Invasive intracranial pressure (ICP) monitoring is considered the gold standard for the management of patients with an acute brain injury and at risk of developing intracranial hypertension (IH). However, invasive devices (e.g., intraparenchymal probe or external ventricular drain) are expensive, not available worldwide, and might be associated with some risks. Recently, a consensus for the monitoring and management of traumatic brain injury (TBI) patients when invasive ICP is not available (B-ICONIC) was developed. This approach is based on repeated neurological evaluation, neuroimaging, and the use of non-invasive ICP monitoring tools, such as transcranial Doppler, automated pupillometry, and ultrasound optic nerve sheath diameter measurement, to titrate interventions aiming at controlling ICP. Despite this clinical algorithm was mainly proposed for low and middle-income countries where invasive ICP is not widely implemented, a potential application of this approach may exist even in healthcare facilities where direct ICP monitoring is available. This includes patients who may have contraindications to invasive monitoring, such as coagulopathy, as well as those in whom ICP monitoring is not routinely implemented, such as individuals with post-anoxic brain injury or acute liver failure, for the reported occurrence of cerebral edema and potential risk of IH in these cases. Therefore, the aim of this manuscript is to propose the extension of the B-ICONIC algorithm to a wider population, regardless of the decision to insert an ICP sensor, and to guide their management using this multimodal approach.

Antiplatelet and anticoagulant medications are widely prescribed to the general population for therapeutic and prophylactic purposes in a wide range of diseases, mainly of cardiovascular interest, spanning from acute events such as acute coronary syndromes (ACS), strokes, and thromboembolic disorders to chronic conditions like atrial fibrillation (AF) and peripheral vascular diseases. The management of such therapies is expected to escalate over time due to the aging population, which has a growing need for these medications, and the rising demand for surgical procedures. The management of anticoagulants and antiplatelets still represents a tough challenge for clinicians in elective neurosurgical procedures, where the balance between preventing thromboembolic events and an increased bleeding risk plays a crucial role in all phases of the perioperative setting. Managing antiplatelet and anticoagulant drugs in elective neurosurgery is complex and requires a tailored and multidisciplinary approach. Careful assessment of patient factors, surgery type, and potential risks and benefits is essential. POC testing can be valuable in optimizing therapy management and bleeding risk assessment. This narrative review for clinicians aims to provide an updated overview of the management of these drugs in the perioperative setting of elective neurosurgical procedures. We explored coagulation abnormalities commonly found in neurosurgical patients, the pharmacological profile of each class of drugs, the appropriate management according to the type of procedure (brain or spinal), and the available diagnostic tests, focusing on the application of point-of-care (POC) coagulation testing.

BackgroundInvasive systems are commonly used for monitoring intracranial pressure (ICP) in traumatic brain injury (TBI) and are considered the gold standard. The availability of invasive ICP monitoring is heterogeneous, and in low- and middle-income settings, these systems are not routinely employed due to high cost or limited accessibility. The aim of this consensus was to develop recommendations to guide monitoring and ICP-driven therapies in TBI using non-invasive ICP (nICP) systems.MethodsA panel of 41 experts, that regularly use nICP systems for guiding TBI care, was established. Three scoping and four systematic reviews with meta-analysis were performed summarizing the current global-literature evidence. A modified Delphi method was applied for the development of recommendations. An in-person meeting with group discussions and voting was conducted. Strong recommendations were defined for an agreement of at least 85%. Weak recommendations were defined for an agreement of 75-85%.ResultsA total of 34 recommendations were provided (32 Strong, 2 Weak) divided into three domains: general consideration for nICP use, management of ICP using nICP methods and thresholds of nICP tools for escalating/de-escalating treatment. We developed four clinical algorithms for escalating treatment and heatmaps for de-escalating treatment.ConclusionsUsing a mixed-method approach involving literature review and an in-person consensus by experts, a set of recommendations designed to assist clinicians managing TBI patients using nICP systems plus clinical assessment, in the presence or absence of brain imaging, were built. Further clinical studies are required to validate the potential use of these recommendations in the daily clinical practice.

