Abstract Background Intracranial teratomas are rare tumors of the central nervous system (CNS). Their occurrence in the posterior fossa is particularly uncommon in adults, with only three previously reported cases in the cerebellopontine (CP) angle, all in women and located in the right cistern. Case presentation We present the case of a 51-year-old male patient with left-sided hearing loss, diplopia, and balance disturbances. Magnetic resonance imaging (MRI) revealed a large extra-axial mass in the left CP angle compressing the left cerebellar hemisphere and brainstem. An epidermoid cyst was suspected initially. The patient underwent surgical treatment, and histopathological analysis revealed mature teratoma. Conclusion Posterior fossa mature teratomas, though extremely rare in adults, should be considered in the differential diagnosis of large CP angle masses, especially - but not exclusively - when MRI findings are “atypical”. Complete surgical resection and continuous follow-up are essential to prevent malignant transformation and to monitor recurrence.

BACKGROUND:Anterior frontobasal fractures are complex injuries, with treatment strategies varying based on fracture type and associated complications, particularly pneumocephalus and cerebrospinal fluid (CSF) leaks. The optimal timing for surgical intervention remains a topic of debate. METHODS:We retrospectively reviewed data from 314 patients with anterior frontobasal fractures treated at our department (Neurosurgery, "Sapienza" University of Rome) between 2012 and 2023. Fractures were classified into types A, B, and C, with subtypes, based on clinical and radiological features. The duration of pneumocephalus and CSF leaks was analyzed with 1-way analysis of variance and Tukey-Kramer post hoc tests. Posterior frontal sinus (FS) wall diastasis and its impact on surgical decisions were assessed using chi-square and Fisher exact tests. RESULTS:The mean duration of pneumocephalus was significantly longer in the surgical group (5.13 days, standard deviation [SD]: 0.79) compared to the conservative group (2.3 days, SD: 0.69) (P<0.0001). Similarly, the mean duration of CSF leaks was 5 days (SD: 0.84) in the surgical group and 1.74 days (SD: 0.76) in the conservative group (P<0.0001). Critical thresholds for surgery were 3 days for pneumocephalus and 3.5 days for CSF leaks. Posterior FS wall diastasis >2 mm was significantly associated with the need for surgery (P<0.0001). Clinical outcomes were comparable between groups. CONCLUSIONS:Conservative management is effective for pneumocephalus and CSF leaks up to 3 and 3.5 days, respectively. Surgery is recommended when these complications persist or recur, especially in cases with significant posterior FS wall diastasis.

BACKGROUND: Inserting cerebrospinal fluid diversion devices such as external ventricular drains (EVDs) and ventriculoperitoneal shunts (VPSs) is a critical procedure. Unfortunately, complications such as catheter misplacement, dislocation, or infection can occur. Various surgical strategies aim to reduce these risks. One recent innovation is the "catheter -locking device -assisted" technique for EVD surgery. In this study, we examined its application in a larger group of cases encompassing both EVDs and VPSs over a 30 -month period, with a focus on these complications. METHODS: All adult patients who underwent a shunt procedure for noninfectious hydrocephalus at our institution from January 2021 to June 2023 were reviewed. We compared complications between those treated with the "standard" technique (subgroup A) and those managed with the "catheter -locking device -assisted" approach (subgroup B). RESULTS: In the EVD surgical group (initial procedures, n = 161), 6 patients (3.7%) required reoperation owing to the catheter misplacement caused by inadvertent migration of the ventricular catheter within the operating room ("early" migration), while 11 patients (6.8%) experienced - nintentional postoperative dislodgement ("delayed" migration). Seven patients (4.3%) developed an EVD-related infection after an average duration of 7.4 days. None of these complications were observed in subgroup B patients (P < 0.05). Among VPS patients (n = 137), 4 (2.9%), all in subgroup A, required reoperation due to intraoperative migration of the catheter (P = 0.121); no other complications were identified. CONCLUSIONS: The "catheter -locking device -assisted" technique may significantly decrease the occurrence of the most common EVD complications and can also prove beneficial in VPS surgery. However, further investigation is necessary.

