Giannantonio Spena

Say “no” to spinal cord injury: is nitric oxide an option for therapeutic strategies?

Purpose: a literature review was made to investigate the role of nitric oxide (NO) in spinal cord injury, a pathological condition that leads to motor, sensory, and autonomic deficit. Besides, we were interested in potential therapeutic strategies interfering with NO mechanism of secondary damage. Materials: A literature search using PubMed Medline database has been performed. Results: excessive NO production after spinal cord injury promotes oxidative damage perpetuating the injury causing neuronal loss at the injured site and in the surrounding area. Conclusion: different therapeutic approaches for contrasting or avoiding NO secondary damage have been studied, these include nitric oxide synthase inhibitors, compounds that interfere with inducible NO synthase expression, and molecules working as antioxidant. Further studies are needed to explain the neuroprotective or cytotoxic role of the different isoforms of NO synthase and the other mediators that take part or influence the NO cascade. In this way, it would be possible to find new therapeutic targets and furthermore to extend the experimentation to humans.

Bubbles in the head: a new method for brain retraction during craniotomy

BackgroundA key aspect of neurosurgery is the challenge of ensuring adequate visualization through brain retraction whilst ensuring that underlying brain remains protected. Self-retaining retractors (SRR) are specially designed for this purpose. Their limitation however is the potential for ischaemic damage that accompanies any pressure on the cerebral cortex.Methods and techniqueWe use balloon tips of Fogarty catheters to provide gentle brain retraction during surgery for skull base and midline tumours as well as aneurysms of anterior circulation. Following completion of the craniotomy and dural opening, the balloon tip is inserted under the frontal or temporal lobes or into the interemispheric fissure, and then inflated. This results in distension of the arachnoid, thereby favouring the dissection process.ConclusionDiverting the brain from operative view with a more elastic, less traumatic, and easily adjustable Fogarty catheter balloon tip is a safe and effective tool that can either act as a substitute for SRR or alternatively minimise their duration of use.

Brain tumors in eloquent areas: A European multicenter survey of intraoperative mapping techniques, intraoperative seizures occurrence, and antiepileptic drug prophylaxis

Intraoperative mapping and monitoring techniques for eloquent area tumors are routinely used world wide. Very few data are available regarding mapping and monitoring methods and preferences, intraoperative seizures occurrence and perioperative antiepileptic drug management. A questionnaire was sent to 20 European centers with experience in intraoperative mapping or neurophysiological monitoring for the treatment of eloquent area tumors. Fifteen centers returned the completed questionnaires. Data was available on 2098 patients. 863 patients (41.1%) were operated on through awake surgery and intraoperative mapping, while 1235 patients (58.8%) received asleep surgery and intraoperative electrophysiological monitoring or mapping. There was great heterogeneity between centers with some totally AW oriented (up to 100%) and other almost totally ASL oriented (up to 92%) (31% SD). For awake surgery, 79.9% centers preferred an asleep-awake-asleep anesthesia protocol. Only 53.3% of the centers used ECoG or transcutaneous EEG. The incidence of intraoperative seizures varied significantly between centers, ranging from 2.5% to 54% (p < 0.001). It there appears to be a statistically significant link between the mastery of mapping technique and the risk of intraoperative seizures. Moreover, history of preoperative seizures can significantly increase the risk of intraoperative seizures (p < 0.001). Intraoperative seizures occurrence was similar in patients with or without perioperative drugs (12% vs. 12%, p = 0.2). This is the first European survey to assess intraoperative functional mapping and monitoring protocols and the management of peri- and intraoperative seizures. This data can help identify specific aspects that need to be investigated in prospective and controlled studies.

Acute Supratentorial Ischemic Stroke: When Surgery Is Mandatory

Acute occlusion of middle cerebral artery (MCA) leads to severe brain swelling and to a malignant, often fatal syndrome. The authors summarize the current knowledge about such a condition and review the main surgical issues involved. Decompressive hemicraniectomy keeps being a valid option in accurately selected patients.

