Roberto Stefini

Use of "custom made" porous hydroxyapatite implants for cranioplasty: postoperative analysis of complications in 1549 patients.

Background: Cranioplasty is a surgical intervention aimed at reestablishing the integrity of skull defects, and should be considered the conclusion of a surgical act that began with bone flap removal. Autologous bone is still considered the treatment of choice for cranioplasty. An alternative choice is bioceramic porous hydroxyapatite (HA) as it is one of the materials that meets and comes closest to the biomimetic characteristics of bone. Methods: The authors analyzed the clinical charts, compiled by the neurosurgeon, of all patients treated with custom-made porous HA devices (Custom Bone Service Fin-Ceramica, Faenza) from which epidemiological and pathological data as well as material-related complications were extrapolated. Results: From November 1997 to December 2010, 1549 patients underwent cranioplasty with the implantation of 1608 custom-made porous HA devices. HA was used in 53.8% of patients for decompressive craniectomy after trauma or intracranial hemorrhage, while the remaining cases were for treated for comminuted fracture, cutaneous or osseous resection, cranial malformation, autologous bone reabsorption or infection or rejection of previously implanted material. The incidence of adverse events in patients treated for cranioplasty, as first line treatment was 4.78% (56 events/1171 patients), and 5.02%, (19 events/378 patients) at second line. Conclusion: This study demonstrates that HA is a safe and effective material, is well tolerated in both adult and pediatric patients, and meets the requirements necessary to repair craniolacunia.

Ruptured Aneurysm in Sphenoid Sinus: Which Is the Best Treatment?

Internal carotid artery (ICA) aneurysms involving the sphenoid sinus are uncommon, and their optimal treatment remains debated. We report the case of a patient presenting with recurrent epistaxis due to a bleeding cavernous ICA aneurysm. We suggest a combined endovascular and endoscopic approach when ICA occlusion may not be performed.

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.

Dorsal paddle leads implant for spinal cord stimulation through laminotomy with midline structures preservation

Background: Pain relief obtained with spinal cord stimulation (SCS) in failed back surgery syndrome (FBSS) has been shown to be more effective with paddle leads than with percutaneous catheters. A laminectomy is generally required to implant the paddles, but the surgical approach may lead to iatrogenic spinal instability in flexion. In contrast, clinical and experimental data showed that a laminotomy performed through flavectomy and minimal resection of inferior and superior lamina with preservation of the midline ligamentous structures allowed to prevent iatrogenic instability. Aim of the study was to assess degree of instability and pain level in patients operated for SCS through laminectomy or laminotomy with midline structures integrity. The surgical technique is described and our preliminary results are discussed. Methods: Nineteen patients with FBSS underwent SCS, 12 through laminectomy and 7 through uni- or bilateral interlaminotomy with supraspinous ligament preservation. Postoperative local pain was evaluated at 15, 30, and 60 days. Static and dynamic X-rays were performed after 2 months. Results: The techniques allowed implanting the paddle leads in all cases. No intraoperative complications occurred. Local pain was higher and recovery time was longer in patients with laminectomy. We did not observe radiological signs of postoperative iatrogenic vertebral instability. Nevertheless, two patients who underwent laminectomy showed persistence of local pain after 2 months probably due to pathologic compensatory stability provided by the paraspinal musculature. Conclusions: The laminotomy is a minimally invasive approach that ensures rapid recovery after surgery, spinal functional integrity, and complete reversibility. Further studies are needed to confirm our preliminary results.

Post-neurosurgical meningitis: Management of cerebrospinal fluid drainage catheters influences the evolution of infection