Background: Spontaneous and nontraumatic epidural hematoma (SEDH) is a rare entity. Etiology is various, including vascular malformations of the dura mater, hemorrhagic tumors, and coagulation defects. The association between SEDH and craniofacial infections is rather unusual. Methods: We performed a systematic review of the available literature using the PubMed, Cochrane Library, and Scopus research databases. Literature research was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We exclusively included studies reporting demographic and clinical data, published until October 31, 2022. We also report one case from our experience. Results: A total of 18 scientific publications, corresponding to 19 patients, met the inclusion criteria for the qualitative and quantitative analysis. Patients were mostly adolescents, with a clear male predominance. SEDHs frequently occurred in the frontal area, usually near the site of the infection. Surgical evacuation was the treatment of choice with good postoperative outcomes. Endoscopy of the involved paranasal sinus should be achieved as soon as possible to remove the cause of the SEDH. Conclusion: SEDH may occur as a rare and life-threatening complication of craniofacial infections; therefore, prompt recognition and treatment are mandatory.

The aim of this anatomical study is to describe the anatomy of the hypoglossal nerve (HN) from its origin to the extracranial portion as it appears by performing a combined posterolateral and anterolateral approach to the craniovertebral junction (CVJ). Twelve fresh, non-formalin-fixed adult cadaveric heads (24 sides) were analyzed for the simulation of the combined lateral approach to the CVJ. The HN is divided into three main parts: cisternal, intracanalicular, and extracranial The anatomical relationships between the HN and other nerves, muscles, arteries and veins were carefully recorded, and some measurements were made between the HN and related structures. Thus, various landmarks were determined for the easy identification of the HN. Understanding the detailed anatomy of the HN and its relationships with the surrounding structures is crucial to prevent some complications during CVJ surgery.

Background  External ventricular drain (EVD) placement is frequently performed in neurosurgical patients to divert cerebrospinal fluid (CSF) and monitor intracranial pressure. The traditional practice is the tunneled EVD technique performed in the operating room. EVD insertion through a bolt in intensive care units has also been reported. We describe here the usage of a novel technique, the “ catheter-locking device -assisted” EVD placement, reporting our preliminary, observational single-center results. Methods  From January to October 2021, 15 patients underwent a “catheter-locking device-assisted” EVD placement at our institute. For each of these patients, the following data were evaluated: (1) demographics, (2) etiology, (3) clinical presentation, (4) EVD complications, and (5) final clinical outcomes. Results  Median age of our population was 64 years, with a female/male ratio of 2:1. Average Glasgow Coma Scale score on admission was 8. Each patient maintained the drainage for an average time of 14 days. None of the patients suffered from postoperative intracerebral hemorrhage, CSF leakage, catheter migration, or discontinuation of the drainage system; none developed signs of infection. Nine patients required a permanent CSF diversion system. Outcome was good in 14 patients. One patient died for the underlying disease. Conclusions  The “catheter-locking device-assisted” EVD placement appears to be a safe and accurate alternative to both the standard tunneled and the bolt-assisted EVD insertion techniques. The use of this procedure may significantly reduce the incidence of the commonest EVD complications, though further investigation is required.

Background: Cavernous angiomas, also referred to as cavernous hemangiomas or cavernomas (CMs), are vascular malformative benign neoplasms that may develop in any part of the central nervous system. Spinal CMs are uncommon (overall incidence rate of 0.04–0.05%). Pure epidural CMs account for 1–2% of all spinal CMs and 4% of all spinal epidural tumors. Diagnosis is extremely rare in the pediatric age. To the best of our knowledge, only 10 cases have been described so far. The treatment of choice is microsurgical resection. Case Description: We describe here the rare case of a cervicothoracic hemorrhagic spinal epidural cavernoma in a paucisymptomatic, 8-year-old female Bangladeshi child. C7–T2 laminectomy with excision of a scarcely defined, capsulated dark red lesion was performed with good recovery. Conclusion: Spinal epidural cavernomas are rare. Childhood presentation is even rarer. The reason could be found in a greater “compliance” and to a rarer occurrence of acute bleeding in children, thus resulting in a delayed diagnosis. Surgical excision is the gold standard of treatment.

