Giulio Anichini

Neurinoma of the hypoglossal nerve in the submandibular space: case report and review of the literature.

SummaryNeurinomas of the hypoglossal nerve extending extra-cranially are rare; a schwannoma in a 63-year-old woman causing nerve palsy is reported. The tumour presented as a slow-growing mass in the right submandibular space; a surgical approach with transcervical exploration was performed. The post-operative course was uneventful.

Benign osteoblastoma of the odontoid process of the axis with secondary aneurysmal bone cyst component: a case report

The authors report their experience on one patient with osteoblatoma of the odontoid process of the axis with secondary aneurysmal bone cyst. According to their knowledge, this is the first case, reported in the literature, of this kind of lesion in that particular anatomical region. Because of the rarity of this lesion, it was difficult to have a certain preoperative diagnosis. Therefore, the patient underwent a biopsy via a transoral route. The biopsy was performed over the noncalcified component of the lesion. The intraoperative histological examination showed the benign nature of the lesion. Thereafter, the lesion was totally removed, succeeding in preserving the remaining part of the odontoid process and the anterior arch of C1. In the follow-up, there was no evidence of cranio-vertebral instability. The histological examination revealed an osteoblastoma of the odontoid process of the axis with a secondary aneurysmal bone cyst. To the best of our knowledge, this is the first case reported in the literature.

Awake craniotomy for trapping a giant fusiform aneurysm of the middle cerebral artery.

Background: Giant fusiform aneurysms of the distal middle cerebral artery (MCA) are rare lesions that, because of the absence of an aneurysm neck and the presence of calcified walls and partial thrombosis, can be difficult to clip without sacrificing the parent vessel. Moreover, when the aneurysm is located in the dominant hemisphere, it is not possible to test language and cognitive functions during surgical intervention, making the closure of the parent vessel extremely dangerous. Case Description: A 46-year-old woman presented with a one-year history of frontal headache without neurological deficit. A magnetic resonance imaging and an angiography showed a giant fusiform aneurysm of the left M2 tract. Because of the location and the absence of a neck, the aneurysm was considered difficult to coil and not amenable to preoperative balloon occlusion; thus, the patient was a candidate for surgical treatment. After a preoperative psychological evaluation, patient underwent awake craniotomy with the asleep–awake–asleep technique. A standard left pterional approach was performed to expose the internal carotid artery, the MCA and the aneurysm originating from the frontal branch of the MCA. Neurological examination responses remained unchanged during temporary parent artery occlusion, and trapping was successfully performed. Conclusions: Awake craniotomy is a useful option in intracranial aneurysm surgery because it permits neurological testing before vessels are permanently clipped or sacrificed. With the asleep–awake–asleep technique, it is possible to perform a standard pterional craniotomy, which allows good exposure of the vascular structures without cerebral retraction.

Neurosurgical Applications of the 2-μm Thulium Laser: Histological Evaluation of Meningiomas in Comparison to Bipolar Forceps and an Ultrasonic Aspirator

OBJECTIVE The authors evaluated the histological effects of the 2-μm thulium laser on meningioma tissue, comparing them to the results obtained using bipolar forceps and an ultrasonic aspirator. METHODS The authors analyzed nine samples of intracranial meningiomas. Four slices were obtained for every sample, and one incision was performed on each slice. Two incisions were made with a 2-μm thulium laser (one set to a 6 W and another set to a 12 W power level). One incision was made using a bipolar forceps and the other using an ultrasonic aspirator. Tissue was addressed and analyzed. Upon microscope analysis, three zones of laser action were identified: (A) a central crater; (B) a vaporized zone; and (C) a shrunken layer. These three layers were measured and compared. RESULTS When addressed with the laser, all nine meningiomas presented a crater having an average depth of 1 mm. Three layers were clearly distinguished and measured: A (average depth: 0.8 mm at 6 W and 1.24 mm at 12 W); B (average depth: 0.32 mm at 6 W and 0.72 mm at 12 W); and C (average depth: 0.39 mm at 6 W and 0.44 mm at 12 W). On slices treated with bipolar forceps incisions, only zones B and C were identified. Ultrasonic aspirator incisions showed a deeper A zone (average depth: 2.93 mm), no B zone, and a tiny C zone (average depth: 0.16 mm). CONCLUSIONS Thulium laser can be safely used for the surgical removal of intracranial meningiomas; beyond 2 mm under the surface of action, no tissue alterations were found. The lesions produced on meningiomas were characterized by vaporization and shrinking. When compared with bipolar forceps, the thulium laser offers cutting precision and vaporization of the tissue. When compared to the cavitron ultrasonic surgical aspirator (CUSA), the laser offers shrinking and coagulation of small vessels.

Assessment of the utility of the 2‐µ thulium laser in surgical removal of intracranial meningiomas

Since the 1960s, lasers have been used in neurosurgery for surgical removal of intracranial tumors. Because of its limited penetration (2 mm) through tissues and its wavelength, which is useful in water medium, the 2‐µ thulium laser has been applied primarily in urology. Its features are attractive for application under microscope magnification during neurosurgical procedures. The aim of this study was to evaluate the usefulness of the 2‐µ thulium laser during microsurgical removal of intracranial meningiomas.