Cerebral Wegener's Granuloma: Surgery Mandatory for Diagnosis and Treatment

The involvement of the central nervous system in case of Wegener granulomatosis (WG) is infrequent and usually leads to cranial nerve abnormalities, cerebrovascular events, and seizures. Meningeal involvement is quite rare and usually is due to the spreading from adjacent disease in the skull base. We described the case of a remote intraparenchymal Wegeners granuloma in a 55-year-old man presenting with seizures and a history of severe generalized WG. The radiological findings were not useful for the diagnosis, and the pharmacological treatment was ineffective. The importance of a surgery in case of localized WG has been emphasized, in order to confirm the diagnosis and to avoid additional medicaments, like antiepileptic drugs, potentially harmful in immunosuppressed patients.

Practical prognostic score for predicting the extent of resection and neurological outcome of gliomas in the sensorimotor area

OBJECTIVE In this prospective study, we assessed the utility of a novel prognostic score (PS) in guiding the surgical strategy of patients with sensorimotor area gliomas. PATIENTS AND METHODS Form December 2012 to April 2016, we collected data from patients diagnosed with brain gliomas in the sensorimotor area. All the patients had intraoperatively confirmed contiguity or continuity with sensorimotor cortical and subcortical structures. Several clinical and radiological factors were analyzed to generate a PS for each patient (range 1-8). The end-points included the extent of resection (EOR) and neurological outcome (modified Rankin Score; mRS). We assessed the predictive power of the PS using different analyses. Crosstabs analyses and Fishers exact test (Fet) were used to evaluate the possible predictive parameters, and for the classification of positive or negative outcomes for the chosen proxies; the significance threshold was set at p<0.05. RESULTS Using independent t-tests, we compared the mRS at different time points (pre, post, and at 6 months) for 2 subgroups from the total sample using a cut-off PS value of 4. For the EOR, a PS value of ≥5 was predictive of successful outcome, a value of 4 indicated an uncertain outcome, and a value of ≤3 predicted a worse outcome. CONCLUSIONS This PS value can be easily used in clinical settings to help predict the functional outcome and EOR in sensorimotor area tumors. Integration with information from fMRI, DTI, and TMS, along with MRI spectroscopy could further enhance the value of this PS.

Multimodal approach to the surgical removal of gliomas in eloquent brain regions.

Supratentorial glial neoplasms are the most common primary brain tumor in adults and one of the leading causes of cancer-related death in the general population. Glioblastomas carry the worst prognosis, while low-grade gliomas have the best chance for survival. It has been demonstrated, however, that low-grade gliomas represent a precancerous state, as they have the potential to evolve into higher-grade malignancies. Although management algorithms vary among different types of tumors, surgery remains the mainstay of treatment for several reasons. Surgical resection allows the opportunity to obtain a sufficient amount of tumor for histological identification. This point is of utmost importance, as the best predictors of survival are the World Health Organization (WHO) grade and other immunohistological characteristics of the tumor. Additionally, it has been demonstrated that radical or subtotal resection correlates positively with prolongation of survival and longer time to progression. Given this information, neurosurgeons aim to achieve maximal surgical resection of these tumors whenever feasible. Unfortunately, gliomas are often located in regions of the brain defined as “eloquent” or “critical,” meaning that physical damage to these areas can create permanent neurological deficits. A careful evaluation of surgical strategy is mandatory in light of this fact, with the goal being to maximize tumor resection while respecting the highly functional cortical and subcortical regions of the brain. Different techniques are available that allow the neurosurgeon to study the brain function topography both preoperatively and intraoperatively. These methods of preoperative and intraoperative brain mapping are used to gain essential information about functional and topographic organization in a specific patient. Functional magnetic resonance imaging (fMR) is the most commonly used tool for preoperative visualization of the motor, sensory, language, and visual functional organization of a patient’s brain. Since gliomas typically invade white matter, the extent of resection is additionally limited by the degree of infiltration, particularly when critical bundles are involved (e.g., the pyramidal tract). As with the eloquent cortical areas, the relationship of the tumor to the subcortical pathways should be defined in order to avoid permanent deficits. Diffusion tensor imaging (DTI), the