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The treatment strategy for thoracolumbar burst fractures is still debated. The aim of this study is to evaluate clinical and radiologic outcomes of a 2-stage strategy with immediate posterior percutaneous instrumentation and delayed anterolateral fusion (group A) versus a single-stage open posterior instrumented fusion (group B).Demographics and clinical and surgical data of patients operated for AO Spine A3 and A4 fractures were prospectively collected. Vertebral height and deformity were evaluated before and after surgery. Visual analog scale score for back pain, Oswestry Disability Index, and 12-Item Short Form Health Survey results for quality-of-life assessment were collected during follow-up.Among the 110 patients enrolled, 66 were allocated to group A and 44 to group B; the most common fractured level was T12 (34%). Postoperative complications were higher in group B, especially the wound infection rate (18% vs. 3%), and pseudomeningocele (14% vs. 0%). The 2-stage approach allowed an average long-term gain of 15.8° at the local kyphosis of fractured vertebra and 5.8° at the regional level (Cobb angle), versus 15.4° and 5.5° in group B. At 2 years follow-up, both groups showed significant functional improvements; however, the visual analog scale and Oswestry Disability Index metrics seemed more favorable for group A patients (P0.0001 vs. P0.003). A complete fusion rate was obtained in 100% of group A vs. 65% of group B.Our study indicates that percutaneous instrumentation and anterior fusion or an expandable cage lead to excellent long-term clinical and radiologic outcomes with a lower complication rate and higher fusion rate than those of open posterior approaches.

Object Despite the improvement in the overall management of medulloblastomas in recent years, certain phenomena and in particular postoperative cerebellar swelling remain an enigma. This rare complication, little described in the literature, is nonetheless life threatening for the patients. Case reports We report our experience about two children who developed severe cerebellar swelling with hydrocephalus and upward herniation soon after a gross total resection of a fourth ventricle medulloblastoma by a telo-velar approach. Despite rapid management of ventricular dilation and optimal medical intensive treatment of intracranial hypertension, both children died quickly after the surgery. Pathological examination analyses were in favour of anaplastic/large cell medulloblastoma. Discussion Diffuse cerebellar swelling with upward herniation may occur postoperatively in young children with anaplastic/large cell medulloblastoma with leptomeningeal spread. In the literature, only 4 cases have been so far described with delayed onset of symptoms. Two children survived with an aggressive management (decompressive surgery and early radio-chemotherapy). Conclusion Cerebellar swelling is an unrecognised and sudden complication of posterior fossa surgery for metastatic anaplastic medulloblastoma with leptomeningeal dissemination in young children. An initial less invasive surgical approach could be considered in such cases, in order to prevent this complication with potentially tragic issue, and which cannot be managed with a CSF shunt alone.

BackgroundThere is no consensus regarding the best treatment option for unruptured aneurysms of the posterior communicating artery (PCom) presenting with oculomotor nerve palsy (ONP). We aimed to assess predictors of ONP recovery in a multicenter series of consecutive patients.Materials and methodsA retrospective review of prospective databases in three tertiary neurosurgical centers was carried out, selecting patients with ONP caused by unruptured PCom aneurysms, treated by surgical clipping or embolization, between January 2006 and December 2013. Patient files and imaging studies were used to extract ophthalmological assessments, treatment outcomes, and follow-up data. Predictors of ONP recovery during follow-up were explored using univariate and multivariate analyses.ResultsWe identified 55 patients with a median ONP duration before treatment of 11 days (IQR 4.5–18); the deficit was complete in 27 (49.1%) and incomplete in 28 (50.9%) cases. Median aneurysm size was 7 mm (IQR 5–9). Twenty-four (43.6%) patients underwent surgical clipping and 31 (56.4%) embolization as the primary treatment. Overall, ONP improved in 40 (72.7%) patients and persisted/recurred in 15 (27.3 %). Surgery, interval to complete treatment ConclusionThere was no significant difference in ONP recovery between surgical clipping and embolization. The best predictor for ONP recovery was timely, complete, and durable aneurysm exclusion.