Background The early management of polytrauma patients with traumatic spinal cord injury (tSCI) is a major challenge. Sparse data is available to provide optimal care in this scenario and worldwide variability in clinical practice has been documented in recent studies. Methods A multidisciplinary consensus panel of physicians selected for their established clinical and scientific expertise in the acute management of tSCI polytrauma patients with different specializations was established. The World Society of Emergency Surgery (WSES) and the European Association of Neurosurgical Societies (EANS) endorsed the consensus, and a modified Delphi approach was adopted. Results A total of 17 statements were proposed and discussed. A consensus was reached generating 17 recommendations (16 strong and 1 weak). Conclusions This consensus provides practical recommendations to support a clinician’s decision making in the management of tSCI polytrauma patients.

-OBJECTIVE: A standardized definition and classification of primary posterior petrous meningiomas (PPMs) is lack-ing, with consequent challenges in comparing different case series. This study aimed to provide an anatomical description and classification of PPMs analyzing a homo-geneous series of patients operated via the retrosigmoid approach.-METHODS: PPMs originate laterally to the petro-occipital fissure within the venous ring composed of the superior petrosal, sigmoid, inferior petrosal, and cavernous sinuses. We proposed a classification based on tumor site of origin, direction of growth relative to the internal acoustic meatus, and cranial nerves' displacement. Four types of PPMs were defined: retromeatal (type A), meatal (type B), premeatal (type C), and broad-based (type D). We performed a retrospective analysis of 130 consecutive pa-tients with PPMs who underwent surgery as first-line treatment.-RESULTS: The PPM classification predicted clinical presentation, postoperative morbidity, and resection rates. Headache, hydrocephalus, and cerebellar deficits were more common in type A (59.0%, 37.7%, 49.2%) and type D (66.7%, 66.7%, 33.3%). Hypoacusia/anacusia was more common in type B (87.5%), while trigeminal hypoesthesia/ anesthesia was more common in type C (85.0%). After surgery, patients with type A and D PPMs were at higher risk to develop cerebellar deficits (11.5%-22.2%), whereas patients with type B and C PPMs presented with hypo-acusia/anacusia (12.5%) and trigeminal deficits (10.0%), respectively. The near-total resection rate was higher in type A (91.8%), followed by types B (82.5%), C (80.0%), and D (77.8%) PPMs.-CONCLUSIONS: The PPM surgical classification has an operative and prognostic relevance. In expert hands, the retrosigmoid approach represents a safe and effective approach to remove PPMs.

Introduction: Traumatic brain injury (TBI) represents a severe pathology with important social and economic concerns, decompressive craniectomy (DC) represents a life-saving surgical option to treat elevated intracranial hypertension (ICP). The rationale underlying DC is to remove part of the cranial bones and open the dura mater to create space, avoiding secondary parenchymal damage and brain herniations. The scope of this narrative review is to summarize the most relevant literature and to discuss main issues about indication, timing, surgical procedure, outcome, and complications in adult patients involved in severe traumatic brain injury, underwent to the DC. The literature research is made with Medical Subject Headings (MeSH) terms on PubMed/MEDLINE from 2003 to 2022 and we reviewed the most recent and relevant articles using the following keywords alone or matched with each other: decompressive craniectomy; traumatic brain injury; intracranial hypertension; acute subdural hematoma; cranioplasty; cerebral herniation, neuro-critical care, neuro-anesthesiology. The pathogenesis of TBI involves both primary injuries that correlate directly to the external impact of the brain and skull, and secondary injuries due to molecular, chemical, and inflammatory cascade inducing further cerebral damage. The DC can be classified into primary, defined as bone flap removing without its replacement for the treatment of intracerebral mass, and secondary, which indicates for the treatment of elevated intracranial pressure (ICP), refractory to intensive medical management. Briefly, the increased brain compliance following bone removal reflects on CBF and autoregulation inducing an alteration in CSF dynamics and so, eventual complications. The risk of complications is estimated around 40%. The main cause of mortality in DC patients is due to brain swelling. In traumatic brain injury, primary or secondary decompressive craniectomy is a life-saving surgery, and the right indication should be mandatory in multidisciplinary medical–surgical consultation.

