Advances and Technical Standards in Neurosurgery

Values-based medicine (VsBM) is an ethical concept, and bioethical framework has been developed to ensure that medical ethics and values are implemented, pervasive, and powerful parameters influencing decisions about health, clinical practice, teaching, medical industry, career development, malpractice, and research. Neurosurgeons tend to adopt ethics according to their own values and to what they see and learn from teachers. Neurosurgeons, in general, are aware about ethical codes and the patient's rights...

The diagnosis of Chiari I malformation is straightforward in patients with typical signs and symptoms of Chiari I malformation and magnetic resonance imaging (MRI) confirming ≥5 mm of cerebellar tonsillar ectopia, with or without a syrinx. However, in many cases, Chiari I malformation is discovered incidentally on MRI to evaluate global headache, cervical radiculopathy, or other conditions. In those cases, the clinician must consider if cerebellar tonsillar ectopia is related to the presenting symptoms...

Surgical approaches directed toward craniovertebral junction (CVJ) can be addressed to the ventral, dorsal, and lateral aspects through a variety of 360° surgical corridors Herein, we report features, advantages, and limits of the updated technical support in CVJ surgery in clinical setting and dissection laboratories enriched by our preliminary surgical results of the simultaneous application of O-arm intraoperative neuronavigation and imaging system along with the 3D-4K EX in TOA for the treatment of CVJ pathologies...

This paper reviews current knowledge on minimally invasive spine surgery (MISS). Although it has significant advantages, such as less postoperative pain, short hospital stay, quick return to work, better cosmetics, and less infection rate, there are also disadvantages. The long learning curve, the need for special instruments and types of equipment, high costs, lack of tactile sensation and biplanar imaging, some complications that are hard to treat, and more radiation to the surgeon and surgical team are the disadvantages...

The treatment of pathologies located within and surrounding the orbit poses considerable surgical challenges, due to the intricate presence of critical neurovascular structures in such deep, confined spaces. Historically, transcranial and craniofacial approaches have been widely employed to deal with orbital pathologies. However, recent decades have witnessed the emergence of minimally invasive techniques aimed at reducing morbidity. Among these techniques are the endoscopic endonasal approach and the subsequently developed endoscopic transorbital approach (ETOA), encompassing both endonasal and transpalpebral approaches...

INTRODUCTION: Due to the constant development of the technique, in the last 30 years, the endovascular treatment of the intracranial aneurysms (IAs) has gradually superseded the traditional surgery in the majority of centers. However, clipping still represents the best treatment for some anterior circulation IAs according to their angioarchitectural, topographical, and hemodynamic characteristics. Thus, the identification of residual indications for clipping and the maintenance of training programs in vascular neurosurgery appear nowadays more important than ever...

Favorable clinical outcomes in adult and pediatric neurosurgical oncology generally depend on the extent of tumor resection (EOR). Maximum safe resection remains the main aim of surgery in most intracranial tumors. Despite the accuracy of intraoperative magnetic resonance imaging (iMRI) in the detection of residual intraoperatively, it is not widely implemented worldwide owing to enormous cost and technical difficulties. Over the past years, intraoperative ultrasound (IOUS) has imposed itself as a valuable and reliable intraoperative tool guiding neurosurgeons to achieve gross total resection (GTR) of intracranial tumors...

Pediatric brain tumors are different to those found in adults in pathological type, anatomical site, molecular signature, and probable tumor drivers. Although these tumors usually occur in childhood, they also rarely present in adult patients, either as a de novo diagnosis or as a delayed recurrence of a pediatric tumor in the setting of a patient that has transitioned into adult services.Due to the rarity of pediatric-like tumors in adults, the literature on these tumor types in adults is often limited to small case series, and treatment decisions are often based on the management plans taken from pediatric studies...

Hypothalamic hamartomas (HHs) are rare congenital lesions formed by heterotopic neuronal and glial cells attached to the mammillary bodies, tuber cinereum, and hypothalamus.They often present with an intractable epilepsy typically characterized by gelastic seizures but commonly associated with other types of refractory seizures. The clinical course is progressive in most of the cases, starting with gelastic seizures in infancy and deteriorating into complex seizure disorders that result in catastrophic epilepsy associated with cognitive decline and behavioral disturbances...

Management of lateral and third ventricular tumors has been a challenge for neurosurgeons. Advances in imaging and pathology have helped in a better understanding of the treatment options. Technical refinement of microsurgical technique and addition of endoscopy has enabled more radical excision of tumors, when indicated, and added more safety.A proper understanding of the pathology at various ages and treatment options is continuously evolving. Many pediatric tumors are amenable to conservative surgical methods with effective complementary treatments...

