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Prostate carcinoma rarely develops intracranial metastasis. In case it does, the dura is the most affacted area. In general, brain computed tomography (CT) findings mimic subdural hematoma making surgery challenge. We report the case of a 52-year-old male, presented as an emergency with a month history of headache, progressive temporospatial disorientation, mental confusion, and abrupt consciousness deterioration up to coma occurring few hours prior admission. An urgent brain CT scan showed a subdural collection in favor of a chronic subdural hematoma. The patient underwent surgery by standard burr hole, and surprisingly, peroperatively, there was a very bloody diffuse thickening of the dura without a real hematoma obliging to switch to a large fronto-temporoparietal craniotomy revealing a subdural mass that was completely removed. Histopathology disclosed a metastatic prostatic carcinoma confirming that such a subdural collection could behave as a great simulator. A contrast brain CT scan, is advisable, even in emergency, in selected case, with atypical images finding, especially if, a malignant disease is already known; the former could be of great help in the differential diagnosis and the best prompt management.

Object Transtentorial brain herniation is a major cause of morbidity and death following severe closed head injury. The purpose of this study was to evaluate the efficacy of selective uncoparahippocampectomy and tentorial splitting as an adjuvant method of treating otherwise uncontrollable elevated intracranial pressure (ICP) while attempting to prevent or minimize the devastating consequences caused by transtentorial herniation. Methods The authors retrospectively reviewed data from a series of 80 consecutive cases of severe closed head injury (Glasgow Coma Scale [GCS] score Results All injuries were caused by blunt trauma with signs of acute and/or progressive increased ICP causing downward transtentorial herniation. Fifty-eight patients were male and 22 were female with a mean age of 35 years and a mean preoperative GCS score of 5. Based on the current American Association of Neurological Surgeons guidelines for head trauma, an intraparenchymal ICP device (Camino, Integra) was placed in all patients who had a GCS score 20 cm H2O. Whenever possible, risks and benefits were explained to family members, and then surgery was performed within 3–16 hours (median 6 hours). At a mean follow-up of 30 months, the outcome was favorable (Glasgow Outcome Scale [GOS] score of 4 or 5) in 60 patients (75%) and unfavorable (GOS score of 3) in 8 (10%), whereas the remaining 12 patients (15%) died at some point during the postoperative course. There was no survivor patient in a vegetative state. A younger age had a significant effect on positive outcome (p < 0.0005), as did an earlier operation (p < 0.04). The preoperative neurological status as assessed using the GCS as well as pupillary reactivity had no significant effect on outcome (p = 0.054 and p > 0.05, respectively). Conclusions A selective uncoparahippocampectomy with a tentorial edge incision and a wide decompressive craniectomy with duraplasty can be an effective adjuvant form of aggressive treatment to improve outcome in patients with severe closed head injury, especially in those who are younger if they are treated promptly.

Background: Decompressive craniectomy (DC) is a procedure performed increasingly often in current neurosurgical practice. Significant perioperative morbidity may be associated to this procedure because of the large skull defect; also, later closure of the skull defect (cranioplasty) may be associated to post‑operative morbidity as much as any other reconstructive operation. The authors present a newly conceived/developed device: The “Skull Flap” (SF). This system, placed at the time of the craniectomy, offers the possibility to provide cranial reconstruction sparing patients a second operation. In other words, DC and cranioplasty essentially take place at the same time and in addition, patients retain their own bone flap. The current study conducted on animal models, represents the logical continuation of a prior recent study, realized on cadaver specimens, to assess the efficacy and safety of this recently developed device. Materials and Methods: This is an experimental pilot study on dogs to assess both safety and efficacy of the SF device. Two groups of experimental raised intracranial pressure animal models underwent DC; in the first group of dogs, the bone flap was left in raised position above the skull defect using the SF device; on the second group the flap was discarded. All dogs underwent transcranial Doppler (TCD) to assess brain perfusion. Head computed tomography (CT) scan to determine flap position was also obtained in the group in which the SF device was placed. Results: SF has proved to be a strong fixation device that allows satisfactory brain decompression by keeping the bone flap elevated from the swollen brain; later on, the SF allows cranial reconstruction in a simple way without requiring a second staged operation. In addition, it is relevant to note that brain perfusion was measured and found to be better in the group receiving the SF (while the flap being in a raised as well as in its natural position) comparing to the other group. Conclusion: The SF device has proved to be very easy to place, well‑adaptable to a different type of flaps and ultimately very effective in maintaining satisfactory brain decompression and later on, making easy bone flap repositioning after brain swelling has subsided.

Background. The authors describe a lateral approach to the cervical spine for the management of spondylotic myeloradiculopathy. The rationale for this approach and surgical technique are discussed, as well as the advantages, disadvantages, complications, and pitfalls based on the author's experience over the last two decades.Methods. Spondylotic myelo-radiculopathy may be treated via a lateral approach to the cervical spine when there is predominant anterior compression associated with either spine straightening or kyphosis, but without vertebral instability.Results. By using a lateral approach, the lateral aspect of the cervical spine and the vertebral artery are easily reached and visualized. Furthermore, the lateral part of the affected intervertebral disc(s), uncovertebral joint(s), vertebral body(ies), and posterior longitudinal ligament can be removed as needed to decompress nerve root(s) and/or the spinal cord.Conclusion. Multilevel cervical oblique corpectomy and/or lateral foraminotomy allow wide decompression of nervous structures, while maintaining optimal stability and physiological motion of the cervical spine.

Objective: This study aims to provide morphometric analysis of endoscopic endonasal approach (EEA) to ventral-medial portion of posterior paramedian skull base (VMPPSB). Furthermore, it aims to investigate the surgical exposure obtained through EEA with and without Eustachian tube (ET) removal, emphasizing the role of contralateral nostril (CN) access. Methods: Five fresh adult head specimens were prepared for dissection. A pre-dissection and a post-dissection CT study was performed. A surgically oriented classification into 4 regions was used: 1) tubercular region; 2) occipital condyle region; 3) parapharyngeal space (PPhS) region; 4) jugular foramen (JF) region. Student's t-test was used to compare angulations and measures of EEA with access from the ipsilateral and CN, respectively with and without ET removal. Results: EEA to VMPPSB encompasses two medial trajectories (transtubercular and transcondylar) and two lateral pathways to PPhS and JF. The CN access, without removal of ET, allows a complete exposure of petrous and intrajugular portion of JF and superior PPhS without exposition of parapharyngeal segment of internal carotid artery. The ipsilateral nostril approach with ET removal allows to obtain a wider exposure, reaching medial sigmoid part of JF. No significant differences exist in regards to transtubercular and transcondylar approaches. Conclusions: This study suggests that EEA to PPSB allow the realization of a corridor directed to jugular tubercle, occipital condyle, medial parapharyngeal space and ventral-medial JF. The CN approach with ET preservation can expose petrous and intrajugular parts of JF and PPhS. Case series are needed to demonstrate benefits and drawbacks of these approaches.