External ventricular drainage is often considered a life-saving treatment in acute hydrocephalus. Given the large number of discussion points, the ideal management of EVD has not been completely clarified. The objective of this study was to review the most relevant scientific evidence about the management of EVD in its main clinical scenarios. We reviewed the most recent and relevant articles about indications, timing, management, and complications of EVD in neurocritical care, with particular interest in patients with subarachnoid hemorrhage (SAH), severe traumatic brain injury (TBI), and intraventricular hemorrhage (IVH) using the following keywords alone or matching with one another: intracranial pressure, subarachnoid hemorrhage, traumatic brain injury, intraventricular hemorrhage, external ventricular drainage, cerebrospinal shunt, intracranial pressure monitoring, and ventriculoperitoneal shunt. In the management of EVD in SAH, the intermittent drainage strategy is burdened with an elevated risk of complications (e.g., clogged catheter, hemorrhage, and need for replacement). There seems to be more ventriculoperitoneal shunt dependency in rapid weaning approach-managed patients than in those treated with the gradual weaning approach. Although there is no evidence in favor of either strategy, it is conventionally accepted to adopt a continuous drainage approach in TBI patients. Less scientific evidence is available in the literature regarding the management of EVD in patients with severe TBI and intraparenchymal/intraventricular hemorrhage. EVD placement is a necessary treatment in several clinical scenarios. However, further randomized clinical trials are needed to clarify precisely how EVD should be managed in different clinical scenarios.

Purpose. - We assessed the impact of frailty on surgical outcomes, survival, and functional dependency in elderly patients harboring a glioblastoma, isocitrate dehydrogenase (IDH)-wildtype.Methods. - We retrospectively reviewed records of old and frail patients surgical treated at a single neu-rosurgical institution between January 2018 to May 2021. Inclusion criteria were: (1) neuropathological diagnosis of glioblastoma, IDH-wildtype; (2) patient >= 65 years at the time of surgery; (3) available data to assess the frailty index according to the 5-modified Frailty Index (5-mFI).Results. - A total of 47 patients were included. The 5-mFI was at 0 in 11 cases (23.4%), at 1 in 30 cases (63.8%), at 2 in two cases (4.2%), at 3 in two cases (4.2%), and at 4 in two cases (4.2%). A gross total resection was performed in 26 patients (55.3%), a subtotal resection was performed in 13 patients (27.6%), and a biopsy was performed in 8 patients (17.1%). The rate of 30-day postoperative complications was higher in the biopsy subgroup and in the 5-mFI = 4 subgroup. Gross total resection and age <= 70 years were inde-pendent predictors of a longer overall survival. Sex, 5-mFI, postoperative complications, and preoperative Karnofsky Performance Status score did not influence overall survival and functional dependency.Conclusion. - In patients >= 65 years harboring a glioblastoma, IDH-wildtype, gross total resection remains an independent predictor of longer survival and good postoperative functional recovery. The frailty, assessed by the 5-mFI score, does not influence surgery and outcomes in this dataset. Further confirmatory analyses are required.(c) 2023 Elsevier Masson SAS. All rights reserved.