Midline medulloblastoma versus astrocytoma: the position of the superior medullary velum as a sign for diagnosis

PurposeWe wish to describe the position of the superior medullary velum (SMV) in midline posterior fossa tumours as a sign in helping to distinguish between midline medulloblastoma and midline astrocytoma.Material and methodsSagittal T1-weighted MRI images of 21 consecutive patients with histologically documented posterior fossa midline astrocytomas (nine cases) and medulloblastomas (12 cases) were reviewed, with respect to the position of the velum medullare superius.ResultsIn all medulloblastomas the SMV was superiorly dislocated; in eight astrocytomas it was anteriorly and/or inferiorly disclocated; only in one astrocytoma the SMV presented upward dislocation.ConclusionIn the differential diagnosis between medulloblastoma and astrocytoma the upward dislocation of the SMV is strongly suggestive of medulloblastoma.

Anterior Cranial Fossa Traumas: Clinical Value, Surgical Indications, and Results—A Retrospective Study on a Series of 223 Patients

Objective Frontobasal fractures are relatively common traumas but surgical indications are still discussed. The authors report their results on patients showing anterior cranial fossa fractures; clinical data, surgical indications, and results are reported and critically analyzed. Methods From 1991 to 2010, 223 patients were admitted in our institution with diagnosis of anterior cranial fossa fracture. Fractures were classified as type A-fracture of the anterior wall of the frontal sinus; type B-fracture of the posterior wall of the frontal sinus; and type C-frontobasal traumas without involvement of the frontal sinus. All patients entered a follow-up program consisting in periodic controls. Results A total of 105 patients were conservatively treated, while 118 patients underwent surgical intervention. The presence of pneumocephalus (p < 0.0001) and rhinoliquorrhea (p = 0.001) were the factors influencing the surgical indication. In the fractures of group B with signs of pneumocephalus and or rhinoliquorrhea, full sinus cranialization represents the variable mainly influencing the outcome (p < 0.001). Conclusion Patients with frontobasal traumas should be carefully evaluated to choose the best treatment option. Clinical and radiological data suggest that patients with frontobasal fractures with massive pneumocephalus and/or rhinoliquorrhea should be always surgically treated.

Preparation of nasoseptal flap in trans-sphenoidal surgery using 2-μ thulium laser: Technical note

OBJECTIVE The purpose of this study was to assess the feasibility of the use of the 2μ-thulium laser in harvesting nasal septal flaps. BACKGROUND DATA Nasal septal flaps are routinely performed in almost every trans-sphenoidal surgery. The preservation of the arterial vasculature is a mainstay of the procedure. However, the margins of the flap should be sufficiently healthy to regenerate faster, reducing the risk of possible complications. MATERIALS AND METHODS Eight patients underwent trans-sphenoidal surgery and removal of pituitary adenomas. Reparation of the defect was performed with the positioning of a rotational vascularized nasal-septal flap. The flaps were harvested with the aid of the 2μ-thulium laser. Every patient was then monitored for 6 months through seriated endoscopic endonasal controls. RESULTS There were no complications related to the use of the laser, either intraoperatively, or postoperatively. The operative timing did not significantly differ from that of traditional techniques. CONCLUSIONS The use of the 2μ-thulium laser for the harvesting of nasal septal vascularized flaps can be considered safe and feasible. The limited number of treated patients could be considered as the only restriction to the study. A larger study might have uncovered possible instrumentation-related complications, which were not observed in the present study.

Use of 2-μm Continuous-Wave Thulium Laser for Surgical Removal of a Tentorial Meningioma: Case Report

BACKGROUND Since the early 1980s, CO(2), neodymium-doped yttrium aluminum garnet (Nd:YAG), and other laser prototypes have been widely used in neurosurgery as an intraoperative aid along with the cavitron ultrasonic surgical aspirator (CUSA), bipolar forceps, and microdissection. However, the English literature contains almost no reports on the use of thulium lasers during neurosurgical procedures. METHODS We report our experience with a thulium laser during the surgical removal of a tentorial meningioma. The intraoperative technique utilized, as well as the clinical and radiological results of the procedure, are described. RESULTS The thulium laser proved to be a useful tool during coagulation, shrinking, and resection of the basal implant of the tumor. Use of the laser made the surgical procedure faster and easier, and no intraoperative bleeding was noted. No side effects were observed. CONCLUSIONS Our experience indicates that thulium lasers are a valid aid during resection of benign intracranial tumors under microscope magnification. Additional studies are required to define fully the role of these lasers in neurosurgical procedures.

Spinal Nerves Schwannomas: Experience on 367 Cases—Historic Overview on How Clinical, Radiological, and Surgical Practices Have Changed over a Course of 60 Years

Background Spinal schwannomas are common benign spinal tumors. Their treatment has significantly evolved over the years, and preserving neurological functions has become one of the main treatment goals together with tumor resection. Study Design and Aims Retrospective review focused on clinical assessment, treatment techniques, and outcomes. Methods A retrospective study on our surgical series was performed. Clinical and operative data were analyzed. In regard to neurophysiologic monitoring, patients were retrospectively divided into two groups comparing the outcomes before and after introduction of routine intraoperative neurophysiology tests. Results From 1951 to 2010, 367 patients overall were treated. Diagnosis was obtained using angiography and/or myelography (pre-CT era), MRI, or CT scan. A posterior spinal approach was used for most patients; complex approaches were adopted for treatment of giant/dumbbell tumors. A trend of neurophysiology monitoring decreasing the rate of post-op neurological deficits was observed but was not statistically significant enough to draft evidence-based conclusions. Conclusions Clinical and radiological assessment of spinal schwannomas has markedly changed over the course of 50 years. Diagnostic tools have improved, and detection of recurrence has become way more sensitive. Neurophysiologic monitoring has become a useful intraoperative tool to guide resection and prevent post-op neurological impairment.