Ependymomas comprise biologically distinct tumor types with respect to age distribution, (epi)genetics, localization, and prognosis. Multimodal risk-stratification, including histopathological and molecular features, is essential in these biologically defined tumor types. Gross total resection (GTR), achieved with intraoperative monitoring and neuronavigation, and if necessary, second-look surgery, is the most effective treatment. Adjuvant radiation therapy is mandatory in high-risk tumors and in case of residual tumor...

As a concept, drainage of excess fluid volume in the cranium has been around for more than 1000 years. Starting with the original decompression-trepanation of Abulcasis to modern programmable shunt systems, to other nonshunt-based treatments such as endoscopic third ventriculostomy and choroid plexus cauterization, we have come far as a field. However, there are still fundamental limitations that shunts have yet to overcome: namely posture-induced over- and underdrainage, the continual need for valve opening pressure especially in pediatric cases, and the failure to reinstall physiologic intracranial pressure dynamics...

Vascular malformation of the spinal cord in children is a rare and complicated disease spectrum. We will start from the basic spinal cord vascular anatomy and the controversial classification of this kind of disease. Then, we will elaborate the clinical manifestations, diagnostic imaging and treatment of pediatric spinal vascular malformations based on the practical experience of our center and from literature.

Internal carotid artery blood blister-like aneurysms are challenging lesions that arise from the artery trunk at non-branching sites. They have been recognized since 1969 and are distinct from typical saccular aneurysms. Usually, these aneurysms are broad-based, with no clearly identifiable neck and have extremely friable and fragile walls, thus with a great propensity to cause subarachnoid hemorrhage and to rupture during treatment. Apparently, blister-like aneurysms are formed through an acquired defect of the inner layers (tunica intima and media) of the internal carotid artery wall, probably due to hemodynamic stress in the carotid siphon...

Corpus callosotomy (CC) is an effective surgical treatment for medically resistant generalized or multifocal epilepsy (MRE). The premise of CC extrapolates from the observation that the corpus callosum is the predominant commissural pathway that allows spread and synchroneity of epileptogenic activity between the hemispheres. Candidacy for CC is typically reserved for patients seeking palliative epilepsy treatment with the goal of reducing the frequency of drop attacks, although reduction of other seizure semiologies (absence, complex partial seizures, and tonic-clonic) has been observed...

The present article describes pathophysiological and clinical aspects of congenital malformations of the cerebral tissue (cortex and white matter) that cause epilepsy and very frequently require surgical treatment. A particular emphasis is given to focal cortical dysplasias, the most common pathology among these epilepsy-related malformations. Specific radiological and surgical features are also highlighted, so a thorough overview of cortical dysplasias is provided.

Pediatric pineal region tumors consist of tumors of pineal gland origin and parapineal origin. The former are comprised of germ cell tumor (GCT) and pineal parenchymal tumor. The latter originate from the surrounding neural structures, such as the midbrain and thalamus; thus, they are often benign gliomas during childhood. Pineal region tumors often cause obstructive hydrocephalus, which is the main cause of presenting symptoms. Advanced imaging discloses precise location and extension of the tumor and associated anomalies such as hydrocephalous, dissemination, hemorrhage, etc...

The term parasagittal meningioma applies to those tumors that are associated with the superior sagittal sinus (SSS), originating from the dura mater in close relation to the parasagittal wall or angle, with no intervening brain tissue, possibly extending to the dura of the convexity and/or falx cerebri.(Cushing et al., Meningiomas: their classification, regional behaviour, life history, and surgeical and results. Hafner, 1938) They make up about 20-30% of all meningiomas. There is a vast literature correlating the Simpson grade of resection with later recurrence...

Petroclival meningiomas (PCMs) are complex skull-base tumors that continue to pose a formidable surgical challenge to neurosurgeons because of their deep-seated location/intimate relationship with the brainstem and neurovascular structures. The advent of stereotactic radiosurgery (SRS), along with the shifting of management goals from complete radiological cure to maximal preservation of the patient's quality of life (QOL), has further cluttered the topic of "optimal management" in PCMs. Not all patients with PCM need treatment ("watchful waiting")...

The third ventricle is located in the deepest part of the brain and is delimited by both telencephalic and diencephalic structures. Its location makes every surgical procedure inside or around it quite challenging, due to the distance from the surface to the fragility of the neurovascular structures that is necessary to dissect before entering its cavity and to the narrow surgical corridors through which it is necessary to work. Its geometric localization inside the cranial cavity and the anatomical relationship with the interhemispheric fissure offers nevertheless to the surgeon an impressive variety of surgical approaches, which allow to reach every millimeter of the third ventricle lumen...