Introduction: Hyponatremia is the most frequently occurring electrolyte disorder in neurocritical care and traumatic brain injury, aneurysmal subarachnoid hemorrhage (SAH), neurosurgery, and ischemic stroke are the clinical conditions more often associated with this condition. SIADH and CSWS are the main causes of hyponatremia in neurologically ill patients. Since hyponatremia is a negative prognostic factor for neurocritical patients, early diagnosis and consequent targeted therapy are of fundamental importance. The present review was carried out to provide a brief recap on the main causes and management of hyponatremia in the neurocritical patient. Methods: A methodical search of the medical literature using the online database MEDLINE was carried out and studies comprising case reports, prospective and retrospective observational studies, or randomized controlled clinical trials in which there is a diagnosis of hyponatremia in neurocritical patients were included. Results: 18 articles were analyzed, consisting of 8 case reports, 4 case series, 3 prospective trials, 1 retrospective study, and 1 multicenter trial. A total of 1371 patients from 18 studies were included. Patients’ average age was 29.28 ± 20.9, respectively. TBI was the main cause of hyponatremia in the literature reviewed; 12 studies were about the relationship between TBI and hyponatremia, 2 studies about stroke, 2 studies about SAH and 1 about hyponatremia postneurosurgical procedure. Discussion: Hyponatremia is the most common electrolyte disorder in hospitalized patients and the main scenarios of hyponatremic neurocritical patients are subarachnoid hemorrhage, ischemic stroke, traumatic brain injury and iatrogenic hyponatremia due to neurosurgical cases. Conclusion: Hyponatremia is a frequent finding in neurocritical care and is also a recognized negative prognostic factor leading to increased mortality and ICU length hospitalization. Its diagnosis and therapy are essential for correct neurocritical management. The most common cause of serum sodium abnormality is SIADH, and an early diagnosis for target treatment is paramount to prevent delayed symptoms and complications.

Severe traumatic brain-injured (TBI) patients should be primarily admitted to a hub trauma center (hospital with neurosurgical capabilities) to allow immediate delivery of appropriate care in a specialized environment. Sometimes, severe TBI patients are admitted to a spoke hospital (hospital without neurosurgical capabilities), and scarce data are available regarding the optimal management of severe isolated TBI patients who do not have immediate access to neurosurgical care. A multidisciplinary consensus panel composed of 41 physicians selected for their established clinical and scientific expertise in the acute management of TBI patients with different specializations (anesthesia/intensive care, neurocritical care, acute care surgery, neurosurgery and neuroradiology) was established. The consensus was endorsed by the World Society of Emergency Surgery, and a modified Delphi approach was adopted. A total of 28 statements were proposed and discussed. Consensus was reached on 22 strong recommendations and 3 weak recommendations. In three cases, where consensus was not reached, no recommendation was provided. This consensus provides practical recommendations to support clinician’s decision making in the management of isolated severe TBI patients in centers without neurosurgical capabilities and during transfer to a hub center.

Background Insular cavernous malformations (iCMs) are very rare vascular lesions. Their surgical management is challenging, due to their complex functional and vascular relationship. The continuous improvement of intra-operative tools and neuroimaging techniques has progressively enhanced the safety of iCM surgery. Nevertheless, the best surgical approach remains controversial. Objective To analyze the potential role of an anatomo-functional classification to guide the iCMs' management. Methods The study included patients affected by iCMs and referred to the Senior Author (FA). All cases were divided in 2 groups, according to a mainly pial growth pattern (exophytic group) or a subcortical one (endophytic group). Endophytic iCM was further subdivided in 3 subgroups, based on the insular gyri involved. According to this classification, each patient underwent a specific additional neuroimaging investigation and surgical evaluation. Results A total of 24 patients were included. In the surgical group, trans-sylvian (TS) approach was used in 6 patients with exophytic or Zone I endophytic iCMs. The transcortical (TC) approach with awake monitoring was used in 6 cases of Zone II endophytic vascular lesions. Both TS and trans-intraparietal sulcal (TIS) approach were used for 3 cases of Zone III endophytic iCM. At follow-up, 3 patients were fully recovered from a transient speech impairment while a permanent morbidity was observed in one case. Conclusions ICMs represent a single entity with peculiar clinical and surgical aspects. The proposed iCM classification focuses on anatomical and functional concerns, aiming to suggest the best pre-operative work-up and the surgical evaluation.

