Slit-like hypertensive hydrocephalus: Report of a late, complex, and multifactorial complication in an oncologic patient

Bilateral post-traumatic hygromas in patient with frontotemporal dementia

Background

Frontotemporal dementia (FTD) is a highly disabling neurologic disorder characterized by behavioral alterations and movement disorders, involving patients with a mean age of 58 years. We present a unique case of a patient suffering from FTD who developed post traumatic bilateral hygromas.

Case Description

A 52-year-old male patient, with an history of head trauma 3 months before, was admitted to our department for recurrent motor seizures. Anamnesis was positive for FTD with severe frontal syndrome. Brain computed tomography and magnetic resonance imaging (MRI) showed the typical "knife-blade" appearance of the cortical atrophy associated to bilateral hemispheric hygromas exerting mild mass effect. Brain MRI showed the signs of the cortical and "anti-cortical" vein. The two subdural collections were evacuated through two bilateral burr holes and controlled drainage. Despite anti-epileptic drugs therapy, in the early postoperative period, the patient presented further tonic-clonic seizures. The patient showed progressive recovery and was transferred to the neurorehabilitation center. After 6-month follow-up, he completely recovered.

Conclusion

In FTD, severe cortical atrophy leads to space increase between arachnoid and pia mater that could affect the anatomical integrity especially after trauma, with possible development of hygromas. The coexistence of radiological findings of the cortical vein and sign of the "anti-cortical" vein can make difficult an exact differential diagnosis between a primitive hygroma and a Virchow hygroma from resorption of previous blood collection. Surgical treatment may be indicated in selected patients, but it is burdened by higher postoperative risks compared to the general population.

Esthesioneuroblastoma with recurrent dural metastases: Long-term multimodality treatment and considerations

Background:

Esthesioneuroblastoma (ENB) is a rare malignant disease and treatment protocols have not been standardized, varying widely by disease course and institutional practices. Management typically includes wide local excision through open or endoscopic resection, followed by radiotherapy, chemotherapy, and stereotactic radiosurgery. Tumor control can differ on a case-by-case basis. Herein, the complex management of a rare case of recurrent disease with multiple dural metastases is presented.

Case Description:

A 60-year-old patient was diagnosed with ENB after presenting with anosmia and epistaxis. The patient underwent combined endonasal and transfrontal sinus craniofacial resection, followed by proton beam radiation therapy and chemotherapy. Subsequently, he developed a total of 25 dural metastases that were controlled with repeated Gamma Knife Radiosurgery (GKRS). In spite of post-treatment course that was complicated by radiation necrosis and local vasculopathy, the patient made significant recovery to functional baseline.

Conclusion:

The management of ENB entails multimodality and multidisciplinary care, which can help patients obtain disease control and long-term survival. Recurrent ENB dural metastases can behave as oligometastatic disease manageable with aggressive focal GKRS. As prognosis continues to improve, chronic treatment effects of radiation in such cases should be taken into consideration.

Cerebrospinal Fluid Leaks After Anterior Skull Base Trauma: A Systematic Review of the Literature

BACKGROUND

Anterior skull base (ASB) fractures are reported in 4% of head injuries and represent 21% of all skull fractures. Cerebrospinal fluid (CSF) leaks may follow, severely exacerbating outcomes. We systematically reviewed the literature to analyze and compare the roles of endoscopic surgery, open surgery, and combined approaches in the management of CSF leak repair after posttraumatic ASB fractures.

METHODS

PubMed, Web of Science, and Scopus databases were searched in accordance with the PRISMA guidelines. Studies reporting clinical data of patients with CSF leaks after ASB fracture were reviewed, focusing on management strategies and posttreatment outcomes.

RESULTS

We included 29 articles comprising 888 patients. The average age at diagnosis was 34 years (range, 18-91 years), with a male predominance (54%) and a male/female ratio of 2.9:1 (647:241). Clinical data were available for 888 patients with CSF leaks after ASB fracture, reporting a median follow-up time of 33.5 months (standard deviation, ±29; range, 0.5-330.0 months). Open surgical repair was the most common approach (67.9%), followed by endoscopic surgical repair (32.1%). The endoscopy cohort showed lower rates of complications (0.7% vs. 11.1%) and fistula recurrence (2.8% vs. 5.3%) compared with open surgery.

CONCLUSIONS

ASB fractures are frequently treated as late surgery, 24 hours from injury or later, especially for endoscopic surgery. Overall, the endoscopic approach is preferred, mostly because of its safety and effectiveness, offering lower failure rates than does open surgery.

A rare diagnosis of an extraventricular neurocytoma

Background:

Extraventricular neurocytoma (EVN) is an extremely rare neoplasm of the central nervous system. As reported, it arises in a variety of locations, but mainly within the cerebral hemispheres. Despite its histological similarity with central neurocytoma (CN), EVN occurs outside the ventricular system and, in 2007, was recognized by the World Health Organization as a separate entity.