Background: Fixation of bone flaps after craniotomy is a routine part of every neurosurgical procedure. The ideal fixation device should be safe, reliable, biologically inert, easy to use, and inexpensive and should not produce artifacts on neuroimaging. The authors describe a new device that meets these criteria. Methods: This is an observational, multicentric, and case series study of 56 patients who underwent a craniotomy and were subject to cranial bone flap fixation with the NT cranial small fixation system. A case–control group in whom titanium miniplates and screws were implanted was collected. All patients underwent CT scans of the head with 3D reconstruction at day 1 and day 90 postoperatively to evaluate bone flap position and fusion. Results: A total of 140 NT cranial small were implanted in 56 patients (mean age 44.2, range 22–63 years). The new device has shown stronger fixation qualities with optimal bone flap fusion and good cosmetic features. No surgical or relevant postsurgical follow-up complications have been associated with the device. Conclusion: Although this is a preliminary report in a relatively small number of patients, NT cranial small provides a safe, reliable, and easily applied postoperative cranial bone flap fixation system.

It is known that intracranial tumors may trigger trigeminal neuralgia (TN) in some patients although the exact prevalence and occurrence is not completely defined yet. In the present study, we present a case series of patients with brain tumor and a clinical diagnosis of TN as the first and main manifestation of the disease. A retrospective analysis was performed involving patients diagnosed with brain tumor whose exclusive clinical feature our department focused on was TN. In addition, a review of all published cases was performed. From January 2017 to November 2018, 718 patients with brain tumor were admitted to our department, 17 of which suffered of TN, of which 8 patients presented with at least another neurologic symptom and 9 patients presented with TN alone, with typical symptoms of stubbing electric pain in 6 cases. In our series, we found that 2.3% of patients admitted for brain tumors had TN. In 0.8% of cases, TN was the main clinical symptom. The prevalence of tumor lesion in patients with facial neuropathic pain is not defined, but it is a well-known recognized initial symptom; however, early cerebral magnetic resonance imaging (MRI) is not yet strongly recommended in patients with newly diagnosed trigeminal neuralgia. The purpose of this article is, especially in unusual cases, to show that the application of such MR techniques and preoperative evaluation may contribute to diagnosis, indication, and surgery planning.

In 1863, Virchow proposed the first classification of vascular anomalies. He considered these lesions to be tumors (“angiomas”) and classified them into three categories (“simplex”, “cavernosum”, and “racemosum”) according to the microscopic appearance of the diseased vascular channels [2]. It was subsequently stated that angiomas could be either capillary, venous or arterial (with or without fistulae) based on the stage at which vascular morphogenesis was altered [3]. Setting aside Virchow’s hypothesis, Mulliken and Glowacki, in 1982, developed a new, “binary” classification model in which they distinguished true (1) vascular “hemangiomas”, characterized by cellular hyperplasia, from (2) vascular “malformations” which instead demonstrated vessel dysplasia with normal rates of cellular turnover. They also described the different biological behavior of the two “entities” in terms of tendency to spontaneous regression (present in vascular hemangiomas, absent in vascular malformations) [4]. This scheme was later embraced by the “International Society for the Study of Vascular Anomalies” (ISSVA) at the 1996 meeting in Rome [5], “expanded” at the 2014 ISSVA workshop in Melbourne, and last revised in 2018 (the updates were crucial to fully incorporate the genetic and histopathological advances in the knowledge of these lesions) [6,7]. Vascular tumors were divided into benign, borderline/locally aggressive, and malignant, and were also further sub-classified by pattern and location to include syndromic associations, such as PHACE (posterior fossa brain malformations, large facial hemangiomas, anatomical anomalies of the cerebral arteries, aortic coarctation and other cardiac anomalies, eye abnormalities) and LUMBAR (lower body congenital infantile hemangiomas and other skin defects, urogenital anomalies and ulceration, myelopathy, bony deformities, anorectal malformations and arterial anomalies, rectal anomalies) [7].