BACKGROUND:Questions remain on the optimal management of subarachnoid hemorrhage (SAH) patients once they are admitted to the referring center, before and after the aneurysm treatment. To address these issues, we created a consensus of experts endorsed by the Italian Society of Anesthesia and Intensive Care (SIAARTI) to provide clinical guidance regarding this topic. Specifically, in this manuscript (part 2), we aim to provide a list of experts' recommendations regarding the management of SAH patients in a center with neurosurgical/neuroendovascular facilities after aneurysm treatment. METHODS:A multidisciplinary consensus panel composed by 24 physicians selected for their established clinical and scientific expertise in the acute management of SAH patients with different specializations (anesthesia/intensive care, neurosurgery, and interventional neuroradiology) was created. A modified Delphi approach was adopted. RESULTS:A total of 33 statements were discussed, voted, and approved. Consensus was reached on 30 recommendations (28 strong and 2 weak). In 3 cases, where consensus could not be agreed upon, no recommendation was provided. CONCLUSIONS:This consensus provides practical recommendations (and not mandatory standard of practice) to support clinician's decision-making in the management of SAH patients in centers with neurosurgical/neuroendovascular facilities after aneurysm securing.

Background: Ventricular peritoneal shunting (VPS) is a frequent procedure in neurosurgery, unfortunately still burdened with a significant rate of complications. The frontal Kocher’s point is the most frequently used landmark for ventricular puncture. Keen’s point (posterior parietal approach) seems to be a valid alternative. We report a newly described access to the lateral ventricle located in posterior temporal area and the results of a large series of adult patients. Methods: Retrospective analysis of a series of 188 cases of VPS performed with this approach. Results: Mean surgical time was 51.5 +/− 13.1 min (range 25–90 min). Twenty-one patients (11.2%) were subjected to revision surgery: eight cases (4.3%) for displacement or malfunction of ventricular catheter, eight cases (4.3%) for abdominal issues, three cases (1.6%) for hardware failure, and two cases (1.1%) for infection. Optimal catheter placement was reached in 90.1%. Conclusions: The modified Keen’s point approach seems to be safe, technically feasible, and reproducible, showing some potential advantages such as short surgical time, precision in ventricular catheter placement, and short tunneling tract. The need for surgical revision is similar to that reported in the literature, while the rate of catheter malpositioning and infections seems to be low; hemorrhages around catheter and seizures were not reported.

Issues remain on the optimal management of subarachnoid hemorrhage (SAH) patients once they are admitted to the referring center, before and after the aneurysm treatment. To address these issues, we created a consensus of experts endorsed by the Italian Society of Anesthesia and Intensive Care (SIAARTI). In this manuscript, we aim to provide a list of experts’ recommendations regarding the early management of SAH patients from hospital admission, in a center with neurosurgical/neuro-endovascular facilities, until securing of the bleeding aneurysm. A multidisciplinary consensus panel composed of 24 physicians selected for their established clinical and scientific expertise in the acute management of SAH patients with different background (anesthesia/intensive care, neurosurgery, and interventional neuroradiology) was created. A modified Delphi approach was adopted. Among 19 statements discussed. The consensus was reached on 18 strong recommendations. In one case, consensus could not be agreed upon and no recommendation was provided. This consensus provides practical recommendations for the management of SAH patients in hospitals with neurosurgical/neuroendovascular facilities until aneurysm securing. It is intended to support clinician’s decision-making and not to mandate a standard of practice.