Case Description:

A 39-year-old man, with a ventriculoperitoneal shunt inserted for communicating hydrocephalus, was admitted at our Unit of Neurosurgery with a 1-month history of gait disturbance, postural instability, speech disorders, and occasional incontinence. Computed tomography scan and magnetic resonance imaging showed a mixed-density neoplasm in the left frontotemporal area, with anterior cerebral falx shift, and perilesional edema. The patient underwent surgical procedure; microsurgical excision of the lesion was performed through left pterional approach. Histopathological and immunohistochemical examination revealed monomorphic round cells of the neuronal lineage, with a percentage of Ki-67 positive nuclei <5% and no evidence of mitosis or necrotic areas. According to radiologic features, this pattern was compatible with the diagnosis of EVN. Patient had a favorable recovery and he is still in follow-up.

Conclusion:

Because of their rarity, clinical, radiologic, and histopathological characteristics of EVNs are not yet well defined, as well as the optimal therapeutic management. Whereas EVNs are rarely described in literature, we aimed to share and discuss our experience along with a review of the published literature.

Navigated Transcranial Magnetic Stimulation Motor Mapping Usefulness in the Surgical Management of Patients Affected by Brain Tumors in Eloquent Areas: A Systematic Review and Meta-Analysis

Background: The surgical strategy for brain glioma has changed, shifting from tumor debulking to a more careful tumor dissection with the aim of a gross-total resection, extended beyond the contrast-enhancement MRI, including the hyperintensity on FLAIR MR images and defined as supratotal resection. It is possible to pursue this goal thanks to the refinement of several technological tools for pre and intraoperative planning including intraoperative neurophysiological monitoring (IONM), cortico-subcortical mapping, functional MRI (fMRI), navigated transcranial magnetic stimulation (nTMS), intraoperative CT or MRI (iCT, iMR), and intraoperative contrast-enhanced ultrasound. This systematic review provides an overview of the state of the art techniques in the application of nTMS and nTMS-based DTI-FT during brain tumor surgery.

Materials and Methods: A systematic literature review was performed according to the PRISMA statement. The authors searched the PubMed and Scopus databases until July 2020 for published articles with the following Mesh terms: (Brain surgery OR surgery OR craniotomy) AND (brain mapping OR functional planning) AND (TMS OR transcranial magnetic stimulation OR rTMS OR repetitive transcranial stimulation). We only included studies regarding motor mapping in craniotomy for brain tumors, which reported data about CTS sparing.

Results: A total of 335 published studies were identified through the PubMed and Scopus databases. After a detailed examination of these studies, 325 were excluded from our review because of a lack of data object in this search. TMS reported an accuracy range of 0.4–14.8 mm between the APB hotspot (n1/4 8) in nTMS and DES from the DES spot; nTMS influenced the surgical indications in 34.3–68.5%.

Conclusion: We found that nTMS can be defined as a safe and non-invasive technique and in association with DES, fMRI, and IONM, improves brain mapping and the extent of resection favoring a better postoperative outcome.

Brain Mapping-Aided SupraTotal Resection (SpTR) of Brain Tumors: The Role of Brain Connectivity

Brain gliomas require a deep knowledge of their effects on brain connectivity. Understanding the complex relationship between tumor and functional brain is the preliminary and fundamental step for the subsequent surgery. The extent of resection (EOR) is an independent variable of surgical effectiveness and it correlates with the overall survival. Until now, great efforts have been made to achieve gross total resection (GTR) as the standard of care of brain tumor patients. However, high and low-grade gliomas have an infiltrative behavior and peritumoral white matter is often infiltrated by tumoral cells. According to these evidences, many efforts have been made to push the boundary of the resection beyond the contrast-enhanced lesion core on T1w MRI, in the so called supratotal resection (SpTR). SpTR is aimed to maximize the extent of resection and thus the overall survival. SpTR of primary brain tumors is a feasible technique and its safety is improved by intraoperative neuromonitoring and advanced neuroimaging. Only transient cognitive impairments have been reported in SpTR patients compared to GTR patients. Moreover, SpTR is related to a longer overall and progression-free survival along with preserving neuro-cognitive functions and quality of life.

Focused Ultrasound in Neuroscience. State of the Art and Future Perspectives

Transcranial MR-guided Focused ultrasound (tcMRgFUS) is a surgical procedure that adopts focused ultrasounds beam towards a specific therapeutic target through the intact skull. The convergence of focused ultrasound beams onto the target produces tissue effects through released energy. Regarding neurosurgical applications, tcMRgFUS has been successfully adopted as a non-invasive procedure for ablative purposes such as thalamotomy, pallidotomy, and subthalamotomy for movement disorders. Several studies confirmed the effectiveness of tcMRgFUS in the treatment of several neurological conditions, ranging from motor disorders to psychiatric disorders. Moreover, using low-frequencies tcMRgFUS systems temporarily disrupts the blood-brain barrier, making this procedure suitable in neuro-oncology and neurodegenerative disease for controlled drug delivery. Nowadays, tcMRgFUS represents one of the most promising and fascinating technologies in neuroscience. Since it is an emerging technology, tcMRgFUS is still the subject of countless disparate studies, even if its effectiveness has been already proven in many experimental and therapeutic fields. Therefore, although many studies have been carried out, many others are still needed to increase the degree of knowledge of the innumerable potentials of tcMRgFUS and thus expand the future fields of application of this technology.