Capillary hemangiomas (CHs) of the central nervous system represent a rare diagnosed pathology. CHs are benign vascular tumors whose most common manifestations are dermal and mucous and mainly occur during childhood or adolescence, while the involvement of the central nervous system can occur in a wider age range. We conducted a PubMed research on literature published until March 2020. We only enrolled cases with histological documented presence of intracranial CH. For every case collected, we analyzed age, sex, localization, neuroimaging studies performed, the presence of extracranial CHs, symptoms, neurological deficits, extent of surgical resection (biopsy, partial or gross total), adjunct treatment received (radiotherapy, chemotherapy, Trans-Arterial Embolization TAE), and outcome. Up to March 2020, the literature review identified 52 cases to which we added the case of our personal experience. The mean age was 26 with slightly female prevalence (28 F, 25 M). The most common presenting symptom was headache (21 cases, 40%). The surgical treatment consisted of biopsy in 7 cases (13%), partial resection in 10 cases (19%), gross total resection in 31 cases (58.5%), biopsy followed by total resection in 2 cases (3%), and partial resection followed by total resection in 1 case (1.5%), and the diagnosis was obtained from an autopsy sample in 1 case (1.5%). For symptomatic lesions, surgery is a valid option to obtain histological characterization, neurological improvement, and where possible a total resection. Stereotactic radiotherapy can be used if the lesion is not surgically approachable or as an adjuvant treatment in case of partial resection, having shown good results in terms of long-term disease control.

Retroclival epidural hematomas (REDHs) are rare and almost exclusively found in the pediatric age group. Frequently, the etiology is related to accidental trauma, though other mechanisms have been observed, including coagulopathy, non-accidental trauma, and pituitary apoplexy. A 76-year-old man was admitted to our emergency department after a loss of consciousness. He presented with a Glasgow Coma Scale of 13(E3V4M6). He complained of headache accompanied by nausea and vomiting. A computer tomography (CT) revealed a hemorrhage along the clivus and dens. Magnetic resonance imaging (MRI) demonstrated the retroclival hematoma in epidural space. At discharge headache resolved without medical or operative intervention. REDHs are likely underdiagnosed in adults and magnetic resonance imaging is superior for identifying these lesions. Atlanto-occipital dislocation should be considered in all cases of REDH. Most cases exhibit a benign clinical course with conservative management, surgical management is dictated based on the presence of hydrocephalus, brainstem compression, and occipitocervical instability.

Ethmoidal dural arteriovenous fistulae are rare vascular malformations associated with a high risk of bleeding. We present a multicenter contemporary series of patients treated with microsurgical and endovascular techniques. Sixteen consecutive patients were evaluated and/or treated between 2008 and 2015 at four centers with large experience in the endovascular and surgical treatment of cerebrovascular diseases. We analyzed demographic and clinical data, risk factors for dural fistulas, treatment type, peri- and post-operative morbidity, clinical and radiological outcomes, rates of occlusion, and long-term neurological outcome. Sixteen patients (81 % men, mean age of 58 years) with ethmoidal dural fistulas were included in the analysis. Seven patients had suffered an intracranial hemorrhage; the remaining presenting with neurological signs and symptoms or the fistula was an incidental finding. Three patients were managed conservatively. Among patients who underwent intervention (n = 13), 46.1 % were treated with endovascular therapy and 53.9 % were treated surgically. Complete angiographic obliteration was achieved in 100 % immediately after treatment and at last follow-up evaluation. All patients experienced a favorable neurological recovery (mRS 0–2) at the last follow-up visit (12 months). Ethmoidal dural AVFs are found mostly in male patients. Nowadays, due to wider use of non-invasive imaging, AVFs are discovered with increasing frequency in patients with minimal or no symptoms. Traditionally, these fistulas were considered “surgical.” However, in the modern endovascular era, selected patients can be effectively and safely treated with embolization although surgical ligation continues to have an important role in their management.

The formation of a post-traumatic delayed epidural hematoma (DEDH) is a rare but well-described complication in the literature. It is defined as an extradural bleeding not evident at the first computed tomography (CT) scan performed after trauma, but evidenced by further radiological evaluations. The most supported hypothesis about the mechanism responsible for the formation of a DEDH concerns above all the loss of a tamponade effect given by the reduction of intracranial pressure with medical or surgical treatment. A 30-year-old man was admitted to the emergency department with an epidural hematoma (EDH) associated with a linear calvarial bitemporal coronal fracture. A few hours after the surgical procedure for hematoma evacuation, the patient developed a DEDH contralateral to the site of surgical procedure. The literature review identified other 27 analogue cases. The presence of a calvarial fracture contralateral to the site of a craniotomy and the intraoperative brain swelling during EDH removal are suspicious for the development of DEDH. A CT scan has to be urgently performed in this situation. The timing of postoperative radiological examinations after EDH removal has to consider possible complications and has to be balanced on the basis of patient’s clinical condition and neuroradiological data, such as skull fractures or intraoperative anomalies. The development of a DEDH after the surgical removal of an EDH is a rare event, characterized by a high mortality rate. DEDH develops preferentially on the contralateral side and with a concomitant skull fracture.

