement volume of 4.5 ml.

EMG-Guided Percutaneous Placement of Cement-Augmented Pedicle Screws for Osteoporotic Thoracolumbar Burst Fractures

BACKGROUNDnPercutaneous techniques have increasingly gained popularity in recent years. The application of technological innovation, including neuromonitoring techniques, has the potential to increase the safety and efficacy of these procedures.nnnMETHODSnThirty patients suffering from osteoporotic dorsolumbar burst fracture were prospectively enrolled in this study. The patients underwent percutaneous fenestrated pedicle screw fixation augmented with polymethylmethacrylate (PMMA) injection. A novel surgeon-dedicated neuromonitoring device was used in order to increase the safety and the accuracy of the screw insertion. A second group of 30 patients who did not undergo neuromonitoring during percutaneous pedicle screw placement, matched for demographic characteristics, constituted the control group.nnnFINDINGSnA total of 296 screws were inserted. All treated patients had a good outcome, documented by an improvement in visual analogue scale (VAS) scores. Excellent trajectories were achieved in all patients. Cobbs angle and anterior vertebral height were satisfactorily restored in all study group patients. Three misplaced screws in three patients and a case of PMMA leakage without neurological deficits were observed in the control group, whereas no complication was recorded in the study group (p = 0.03).nnnCONCLUSIONSnNeuromonitoring in cement-augmented percutaneous pedicle screw placement appears to improve surgeon confidence during surgery, reducing the risk of screw misplacement or cement leakage.

Restoring Neurological Physiology: The Innovative Role of High-Energy MR-Guided Focused Ultrasound (HIMRgFUS). Preliminary Data from a New Method of Lesioning Surgery

BACKGROUNDnTremor is a disabling condition, common to several neurodegenerative diseases. Lesioning procedures and deep brain stimulation, respectively, of the ventralis intermedius nucleus for intentional tremor, and of the subthalamic nucleus for parkinsonian resting tremor, have been introduced in clinical practice for patients refractory to medical treatment. The combination of high-energy focused ultrasound (HIFUS) with sophisticated magnetic resonance (MR) instrumentation, together with accurate knowledge of the stereotactic brain coordinates, represents a revolution in neuromodulation.nnnMETHODSnAt the Neurosurgical Clinic and the Radiology Department of the University of Palermo,, two patients affected by severe and refractory forms of intentional tremor were treated by MRI-guided FUS (MRgFUS) with a unique 1.5 T MR scanner prototype that uses FUS. This apparatus is the only one of its type in the world.nnnFINDINGSnThis is the first Italian experience, and the second in Europe, of treatment with MRI-gFUS for intentional tremor. But this is the very first experience in which a 1.5 T MRI apparatus was used. In both patients, the treatment completely abolished the tremor on the treated side, with results being excellent and stable after 7 and 5 months, respectively; no side effects were encountered.nnnCONCLUSIONnMRgFUS, recently introduced in clinical practice, and widely used at several clinical centers, has been shown to be a valid therapeutic alternative in the treatment of tremor in several neurodegenerative diseases. It is virtually safe, noninvasive, and very efficacious. We report this technique in which a 1.5 T MR scanner was used. Further investigations with long-term follow up and larger clinical series are needed.

Spinal Cord Stimulation: An Alternative Concept of Rehabilitation?

BACKGROUNDnChronic low back and leg pain is a disabling condition, affecting, in most cases, older patients with congenital or acquired spinal stenosis or patients with failed back surgery syndrome. Spinal cord stimulation has been introduced as an effective therapeutic option for those patients who have previously been operated without significant clinical benefits, or for all those patients who are ineligible for traditional surgery.nnnMETHODSnWe report our experience with ten patients treated with spinal cord stimulation plus medication and physical therapy between November 2014 and September 2015. Inclusion criteria were: previous surgical treatments for lumbar stenosis and metameric instability and persistent or ingravescent disabling low back and leg pain, with a mean duration of symptoms of at least 18 months. A visual analog scale (VAS) was employed for back and leg pain, and the Oswestry Disability Index (ODI) score was determined, and findings were analyzed after 6 months.nnnFINDINGSnNo intra- or postoperative complication was recorded. The mean VAS score for back pain decreased from 7.5 to 2.9, while leg VAS decreased from 8.2 to 3.0. Analysis of ODI values showed evident improvement in daily life activities, ranging from a median value of 75.7% to 32.7 % after the stimulation.nnnCONCLUSIONnSpinal cord stimulation has a recognized impact on the pain and on the quality of life of patients with failed back surgery syndrome.

Vertebrobasilar junction giant aneurysm: Lessons learned from a neurosurgical audit and anatomical investigation.

The treatment of vascular lesions of the vertebrobasilar junction (VBJ) remains a challenging task in the neurosurgical practice and the gold standard therapy is still under debate. In this article, the authors report a detailed postmortem study of a VBJ giant aneurysm (GA) previously endovascularly treated. Although the decision-making process for the vast majority of neurosurgical treatment can nowadays be accurately carried out during the preoperative planning (i.e., with the aid of neuroimaging fusion protocols, neuronavigation platforms, etc.) meant to maximize the anatomical understanding of the lesions and minimize possible intraprocedural challenges, this postmortem study represents the ultimate essence of neurosurgical audit as the laboratory investigations allowed to reevaluate the clinical history of VBJ GA, and reassess the multiple strategies available for its treatment with a straightforward anatomical perspective. Specifically, the lessons learned through this clinical and laboratory work uphold a great educational value regarding the complex management of those lesions, including the possible role of combined skull base surgical approaches.

Conservative vs. Surgical Management of Post-Traumatic Epidural Hematoma: A Case and Review of Literature

Patient: Male, 30 Final Diagnosis: Acute epidural hematoma Symptoms: — Medication: — Clinical Procedure: Observation Specialty: Neurosurgery Objective: Unusual clinical course Background: Trauma is the leading cause of death in people younger than 45 years and head injury is the main cause of trauma mortality. Although epidural hematomas are relatively uncommon (less than 1% of all patients with head injuries and fewer than 10% of those who are comatose), they should always be considered in evaluation of a serious head injury. Patients with epidural hematomas who meet surgical criteria and receive prompt surgical intervention can have an excellent prognosis, presumably owing to limited underlying primary brain damage from the traumatic event. The decision to perform a surgery in a patient with a traumatic extraaxial hematoma is dependent on several factors (neurological status, size of hematoma, age of patients, CT findings) but also may depend on the judgement of the treating neurosurgeon. Case Report: A 30-year old man arrived at our Emergency Department after a traumatic brain injury. General examination revealed severe headache, no motor or sensory disturbances, and no clinical signs of intracranial hypertension. A CT scan documented a significant left fronto-parietal epidural hematoma, which was considered suitable for surgical evacuation. The patient refused surgery. Following CT scan revealed a minimal increase in the size of the hematoma and of midline shift. The neurologic examination maintained stable and the patient continued to refuse the surgical treatment. Next follow up CT scans demonstrated a progressive resorption of hematoma. Conclusions: We report an unusual case of a remarkable epidural hematoma managed conservatively with a favorable clinical outcome. This case report is intended to rather add to the growing knowledge regarding the best management for this serious and acute pathology.