R Galzio

Less invasive approaches for the treatment of cervical schwannomas: our experience

PurposeThe purpose of our paper is to illustrate our experience with minimally invasive approaches for the treatment of cervical schwannomas. Moreover, a brief review of the literature was conducted.MethodsAll data regarding patients treated for cervical schwannomas were retrospectively revised. Site, size and extension of the lesions and preoperative neurological status were obtained through re-examination of neuroimaging and clinical records. Postoperative clinical examinations and radiological images were available for all patients. The clinical course was documented using the visual analog scale (VAS), Karnofsky score (KPS) and the Klekamp–Samii score system.ResultsSixteen patients harboring cervical schwannomas were treated from 2003 to 2009. Hemilaminectomy was performed in eight cases, subtotal hemilaminectomy in four cases, interlaminar fenestration in two cases, osteoplastic hemilaminotomy and laminoplasty in one case each. Postoperative neuroimaging revealed complete removal of the lesion and no signs of spinal instability. At discharge, neurological improvement was observed in 14 patients and all patients demonstrated reduction of VAS score and improvement of KPS and Klekamp–Samii’s score.ConclusionsMinimal access procedures are increasingly gaining popularity but their use is poorly described in the treatment of cervical tumors. Less invasive approaches may effectively be used instead of traditional laminectomy in the treatment of cervical tumors, especially schwannomas, providing less iatrogenic traumatism and preventing postsurgical spinal instability. Modern neuroimaging allows adequate preoperative planning and microsurgical techniques provide adequate execution of the surgical act. The procedure has to be tailored case by case considering the specific lesional features and the individual anatomical situation.

Parasagittal meningiomas: Our surgical experience and the reconstruction technique of the superior sagittal sinus

Background: The radical resection of parasagittal meningiomas without complications and recurrences is the goal of the neurosurgeon. Nowadays, different managements are proposed. This study describes our surgical technique during the lesional excision and the reconstruction of the superior sagittal sinus (SSS). Methods: The total removal (Simpson I and II) of parasagittal meningiomas (WHO grade I and II) was obtained in 75 patients from September 2000 to January 2010. The indocyanine green videoangiography was used before the dural opening and, when necessary, to identify and preserve the cortical veins. The surgery of the SSS was performed in accordance with Sindous classification, and its reconstruction was achieved through the use of a patch of galea capitis. Results: We had no cases of recurrence and thrombotic occlusion of the SSS in 5 years after the reconstruction. No complications were observed in 65 patients, and no cases of mortality were reported. Neurological focal deficits were observed in 5 patients. A brain swelling and a venous infarction were observed in 1 patient. Only one case of thrombotic occlusion was observed. A cerebrospinal fluid leak was observed in 2 patients, and a systemic complication was found in 1 patient. Conclusion: Several factors contribute to the success of the parasagittal meningioma surgery. We consider the preservation of the cortical veins to be important, and, when possible, we recommend the reconstruction of the anterior third of the SSS. Our experience has led us to believe that until now surgery is a winning choice if practiced by expert hands.

Systemic sclerosis associated with colliquative necrosis in the cerebellum

Background: The scleroderma is a complex autoimmune collagen disorder that can affect many organs simultaneously, as it occurs in the systemic sclerosis (SS), or only the skin, as it occurs in the localized scleroderma (LS). The neurological presentation is extremely uncommon, and even more uncommon are the symptoms of the scleroderma in the cerebellum. Case Description: We report the case of a 56-year-old male with cerebellar lesions mimicking a brain abscess. After surgical excision, the histopathological diagnosis deposed for an ischemic necrosis caused by a vasculopathy. All the bacteriological and viral exams were negative, whereas the rheumatologic tests were compatible with the scleroderma pattern. Conclusion: Up to now, the literature has described only 5 cases of scleroderma in the posterior cranial fossa. The authors report a case of SS causing colliquative necrosis in the cerebellum. Pathogenetic mechanisms, clinical aspects, and radiological features are discussed along with the pertinent literature.

Cortical aneurysms of the middle cerebral artery: A review of the literature

Background: Middle cerebral artery (MCA) aneurysms constitute from 18–40% of all intracranial aneurysms. They are mainly found in the proximal and bifurcation tracts and only in the 1.1-1.7% of cases they are located in the distal segment. The authors report a case of a ruptured saccular cortical MCA aneurysm with unknown etiology. Case Description: A 53-year-old female was admitted with a sudden severe headache, nausea, vomiting, and a slight left hemiparesis. The computed tomography (CT) scan showed subarachnoid hemorrhage (SAH) in the left sylvian fissure and intracerebral hemorrhage (ICH) in the left posterior parietal area. The CT angiography (CTA) reconstructed with 3D imaging showed a small saccular aneurysm in the M4 segment in proximity of the angular area. A left parieto-temporal craniotomy was performed, the aneurysm was clipped and the ICH evacuated. The motor deficit was progressively recovered. At 3-month follow-up examination, the patient was asymptomatic and feeling well. Conclusions: In our opinion, surgery is the best choice for the treatment of ruptured M4 aneurysms with ICH, because it allows to evacuate the hematoma and to exclude the aneurysm from the intracranial circulation. In addition, we suggest both the use of the neuronavigation technique and of the indocyanine green videoangiography (ICGV) for the aneurismal surgery.

91. Multimodal intraoperative neurophysiological monitoring in AcoA aneurysms surgery: Personal experience

The treatment of AcoA aneurysms represents, actually, a great challenge for both neurosurgeon and neuroradiologist. Multimodal neurophysiologic monitoring is frequently used in aneurysm surgery for assessing the level of cerebroprotective anaesthesia and monitoring ischemia. The aim of this study was to determine the efficacy of electroencephalogram, somatosensory evoked potentials and motor evoked potentials for the detection and prediction of perforators ischemia during the AcoA aneurysms surgery, since in the literature there are no specific studies in this regard. From October 2009 to October 2012, 18 patients treated for surgical clipping of AcoA aneurysms underwent multimodal intraoperative neurophysiological monitoring. EEG, SEPs of bilateral median and tibial nerves, TcMEPs were recorded in all patients. A successful intraoperative monitoring of EEG, SEPs and MEPs was possible in all patients. In 5 cases impairments of the neurophysiological parameters were observed. Tibial nerve SEP changes occurred in 2 cases after the definitive aneurysm clipping and in 2 cases after the temporary clipping. In the case where a grade 3 SEP change was noted, the clip was promptly removed. In the remained cases, in the first instance the systemic blood pressure was increased, but in 3 cases a change in surgical maneuvers was necessary. In 3 cases TcMEP variations were noted, too. No post-operative deficits were seen as well as any radiological signs of ischemia. The findings of this our suggest that multimodal intraoperative neurophysiological monitoring is safe and reliable for detecting blood flow insufficiency in AcoA surgery.