Odontoid fractures constitute the most common cervical fractures in elderly. External immobilization is the treatment of choice for Type I and III; there is still no wide consensus about the best management of Type II fractures. Observational multicenter study was conducted on a prospectively built database on elderly patients (> 75 years) with Type II odontoid fracture managed conservatively during the last 10 years. All patients underwent CT scan on admission and at 3 months; if indicated, selected patient had CT scan at 6 and 12 months. All patients were clinically evaluated by Neck Disability Index (NDI), Charlson Comorbidity Index (CCI), and American Society of Anaesthesiologists classification (ASA) on admission; NDI was assessed also at 6 weeks, 3, 6, 12, and 24 months; furthermore, a quality of life (QoL) assessment with the SF-12 form was performed at 3 and 12 months. Among the 260 patients enrolled, 177 (68%) were women and 83 (32%) men, with a median age of 83 years. Patients were followed up for a minimum of 24 months: 247 (95%) showed an excellent functional outcome within 6 weeks, among them 117 (45%) showed a good bony healing, whereas 130 (50%) healed in pseudo-arthrosis. The residual 5% were still variably symptomatic at 12 weeks; however, only 5 out of 13 (2% of the total cohort) required delayed surgery. This study showed that a conservative approach to odontoid Type II fracture in elderly is an effective and valid option, resulting in an excellent functional outcome (regardless of bony fusion) in the majority of cases. Failure of conservative treatment can be safely addressed with surgical fixation at a later stage.

Background Herpes simplex encephalitis (HSE) is the most frequent sporadic encephalitis in the world. In severe cases of HSE, the pathology usually progresses with an increase in intracranial pressure secondary to cerebral edema and/or hemorrhagic necrosis. Currently no high-power studies exist regarding the management of severe HSE and most of the papers reported in the literature are case reports. Decompressive craniectomy, effective in some cases of pharmaco-resistant intracranial hypertension (ICH) resulting from other causes, may be suggested in severe HSE, with several good results reported in the literature. Case description The case of a 26-year-old man with severe HSE and a subsequent ICH is reported. In dealing with an ICH rebellious to conservative treatment, it was decided to perform a right decompressive hemicraniectomy, associated with a right temporal polectomy. The postoperative evolution was satisfactory, with normal neuropsychological tests and a Glasgow Outcome Scale of 1. Conclusion Although herpes simplex encephalitis is sometimes devastatingly complicated by intracranial hypertension, its management lacks consensus and reliable data in the literature remains scarce. Surgical as well as conservative treatment, used together in a multimodal approach, may hold the key to a greater control of intracranial pressure, thus resulting in a better outcome. In this multimodal management, the window of opportunity where surgery may be considered is small, and must be discussed further and more precisely in future articles.

Background Prostate carcinomas rarely metastasize to the central nervous system but, when they do, dural localizations are as common as and far more aggressive than intraparenchymal ones. Those metastases can be further classified according to their extension toward the subdural or extradural space and can frequently simulate other pathologic conditions including chronic subdural hematomas, abscess, and primary bone tumors. Beside the challenges of the preoperative differential diagnostic and complexity of surgical planning and operative excision, subdural metastases seem to carry a much poorer prognosis. Methods A series of consecutive patients admitted during a 12-year period through our oncall pathway for subdural/extradural collections or intraparenchymal lesions found, on histologic analysis, to represent intracranial prostate cancer metastases was retrospectively reviewed. Results A total of 19 patients were included, but only 3 were diagnosed with small cell prostate carcinoma, while the majority had a primary prostate adenocarcinoma. Metastases could be classified as pure subdural space lesions, dural-based lesions, extradural/bony lesions, and pure intraparenchymal lesions. All patients with subdural metastases and 3 out of 5 patients with dural-based lesions required an emergency intervention due to rapidly deteriorating neurologic status. The mean follow-up in our series was 37 months; only subdural localizations had a remarkably unfavorable outcome. Conclusions Supported by our experience and the review of the literature, we suggest that a low threshold for contrast-enhanced computed tomography/magnetic resonance imaging is advisable in case of suspicious subdural collection, even in an emergency setting, for patients with previous medical history of prostate cancer.