Background: Few studies have explored the cerebral venous compartment or the correlation between venous and arterial cerebral blood flows. We aimed to correlate cerebral blood flow velocities in the arterial (middle cerebral artery) and venous (straight sinus) compartments in healthy volunteers and traumatic brain injury (TBI) patients. In addition, we determined the normative range of these parameters. Materials and Methods: A total of 122 healthy volunteers and 95 severe TBI patients of both sexes were included and stratified into 3 age groups as follows: group 1 (aged, 18 to 44 y); group 2 (aged, 45 to 64 y); group 3 (older than 65 y). Transcranial Doppler systolic cerebral blood flow velocity, diastolic cerebral blood flow velocity, and mean cerebral blood flow velocity (FVs, FVd, FVm, respectively) were measured in the middle cerebral artery and peak cerebral venous blood flow velocity (FVVs) was measured in the straight sinus. The arteriovenous correlation was assessed on the basis of a positive relationship between FVs and FVVs. Results: There was an arteriovenous correlation (FVs vs. FVVs) in healthy volunteers (R = 0.39, P < 0.0001). We found no arteriovenous correlation in the TBI cohort overall, but FVs and FVVs were correlated in age group 1 (R = 0.28, P = 0.05) and in males (R = 0.29, P = 0.01). In healthy volunteers, FVs and FVm were significantly higher in males compared with females; and FVs, FVm, FVd, FVVs all increased across the age spectrum. There were no significant differences in any of these parameters in TBI patients. Conclusions: There are age and sex differences in arterial and venous cerebral blood flow velocities in healthy volunteers. Arteriovenous correlation is present in healthy volunteers but absent in TBI patients.

BACKGROUND:Syringomyelia and Chiari malformation are classified as rare diseases on Orphanet, but international guidelines on diagnostic criteria and case definition are missing.AIM OF THE STUDY:to reach a consensus among international experts on controversial issues in diagnosis and treatment of Chiari 1 malformation and syringomyelia in adults.METHODS:A multidisciplinary panel of the Chiari and Syringomyelia Consortium (4 neurosurgeons, 2 neurologists, 1 neuroradiologist, 1 pediatric neurologist) appointed an international Jury of experts to elaborate a consensus document. After an evidence-based review and further discussions, 63 draft statements grouped in 4 domains (definition and classification/planning/surgery/isolated syringomyelia) were formulated. A Jury of 32 experts in the field of diagnosis and treatment of Chiari and syringomyelia and patient representatives were invited to take part in a three-round Delphi process. The Jury received a structured questionnaire containing the 63 statements, each to be voted on a 4-point Likert-type scale and commented. Statements with agreement <75% were revised and entered round 2. Round 3 was face-to-face, during the Chiari Consensus Conference (Milan, November 2019).RESULTS:Thirty-one out of 32 Jury members (6 neurologists, 4 neuroradiologists, 19 neurosurgeons, and 2 patient association representatives) participated in the consensus. After round 2, a consensus was reached on 57/63 statements (90.5%). The six difficult statements were revised and voted in round 3, and the whole set of statements was further discussed and approved.CONCLUSIONS:The consensus document consists of 63 statements which benefited from expert discussion and fine-tuning, serving clinicians and researchers following adults with Chiari and syringomyelia.

Many studies have demonstrated that the optic nerve sheath diameter (ONSD) is a good indicator of intracranial pressure (ICP). There are uncertainties regarding the optimal ONSD threshold, considering age and sex differences in the healthy population, and these differences could lead to uncertainties in evaluation of ONSD in pathological conditions.The aim of this prospective observational study was to investigate if age and sex could influence ONSD in a cohort of healthy Italian volunteers recruited during preanesthetic assessment for low-risk surgical procedures.The population was stratified for sex (males versus females) and for age (18-44 years, 45-64 years, and ≥65 years). The axial and longitudinal ONSD diameters were measured by two trained investigators.A significant difference in ONSD between males and females was found (median 4.2 (interquartile range 3.9-4.6) versus 4.1 (interquartile range 3.6-4.2) mm, P = 0.01), and a positive correlation between ONSD and age was found (R = 0.50, P < 0.0001).It was concluded that ONSD increases with age and is significantly larger in the healthy male population. These discrepancies should be taken into consideration when ONSD measurement is performed.