Background: In order to better define the pathogenic role of cerebrospinal fluid (CSF) drainage catheters in postoperative patients, we comparatively analyze the clinical course of device and non-device-related meningitis. Methods: This is an observational, partially prospective, study on consecutive adult patients who developed meningitis after undergoing neurosurgical procedures at the Neurosurgery and Neurointensive care Departments, Spedali Civili, Brescia, Italy, between January 1999 and August 2007. Results: All 77 consecutive post-neurosurgical meningitis events in 65 patients were included in the analysis. Most were classified as external ventricular drainage (EVD)-related meningitis (23 cases, group A), external spinal drainage (ESD)-related meningitis (12 cases, group B), and non-device-related post-neurosurgical meningitis (30 cases, group C). Proven meningitis was identified in 78.3%, 91.7% and 56.7% of the events, respectively. ESD-related meningitis had a shorter onset time vs EVD and non-device-associated meningitis (3 days versus 6 and 7 days, respectively). Median antibiotic treatment duration was 20, 17, and 22.5 days in groups A, B, and C, respectively. Overall, 8 patients (34.8%) in group A, 3 (25.0%) in group B, and 3 (10.0%) in group C died. Median time to become afebrile was shorter in group C than in group A (10 days versus 12 days, P = 0.04). Removal of the device later than 48 hours after meningitis onset, as well as implantation of a second device were associated with a slower time of meningitis resolution. Conclusions: Early device removal and avoiding implantation of a second device were associated with short illness duration. Larger studies are warranted to confirm the conclusions of this study.

Enhancing dermal and bone regeneration in calvarial defect surgery

Introduction: To optimize the functional and esthetic result of cranioplasty, it is necessary to choose appropriate materials and take steps to preserve and support tissue vitality. As far as materials are concerned, custom-made porous hydroxyapatite implants are biomimetic, and therefore, provide good biological interaction and biointegration. However, before it is fully integrated, this material has relatively low mechanical resistance. Therefore, to reduce the risk of postoperative implant fracture, it would be desirable to accelerate regeneration of the tissues around and within the graft. Objectives: The objective was to determine whether integrating growth-factor-rich platelet gel or supportive dermal matrix into hydroxyapatite implant cranioplasty can accelerate bone remodeling and promote soft tissue regeneration, respectively. Materials and Methods: The investigation was performed on cranioplasty patients fitted with hydroxyapatite cranial implants between 2004 and 2010. In 7 patients, platelet gel was applied to the bone/prosthesis interface during surgery, and in a further 5 patients, characterized by thin, hypotrophic skin coverage of the cranial lacuna, a sheet of dermal matrix was applied between the prosthesis and the overlying soft tissue. In several of the former groups, platelet gel mixed with hydroxyapatite granules was used to fill small gaps between the skull and the implant. To confirm osteointegration, cranial computed tomography (CT) scans were taken at 3-6 month intervals for 1-year, and magnetic resonance imaging (MRI) was used to confirm dermal integrity. Results: Clinical examination performed a few weeks after surgery revealed good dermal regeneration, with thicker, healthier skin, apparently with a better blood supply, which was confirmed by MRI at 3-6 months. Furthermore, at 3-6 months, CT showed good biomimetism of the porous hydroxyapatite scaffold. Locations at which platelet gel and hydroxyapatite granules were used to fill gaps between the implant and skull appeared to show more rapid integration of the implant than untreated areas. Results were stable at 1-year and remain so to date in cases where follow-up is still ongoing. Conclusions: Bone remodeling time could be reduced by platelet gel application during cranioplasty with porous hydroxyapatite implants. Likewise, layering dermal matrix over such implants appears to promote dermal tissue regeneration and the oshtemo mimetic process. Both of these strategies may, therefore, reduce the likelihood of postsurgical fracture by promoting mechanical resistance.

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.

Unruptured Versus Ruptured AVMs: Outcome Analysis from a Multicentric Consecutive Series of 545 Surgically Treated Cases