A 51-year-old woman developed profound coma complicating subarachnoid hemorrhage after aneurysmal rupture. An external ventricular drain was inserted. FDG PET/CT was performed for prognostication purposes and showed global cortical hypometabolism. This was consistent with the clinical findings of an unresponsive wakefulness syndrome. During the follow-up, ventriculitis was diagnosed. Because of no clinical improvement under focused, high-dose antimicrobial treatment, a second FDG PET/CT was performed. It showed an improved diffuse cortical fixation and an intense intraventricular hyperfixation, suggestive of intraventricular abscess. A third functional imaging, performed to monitor treatment, showed progressive metabolic recovery with especially uptake in frontoparietal areas over time.

The presence of cysts is a rare occurrence for intracranial meningiomas in adults. We report our experience in a large consecutive series of cystic meningiomas. We prospectively collected data for a dedicated database of cystic meningioma cases between January 2004 and December 2011 in two tertiary neurosurgical centers. Studied data included preoperative imaging, surgical records, and pathology reports. Among 1214 surgeries for intracranial meningioma, we identified 43 cases of cystic meningioma, corresponding to an incidence of 3.5 %. The most common localization was the hemispheric convexity (17/43 cases). Twenty-eight patients had intratumoral cysts, nine peritumoral, and five mixed intra and extratumoral. In 29 patients with available diffusion imaging, ADC coefficients were significantly lower in grade II-III tumors compared to grade I (p = 0.01). Complete resection of the cystic components was possible in 27/43 patients (63 %); partial resection in 4/43 (9 %); in 6/43 (14 %) cyst resection was not possible but multiple biopsies were performed from the cystic walls; in another 6/43 (14 %) the cystic wall was not identified during surgery. Cells with neoplastic features were identified within the cyst walls at pathology in 26/43 cases (60 %). All patients were followed-up for 24 months; long-term follow-up was available only in 32 patients for an average period of 49 months (range, 36–96 months). No recurrence requiring surgery was observed. Cystic meningiomas are rare. Cells with neoplastic features are often identified within the cyst walls. Complete cyst resection is recommendable when considered technically feasible and safe.

Introduction Diffuse intrinsic pontine gliomas (DIPG) constitute 10–15% of all brain tumors in the pediatric population; currently prognosis remains poor, with an overall survival of 7–14 months. Recently the indication of DIPG biopsy has been enlarged due to the development of molecular biology and various ongoing clinical and therapeutic trials. Classically a biopsy is performed using a stereotactic frame assisted procedure but the workflow may sometimes be heavy and more complex especially in children. In this study the authors present their experience with frameless robotic-guided biopsy of DIPG in a pediatric population. Patients and methods Retrospective study on a series of five consecutive pediatric patients harboring DIPG treated over a 4-year period. All patients underwent frameless robotic-guided biopsy via a transcerebellar approach. Results Among the 5 patients studied 3 were male and 2 female with a median age of 8.6 years [range 5 to 13 years]. Clinical presentation included ataxia, hemiparesis and cranial nerve palsy in all patients. MRI imaging of the lesion showed typical DIPG features (3 of them located in the pons) with hypo-intensity on T1 and hyper-intensity signal on T2 sequences and diffuse gadolinium enhancement. The mean procedure time was 56 minutes (range 45 to 67 minutes). No new postoperative neurological deficits were recorded. Histological diagnosis was achieved in all cases as follows: two anaplastic astrocytomas (grade III), two glioblastomas, and one diffuse astrocytoma (grade III). Conclusion Frameless robotic assisted biopsy of DIPG in pediatric population is an easier, effective, safe and highly accurate method to achieve diagnosis.