The immediate management of subarachnoid hemorrhage (SAH) patients in hospitals without neurosurgical/neurointerventional facilities and their transfer to a specialized center is challenging and not well covered in existing guidelines. To address these issues, we created a consensus of experts endorsed by the Italian Society of Anesthesia and Intensive Care (SIAARTI) to provide clinical guidance.A multidisciplinary consensus panel composed by 19 physicians selected for their established clinical and scientific expertise in the acute management of SAH patients with different specializations (anesthesia/intensive care, neurosurgery and interventional neuroradiology) was created. A modified Delphi approach was adopted.A total of 14 statements have been discussed. Consensus was reached on 11 strong recommendations and 2 weak recommendations. In one case, where consensus could not be agreed upon, no recommendation could be provided.Management of SAH in a non-specialized setting and early transfer are difficult and may have a critical impact on outcome. Clinical advice, based on multidisciplinary consensus, might be helpful. Our recommendations cover most, but not all, topics of clinical relevance.

INTRODUCTION:Aggressive osteoblastoma (AO) represents a rare tumor with borderline features between benign osteoblastoma and osteosarcoma. Having a local aggressive behavior without metastasizing attitude, radical excision is a mainstay treatment. Conversely, spine fusion technique is still debated. We report a rare case of cervicothoracic junction (CTJ) AO and the tailored decision-making process to choose the best treatment.CASE PRESENTATION:A 34-year-old man complaining of neck pain was admitted to our department. Cervicothoracic MRI revealed a well-circumscribed lesion involving C7 left lamina with cortical erosion and mild spinal canal invasion. Additionally, STIR sequences exhibited a bright signal spreading through the posterior third of the C7 and T1 vertebrae which on T1-weighted and T2-weighted sequences appeared isointense and hyperintense, respectively. Therefore, the patient underwent a C7 laminotomy. Histology revealed an aggressive variant of osteoblastoma. Therefore, tumor was classified as AO and surgical management was reconsidered. A combined anterior and posterior approach was recommended to reach oncological radicality and spinal stability. At 6-years follow-up, patient remained neurologically intact without signs of recurrence and/or of instability.DISCUSSION:Due to its rarity and mimicking features, diagnosis of AO results challenging. Due to its aggressive behavior, radical surgery is the mainstay treatment. Conversely, the most suitable fusion technique is still debated. A proper surgical management should be focused on oncological radicality to guarantee the total tumoral removal avoiding progression or recurrences. Similarly, a proper evaluation of the long-term spinal balance should be assessed to avoid developing of spinal deformities or instrumentation failures.

BACKGROUND: Frameless stereotactic biopsy repre-sents a minimally invasive procedure used for the histopathological diagnosis of brain tumors or to safely approach deep-seated lesions near eloquent areas not amenable for classical neurosurgical procedures. Traditionally, biopsy is performed relying on anatomical landmarks, but it can lead itself to intraand postoperative complications, such as hemorrhage and fiber disruption. Diffusion tensor imaging (DTI) tractography represents a useful tool that can analyze the individual fiber tract conformation in cases of brain tumor and consequently identify the best biopsy trajectory, preserving white matter pathways. In our study, we present a novel technique that is based on the use of preoperative DTI for biopsy. METHODS: Between January 2018 and January 2020, data about patients who underwent frameless biopsy using DTI tractography were retrospectively reviewed. The inclusion criterion was adult patients eligible for elective surgery for a single or multiple deep-seated lesions with contraindications to complete surgical resection. RESULTS: We included 12 patients (mean age of 67.9 [9.6] years). A single cranial lesion was detected in 7 cases, and multiple lesions in 5 cases. The use of DTI enabled the identification of white matter pathways in all cases and adjustment of the biopsy trajectory based on anatomical landmarks in 7 cases. Postoperative hematoma was reported in 1 case, and histological diagnosis was obtained in 11 cases. CONCLUSION: According to our results, tractography is a useful tool that can enhance the safety of cerebral lesions biopsy sparing any fiber tract damages.