BACKGROUND Recent literature strongly challenged indications to perform preventive surgery in unruptured arteriovenous malformation (AVM) claiming that invasive AVM treatment is associated with a significant risk of complications and thus conservative management may be a preferable alternative in many patients. On the other hand, the recent improvement of surgical instrumentation and treatment strategies (both surgical and interventional) yielded better outcomes than those achieved only a decade ago. Therefore, even among specialists, a wide variety of opinions, concerning the treatment of unruptured AVM, can be found. METHODS This multicenter retrospective study analyzes a consecutive series of 545 surgically treated AVMs in 10 different hospitals in Italy. RESULTS Patients with AVMs treated after hemorrhage had an unfavorable (modified Rankin Scale score >1) outcome in more than one third (37.69%) of the cases. Conversely, with proper indications, unruptured AVMs treated preventively have a good outcome in 93.8% of cases, increasing to 95.7%, with no death, if only Spetzler-Martin grades 1-3 are considered (P < 0.05). Outcomes on discharge significantly (P < 0.05) improve at 6 months with the disappearance of many of the initial neurologic deficits that turn out to be transient. CONCLUSIONS In unruptured low-risk AVMs (Spetzler-Martin grades 1-3), over time, the risk of surgery-associated neurologic deficits becomes lower than that linked to spontaneous hemorrhage, with a crossover point at 6.5 years. Because the average bleeding age is less than 45 years, preventive surgery can be advocated to safeguard the patient and overcome the risks associated with the natural history of AVMs.

Meningiomas in the canyon: The choice between subcranial trans frontal sinus (TfSA) and endonasal approach (EEa)

Objective: The aim of this study is to present our surgical experience in removal of anterior fossa midline meningiomas (AmM) using the EEa or the TfSa and underline surgical criterias and technical advantages based on anatomical considerations. Method: 54 patients with AmM underwent surgery with[for full text, please go to the a.m. URL]

Letter to the Editor: CSF leak in transsphenoidal surgery

TO THE EDITOR: We read with great interest the article by Mehta and Oldfield2 (Mehta GU, Oldfield EH: Prevention of intraoperative cerebrospinal fluid leaks by lumbar cerebrospinal fluid drainage during surgery for pituitary macroadenomas. J Neurosurg 116:1299–1303, June 2012). The authors investigated the role of lumbar drainage in transsphenoidal surgery, comparing the results of 114 operations without an intraoperative CSF drain to 44 cases in which a lumbar subarachnoid catheter was placed before surgery to drain CSF at the time of tumor removal. The intraoperative CSF leak rate was significantly lower when the spinal drain was used; the postoperative CSF leak rate was the same (5%) in the both groups. The authors’ conclusion is that intraoperative CSF drainage is useful, low risk, and obviates the need for sellar repair by lowering the intraoperative incidence of CSF leakage. The article is of great interest because it provides new data to add to the ongoing discussion on the use of CSF drainage in transsphenoidal surgery. Most advocates stress the usefulness of lowering intracranial pressure (ICP) to allow a definitive sealing of the subarachnoid space; opponents underline the possible risks of lumbar drainage and the lack of clear indications for it. The authors support its use because it lowers the incidence of intraoperative CSF leaks and therefore diminishes the need of sellar reconstruction. Examining the article’s data, though, this conclusion does not seem to be supported; furthermore, some data, which would add even more value to the paper, are missing. The most important clinical outcome reported by Mehta and Oldfield is that the rate of postoperative CSF leak does not decrease in the group with intraoperative drainage compared to the group without it; the rate was 5% in both groups. This might have two possible explanations: 1) the evidence of intraoperative CSF leaks in patients with lumbar drain is underestimated because of CSF diversion during surgery; 2) although the incidence of intraoperative CSF leaks is really lower, some other factors lead to postoperative leakage. The authors do not dwell on sellar packing, but they report that sellar reconstruction was performed less frequently when CSF diversion was used intraoperatively. Could this be the reason for the postoperative CSF leak? In Fig. 1 of their paper, the authors depict the physiopathogenesis of low-flow CSF leaks in transsphenoidal surgery: the removal of a macroadenoma leads to the descent of the suprasellar arachnoid, which then “weeps.” If sellar reconstruction is not performed in these cases, one could assume that a Valsalva maneuver (e.g., during extubation, coughing, or sneezing) might breach the arachnoid that is not supported. We could then interpret the reported data as support for sellar reconstruction rather than for CSF diversion (Fig. 1). This was indeed the case in our clinical practice: When we were not systematically using sellar packing with the endoscopic approach, we observed a postoperative CSF leak in a patient in whom no intraoperative CSF leakage occurred; postoperatively, the patient developed pneumonia, with persistent coughing, and subsequent evidence of a CSF leak. In other words, if the incidence of postoperative CSF leakage is the same regardless of whether we use an intra-