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Background: Incidentally discovered low-grade gliomas (iLGGs) represent a rare neurological condition, which is associated with a good clinical status and usually preserved - or borderline - cognitive functions; only recently, knowledge has increased on their development and clinical features. Better understanding these aspects is fundamental to set up the most appropriate clinical protocol., Methods: We used fMRI to conduct an exploratory investigation of the effects of iLGG growth on the brain and the potential occurrence of early rearrangement in the functional network associated with object naming. We compared this group of 13 patients with an iLGG in the left hemisphere (maximum lesion overlap in the left inferior frontal gyrus and median tumor volume 12 cm 3 ) and with preserved naming skills with that of a healthy control group., Results: No significant differences were observed in the functional activations between the two groups, but a cluster in the controls vs. patients contrast mainly located in the right lateral visual cortex. As this region is unspecific for object naming and no significant changes emerged when checking for covariates, we concluded that iLGG growth did not affect the functional network and plasticity-related reorganization did not occur yet. We attributed this finding to iLGG features, such as small tumor size at the diagnosis and lack or minimal infiltration., Conclusions: These findings are preliminary, and we recommend future investigation to replicate them and test generalizability to other functional networks. Understanding the potential functional effects of iLGG growth is fundamental for the choice of the most appropriate treatment.

Background: The aim of this study was to understand the impact of SARS-COV-2 disease on neurosurgeons and our profession; specifically, to trace the role of women, in particular young neurosurgeons, in addressing this health emergency., Methods: This cross-sectional study evaluated the impact of SARS-COV-2 disease on Italian neurosurgeons stratified by gender (44 [49.9%] males and 49 [52.1%] females) enrolled through a questionnaire-based online survey., Results: Ninety-three Italian neurosurgeons were included in this study. The percentage of female participants was 52.1% (49) and 53% (50) were younger than 40 years. Men were significantly more affected than women by complications (14 versus 3), while there was no gender difference in the COVID-19 infection rate. Furthermore, the social impact of the pandemic was the same between men and women., Conclusions: Our analysis did not show significant differences between the two genders in the susceptibility, and mortality from COVID-19. The possible and immediate implementation of anti-COVID-19 measures and devices, associated with a lower risk of transmission in the treatment of neurosurgical pathologies, has likely, moderated and disregarded the socio-psychological "gender gap" of the Covid-19 pandemic.

Background: Incidentally discovered low-grade gliomas (iLGGs) are poorly reported in the literature and little is still known about their effects on white-matter structure. In this study, we investigated whether iLLG growth in either hemisphere could affect main white-matter association tracts and cortico-spinal tract., Methods: We retrospectively analyzed white-matter integrity in a group of 18 patients with iLGG having a mostly preserved cognitive status [1]. We identified two groups of patients, 13 having iLGG in left hemisphere (LH) and five in right hemisphere (RH) and maximum lesion overlap in inferior frontal gyrus and in medial frontal areas, respectively. A group of healthy controls (N.=20) was included. We carried out a univariate analysis of variance to inspect potential effect of interaction between hemisphere harboring the lesion (i.e., LH or RH) and hemisphere taken into account on number of streamlines and fractional anisotropy (FA) of reconstructed white-matter tracts., Results: The sole significant interaction concerned left arcuate fasciculus, with patients with iLGG in LH having a lower number of streamlines than healthy controls; interaction involving FA was not significant for any of the fascicles. Lack of any other significant findings indicates overall preserved white matter., Conclusions: iLGG size and growth pattern could explain why white-matter status did not markedly differ with respect to the healthy controls. Findings therefore support evidence that iLGGs represent the earlier phase in natural history of LGGs and are discussed in a clinical perspective and in support to safe early surgery.

Background: Decades of therapeutic and molecular refinements, the prognosis of patients with glioblastoma (GBM) still remains unfavorable. Integrative clinical studies allow a better understanding of the natural evolution of GBM. To assess independent predictors of overall survival (OS) and progression free survival (PFS) clinical, surgical, molecular and radiological variables were evaluated. A novel preoperative volumetric magnetic resonance imaging (MRI) Index for tumor prognosis in GBM patients was investigated., Methods: A cohort of 195 cases of patients operated for newly GBM were analyzed. Extent of tumoral resection (EOR), tumor growth pattern, expressed by preoperative volumetric ΔT1-T2 MRI Index, molecular markers such as O6-methylguanine-DNA methyltransferase (MGMT) methylation and isocitrate dehydrogenase 1/2 (IDH1/2) mutation, were analyzed. Analysis of survival was done using Cox-proportional hazard models., Results: The 1-, 2- years estimated OS and PFS rate for the whole population were 61% and 27%, 38% and 17%, respectively. A better survival rate, both in terms of survival and tumor progression, was observed in patient with higher EOR (P=0.000), younger age (P=0.000), MGMT methylation status (P=0.001) and lower preoperative ΔT1-T2 MRI Index (P=0.004). Regarding the tumor growth pattern a cut-off value of 0.75 was found to discriminate patient with different prognosis. Patients with a preoperative ΔT1-T2 MRI Index <0.75 had a 1-year estimated OS of 67%, otherwise patients with a preoperative ΔT1-T2 MRI Index >0.75 had a 1-year estimated OS of 34%., Conclusions: In this investigation longer survival is associated with younger age, EOR, promoter methylation of MGMT and preoperative tumor volumetric features expressed by ΔT1-T2 MRI Index The preoperative ΔT1-T2 MRI Index could be a promising prognostic factor potentially useful in GBM management. Future investigations based on multiparametric MRI data and next generation sequences analysis, may better clarify this result.

