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  • Author or Editor: Francesco Salax
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Communication and collaboration in spine neuromonitoring: time to expect more, a lot more, from the neurophysiologists

斯坦斯金纳和弗朗西斯科·萨拉

InJournal of Neurosurgery: Spine Volume 27 (2017): Issue 1 (Jul 2017)

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Cauda equina ependymomas: surgical treatment and long-term outcomes in a series of 125 patients

Nicolò Marchesini, Nicola Tommasi, Franco Faccioli, Giampietro Pinna, and Francesco Sala

OBJECTIVE

Cauda equina ependymoma (CEE) is a rare tumor for which little information is available on the oncological and clinical outcomes of patients. In this study the authors aimed to address functional, oncological, and quality-of-life (QOL) outcomes in a large series of consecutive patients operated on at their institution during the past 20 years.

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125名患者接受了手术的记录between January 1998 and September 2018 were reviewed. Analyzed variables included demographic, clinical, radiological, surgical, and histopathological features. Neurological outcomes were graded according to the McCormick and Kesselring scales. The QOL at follow-up was evaluated by administering the EQ-5DL questionnaire.

RESULTS

入院时,84%的患者有一个麦考密克研究生e of I and 76.8% had a Kesselring score of 0. At follow-up (clinical 8.13 years; radiological 5.87 years) most scores were unchanged. Sacral level involvement (p = 0.029) and tumor size (p = 0.002) were predictors of poor functional outcome at discharge. Tumor size (p = 0.019) and repeated surgery (p < 0.001) were predictors of poor outcome. A preoperative McCormick grade ≥ III and Kesselring grade ≥ 2 were associated with worse outcomes (p = 0.035 and p = 0.002, respectively). Myxopapillary ependymoma (MPE) was more frequent than grade II ependymoma (EII). The overall rate of gross-total resection (GTR) was 91.2% and rates were significantly higher for patients with EII (98%) than for those with MPE (84%) (p = 0.0074). On multivariate analysis, the only factor associated with GTR was the presence of a capsule (p = 0.011). Seventeen patients (13.7%) had recurrences (13 MPE, 4 EII; 76.4% vs 23.6%; p = 0.032). The extent of resection was the only factor associated with recurrence (p = 0.0023) and number of surgeries (p = 0.006). Differences in progression-free survival (PFS) were seen depending on the extent of resection at first operation (p < 0.001), subarachnoid seeding (p = 0.041), piecemeal resection (p = 0.004), and number of spine levels involved (3 [p = 0.016], 4 [p = 0.011], or ≥ 5 [p = 0.013]). At follow-up a higher proportion of EII than MPE patients were disease free (94.7% vs 77.7%; p = 0.007). The QOL results were inferior in almost all areas compared to a control group of subjects from the Italian general population. A McCormick grade ≥ 3 and repeated surgeries were associated with a worse QOL (p = 0.006 and p = 0.017).

CONCLUSIONS

An early diagnosis of CEE is important because larger tumors are associated with recurrences and worse functional neurological outcomes. Surgery should be performed with the aim of achieving an en bloc GTR. The histological subtype was not directly associated with recurrences, but some of the features more commonly encountered in MPEs were. The outcomes are in most cases favorable, but the mean QOL perception is inferior to that of the general population.

InJournal of Neurosurgery: Spine Volume 36: Issue 3 (Mar 2022)

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Surgery for intramedullary spinal cord ependymomas in the neuromonitoring era: results from a consecutive series of 100 patients

Benjamin Skrap, Vincenzo Tramontano, Franco Faccioli, Mario Meglio, Giampietro Pinna, and Francesco Sala

OBJECTIVE

The established treatment of intramedullary spinal cord ependymomas (ISCEs) is resection. Surgical series reporting treatment results often lack homogeneity, as these are collected over long time spans and their analysis is plagued by surgical learning curves and inconsistent use of intraoperative neurophysiological monitoring (IONM). The authors report the oncological and functional long-term outcomes in a modern series of 100 consecutive ISCEs that were resected between 2000 and 2015 by a surgically experienced team that consistently utilized IONM.

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In this retrospective study, the authors tailored surgical strategy and multimodal IONM, including somatosensory evoked potentials, muscle motor evoked potentials (mMEPs), and D-waves, with the aim of gross-total resection (GTR). Preservation of the D-wave was the primary objective, and preservation of mMEPs was the second functional objective. Functional status was evaluated using the modified McCormick Scale (MMS) preoperatively, postoperatively, and at follow-up.

RESULTS

Preoperatively, 89 patients were functionally independent (MMS grade I or II). A GTR was achieved in 89 patients, 10 patients had a stable residual, and 1 patient underwent reoperation for tumor progression. At a mean follow-up of 65.4 months, 82 patients were functionally independent, and 11 lost their functional independence after surgery (MMS grades III–V). Muscle MEP loss predicted short-term postoperative worsening (p < 0.0001) only, while the strongest predictors of a good functional long-term outcome were lower preoperative MMS grades (p < 0.0001) and D-wave preservation. D-wave monitorability was 67%; it was higher with lower preoperative MMS grades and predicted a better recovery (p = 0.01).