The Coronavirus (COVID-19) pandemic has fast spread throughout the world in more than 200 countries, resulting in the need for a de-prioritization of elective medical care to face the demands of the global health crisis. Although the acute and catastrophic phase of the pandemic seems to have been left behind, it is also clear that the virus will not disappear soon, and we must live with it for a period of unpredictable length, the COVID-19 era. In this setting, a common coordinated approach to treat patients harboring brain tumors is urgently required to guarantee the best updated oncological care and to reduce the risk of viral infection during hospitalization. The study group on Neuro-oncology of Italian Society of Neurosurgery, SINCh gathered pieces of evidence and data and would like to suggest a practice protocol of care for neurosurgical oncologic procedures in the COVID-19 era. The present document aimed at summarizing current evidence and expert opinions to help neurosurgeons in taking decisions on their patients harboring different brain tumors.

In 2018, the SINch (Italian Society of Neurosurgery) Neuro-Oncology Section, AINO (Italian Association of Neuro-Oncology) and SIN (Italian Association of Neurology) Neuro-Oncology Section formed a collaborative Task Force to look at the diagnosis and treatment of low-grade gliomas (LGGs). The Task Force included neurologists, neurosurgeons, neuro-oncologists, pathologists, radiologists, radiation oncologists, medical oncologists, a neuropsychologist and a methodologist. For operational purposes, the Task Force was divided into five Working Groups: diagnosis, surgical treatment, adjuvant treatments, supportive therapies, and follow-up. The resulting guidance document is based on the available evidence and provides recommendations on diagnosis and treatment of LGG patients, considering all aspects of patient care along their disease trajectory.

Background: Increasing the extent of resection (EOR) is considered a main goal in high grade glioma (HGG) surgery. Significant advancements have been recently made to assist surgery: namely the use of 5-aminolevulinic acid (5ALA) and the application of contrast-enhanced ultrasound (CEUS) embody two of the most recently introduced tools in the neuro-oncology field. A combined approach including the two techniques has been suggested in literature. Our primary aim is to identify in which conditions CEUS final survey has a real impact in a 5-ALA guided context and assess which preoperative tumor characteristics, with specific attention to working corridors can predict strains of the fluorescence guided procedure and hence recommend the use of the combined technique., Methods: Forty-nine HGG glioma surgeries were performed at our institution with the abovementioned protocol between January 2016 and June 2016. Based on preoperative MRI, we stratified glioma characteristics according to three determinants: localization (deep versus superficial), size (<3.5 versus >3.5 cm) and shape (regular versus irregular)., Results: CEUS modified 5-ALA guided resection in 11 cases (22.45%): this appeared to be associated with statistically significance to deep tumor localization (P=0.04) and irregular/multi-lobulated margins (P=0.003). On the other hand, tumor size alone did not appear as a statistically significant determinant., Conclusions: When dark corridors are presents or when overlying brain parenchyma hinders illumination, drawbacks to the 5-ALA assistance can be expected, hence CEUS final survey has a crucial role of 'refinement'. In those selected cases, an integrated 5ALA+CEUS protocol was shown as advisable in EOR improvement.

Indocyanine green video angiography (ICG-VA) is a non-invasive, easy to use and very useful tool for various neurosurgical procedures. The first application was in neurovascular surgery, because it was born as an intravascular tracer for vessels visualization; this has been really useful in aneurysms, atero-venous malformations (AVMs) and dural fistulas surgery where identification, obliteration or patency of vessels is essential. Introduced in vascular neurosurgery since 2003, ICG-VA applications have broadened over time, both in vascular and in other neurosurgical fields. In 2003 Raabe et al. have been the first to describe the use of ICG-VA for intraoperative assessment of cerebral vascular flow, enabling visualization of vessel patency and aneurysm occlusion during aneurysm surgery. ICG-VA applications in vascular neurosurgery have significantly increased over time including complex aneurysms, bypass, atero-venous malformations (AVM) artero-venous fistulas (AVF), evaluation of cortical perfusion. The procedure can be easily repeated after 5-10 minutes. Adverse reactions are comparable to those of other types of contrast media, with frequencies of 0.05% (hypotension, arrhythmia, or, more rarely, anaphylactic shock) to 0.2% (nausea, pruritus, syncope, or skin eruptions. The aim of the present study was to systematically analyze ICG-VA applications in vascular neurosurgery, highlighting the reported advantages and disadvantages, and discussing future perspectives.

Achieving a safe and extensive neoplasm resection can be considered the main goal of brain tumor surgery. This paper is first aimed at providing an overview of the evolution of those tools serving the purpose. From the dawn of neurosurgery to the present days, major innovations have followed one another. However, those techniques may frequently lack of an instant biological feedback on the true extension and the infiltration of the tumor. Intraoperative fluorescence modalities could indeed fill this gap. Fluorescence guided surgery will be therefore introduced and discussed in this context. Our focus will be on the most common fluorescence techniques used in neurosurgery, namely 5-aminolevulinic acid, sodium fluorescein and in indocyanine green. Mode of action, strengths and weaknesses and level of evidence of each modality will be discussed.