CONCLUSIONS

In this large series of ISCEs, a high rate of GTR and long-term favorable functional outcome were achieved. Short- and long-term functional outcomes were best reflected by mMEPs and D-wave monitoring, respectively.

InJournal of Neurosurgery: Spine Volume 36: Issue 5 (May 2022)

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Letter to the Editor: Electrical activity in limb muscles after spinal cord stimulation is not specific for the corticospinal tract

Vedran Deletis, Karl F. Kothbauer, Francesco Sala, and Kathleen Seidel

InJournal of Neurosurgery: Spine Volume 26 (2017): Issue 2 (Feb 2017)

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Where the central canal begins: endoscopic in vivo description

Pierluigi Longatti, Alessandro Fiorindi, Elisabetta Marton, Francesco Sala, and Alberto Feletti

OBJECTIVE

Although evidence and descriptions of the central canal (CC) along the medulla oblongata and the spinal cord have been provided by several anatomical and radiological studies, a clear picture and assessment of the opening of the CC, or apertura canalis centralis (ACC), into the fourth ventricle is lacking, due to its submillimetric size and hidden position in the calamus scriptorius.

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The authors reviewed all of their cases in which patients underwent ventricular transaqueductal flexible endoscopic procedures and selected 44 cases in which an inspection of the region of the calamus scriptorius had been performed and was suitable for study inclusion. Patients were divided into different groups, based on the presence or absence of a chronic pathological process involving the fourth ventricle. In each case, the visual appearance of the opening of the CC of the ACC was classified as no evidence (A0), indirect evidence (A1), or clear evidence (A2). Morphometric measurements were inferred from surrounding structures and the size of surgical tools visible in the field.

RESULTS

The opening of the CC could be clearly observed in all cases (A1 4.5%, A2 95.5%). In normal cases, a lanceolate shape along the median sulcus was most frequently found, with an average size of 600 × 250 µm that became rounded and smaller in size in cases of hydrocephalus. The distance between the caudal margin of the ACC and the obex was about 1.8 mm in normal cases, 2.1 mm in cases of obstructive hydrocephalus, and 1 mm in cases of normal pressure hydrocephalus. The two wings of the area postrema, variable in size and shape, were sited just caudal to the opening.

CONCLUSIONS

A flexible scope inserted through the cerebral aqueduct can approach the hidden calamus scriptorius like a pen fits into an inkpot. With this privileged viewpoint, the authors provide for the first time, to their knowledge, a clear and novel vision of the opening of the CC in the fourth ventricle, along with the precise location of this tiny structure compared to other anatomical landmarks in the inferior triangle.

InJournal of Neurosurgery Volume 136: Issue 3 (Mar 2022)

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Intraoperative electrical stimulation in awake craniotomy: methodological aspects of current practice

Andrea Szelényi, Lorenzo Bello, Hugues Duffau, Enrica Fava, Guenther C. Feigl, Miroslav Galanda, Georg Neuloh, Francesco Signorelli, and Francesco Sala

There is increasing evidence that the extent of tumor removal in low-grade glioma surgery is related to patient survival time. Thus, the goal of resecting the largest amount of tumor possible without leading to permanent neurological sequelae is a challenge for the neurosurgeon. Electrical stimulation of the brain to detect cortical and axonal areas involved in motor, language, and cognitive function and located within the tumor or along its boundaries has become an essential tool in combination with awake craniotomy. Based on a literature review, discussions within the European Low-Grade Glioma Group, and illustrative clinical experience, the authors of this paper provide an overview for neurosurgeons, neurophysiologists, linguists, and anesthesiologists as well as those new to the field about the stimulation techniques currently being used for mapping sensorimotor, language, and cognitive function in awake surgery for low-grade glioma. The paper is intended to help the understanding of these techniques and facilitate a comparison of results between users.

InNeurosurgical Focus Volume 28: Issue 2 (Feb 2010): Surgery of Gliomas in Eloquent Areas

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Neurosurgery in times of a pandemic: a survey of neurosurgical services during the COVID-19 outbreak in the Veneto region in Italy

Fabio Raneri, Oriela Rustemi, Giampaolo Zambon, Giulia Del Moro, Salima Magrini, Yuri Ceccaroni, Elisabetta Basso, Francesco Volpin, Martina Cappelletti, Jacopo Lardani, Stefano Ferraresi, Franco Guida, Franco Chioffi, Giampietro Pinna, Giuseppe Canova, Domenico d’Avella, Francesco Sala, and Lorenzo Volpin

OBJECTIVE

The purpose of this study was to analyze the effect of the coronavirus disease 2019 (COVID-19) outbreak and of the subsequent lockdown on the neurosurgical services of the Veneto region in Italy compared to the previous 4 years.

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在所有6神经外科depa进行了一项调查rtments in the Veneto region to collect data about surgical, inpatient care and endovascular procedures during the month of March for each year from 2016 to 2020. Safety measures to avoid infection from SARS-CoV-2 and any COVID-19 cases reported among neurosurgical patients or staff members were considered.

RESULTS

ν均值mber of neurosurgical admissions for the month of March over the 2016–2019 period was 663, whereas in March 2020 admissions decreased by 42%. Emergency admissions decreased by 23%. The average number of neurosurgical procedures was 697, and declined by 30% (range −10% to −51% in individual centers). Emergency procedures decreased in the same period by 23%. Subarachnoid hemorrhage and spontaneous intracerebral hemorrhage both decreased in Veneto—by 25% and 22%, respectively. Coiling for unruptured aneurysm, coiling for ruptured aneurysm, and surgery for ruptured aneurysm or arteriovenous malformation diminished by 49%, 27%, and 78%, respectively. Endovascular procedures for acute ischemic stroke (AIS) increased by 33% in 2020 (28 procedures in total). There was a slight decrease (8%) in brain tumor surgeries. Neurosurgical admissions decreased by 25% and 35% for head trauma and spinal trauma, respectively, while surgical procedures for head trauma diminished by 19% and procedures for spinal trauma declined by 26%. Admissions and surgical treatments for degenerative spine were halved. Eleven healthcare workers and 8 patients were infected in the acute phase of the pandemic.

CONCLUSIONS

This multicenter study describes the effects of a COVID-19 outbreak on neurosurgical activities in a vast region in Italy. Remodulation of neurosurgical activities has resulted in a significant reduction of elective and emergency surgeries compared to previous years. Most likely this is a combined result of cancellation of elective and postponable surgeries, increase of conservative management, increase in social restrictions, and in patients’ fear of accessing hospitals. Curiously, only endovascular procedures for AIS have increased, possibly due to reduced physical activity or increased thrombosis in SARS-CoV-2. The confounding effect of thrombectomy increase over time cannot be excluded. No conclusion can be drawn on AIS incidence. Active monitoring with nasopharyngeal swabs, wearing face masks, and using separate pathways for infected patients reduce the risk of infection.

InNeurosurgical Focus Volume 49 (2020): Issue 6 (Dec 2020): Preparedness and Guidelines for Neurosurgical Practice During Pandemic

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Neurosurgical management of intractable rolandic epilepsy in children: role of resection in eloquent cortex

Clinical article

Mony Benifla, Francesco Sala, John Jane Jr., Hiroshi Otsubo, Ayako Ochi, James Drake, Shelly Weiss, Elizabeth Donner, Ayataka Fujimoto, Stephanie Holowka, Elysa Widjaja, O. Carter Snead III, Mary Lou Smith, Mandeep S. Tamber, and James T. Rutka

Object

The authors undertook this study to review their experience with cortical resections in the rolandic region in children with intractable epilepsy.

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The authors retrospectively reviewed the medical records obtained in 22 children with intractable epilepsy arising from the rolandic region. All patients underwent preoperative electroencephalography (EEG), MR imaging, prolonged video-EEG recordings, functional MR imaging, magnetoencephalography, and in some instances PET/SPECT studies. In 21 patients invasive subdural grid and depth electrode monitoring was performed. Resection of the epileptogenic zones in the rolandic region was undertaken in all cases. Seizure outcome was graded according to the Engel classification. Functional outcome was determined using validated outcome scores.

Results

There were 10 girls and 12 boys, whose mean age at seizure onset was 3.2 years. The mean age at surgery was 10 years. Seizure duration prior to surgery was a mean of 7.4 years. Nine patients had preoperative hemiparesis. Neuropsychological testing revealed impairment in some domains in 19 patients in whom evaluation was possible. Magnetic resonance imaging abnormalities were identified in 19 patients. Magnetoencephalography was performed in all patients and showed perirolandic spike clusters on the affected side in 20 patients. The mean duration of invasive monitoring was 4.2 days. The mean number of seizures during the period of invasive monitoring was 17. All patients underwent resection that involved primary motor and/or sensory cortex. The most common pathological entity encountered was cortical dysplasia, in 13 children. Immediately postoperatively, 20 patients had differing degrees of hemiparesis, from mild to severe. The hemiparesis improved in all affected patients by 3–6 months postoperatively. With a mean follow-up of 4.1 years (minimum 2 years), seizure outcome in 14 children (64%) was Engel Class I and seizure outcome in 4 (18%) was Engel Class II. In this series, seizure outcome following perirolandic resection was intimately related to the child's age at the time of surgery. By univariate logistic regression analysis, age at surgery was a statistically significant factor predicting seizure outcome (p < 0.024).

Conclusions

Resection of rolandic cortex for intractable epilepsy is possible with expected morbidity. Accurate mapping of regions of functional cortex and epileptogenic zones may lead to improved seizure outcome in children with intractable rolandic epilepsy. It is important to counsel patients and families preoperatively to prepare them for possible worsened functional outcome involving motor, sensory and/or language pathways.

InJournal of Neurosurgery: Pediatrics Volume 4: Issue 3 (Sep 2009)

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