Post-operative pediatric cerebellar mutism syndrome (PPCMS) is a clinical syndrome arising from cerebellar injury and characterized by absence of speech and other possible symptoms and signs. Rare reports described some benefit after administration of dopamine agonist therapy, but no treatment has proven efficacy. In this paper, we report on the dramatic, sudden resolution of PPCMS induced by midazolam administration in a boy who underwent posterior fossa surgery for choroid plexus papilloma of the fourth ventricle. In addition to clinical improvement, post-midazolam single-photon emission computed tomography also demonstrated amelioration of brain perfusion.

BACKGROUND: Mesenchymal stem cells (MSCs) are undifferentiated, multipotent cells, which have the ability to self-renew and differentiate into many tissue types. MSCs have shown therapeutic applications in different medical fields and could represent a successful treatment of degenerative disc disease (DDD). Several studies have demonstrated, ex vivo or in animal models, the MSCs efficacy in spine surgery. The authors aim to demonstrate their efficacy in humans.METHODS: Twenty-two consecutive patients, who suffered of spine DDD, were submitted: in 11 cases the MSCs were harvested from red bone marrow, 11 from fat tissue. The red bone marrow withdrawal was performed from the vertebral bodies; processed by a fully-automated, mobile system. The fat tissue withdrawal was acted from the subcutaneous adipose tissue; processed through a microfluidic fractioning procedure. MSCs were implanted in the central part of the nucleus pulposus of the DDD or added to bone chips to accelerate posterolateral arthrodesis.RESULTS: All the 14 posterolateral fusions and MSCs implantations showed at three months a complete bone bridge, stable at follow-up. The one intersomatic implantation gained a complete interbody fusion after one month; while 80% black discs treated with MSCs presented a new T2-W hyperintensity at postoperative MRI. The mean Visual Analogue Scale Pain Score improved from 70 +/- 20 to 10 +/- 5 at 12 months, as the ODI score from 70 +/- 5% to 20 +/- 10%.CONCLUSIONS : There are several questions that need to be answered but MCSs look promising in lumbar spine surgery, both to block the aging of the disc both to accelerate the fusion processes in arthrodesis.

Vertebroplasy is considered an alternative and effective treatment of painful oncologic spine disease. Major complications are very rare, but with high morbidity and occur in less than 1% of patients who undergo vertebroplasty. Spinal subdural hematoma (SDH) is an extremely rare complication, usual developing within 12 h to 24 h after the procedure. We report the case of a tardive SDH in an oncologic patient who underwent VP for Myxoid Liposarcoma metastasis. Trying to explain the pathogenesis, we support the hypothesis that both venous congestion of the vertebral venous plexus of the vertebral body and venous congestion due to a traumatic injury can provoke SDH. To our best knowledge, only 4 cases of spinal subdural hematoma following a transpedicular vertebroplasty have been previously described in International literature and only one of them occurred two weeks after that surgical procedures. Percutaneous verteboplasty is a well-known treatment of pain oncologic spine disease, used to provide pain relief and improvement of quality life and is considered a simple surgical procedure, involving a low risk of complications, but related to high morbidity, such as SDH. Therefore it has to be performed by experienced and skilled surgeons, that should also recognize possible risk factors, making SDH more risky.

We present the first and only case, reported in literature, of a 67-years-old man with a mycotic aneurysm (MA) of the left posterior inferior cerebellar artery (PICA), caused by group B Streptococcus, that we surgically treated, performing neck aneurysm clipping, preserving patency of parent vessel. Moreover the peculiarity of this case is represented by the fact that the MA is originated from a tooth abscess, treated about two years before. To date, there have been only 10 cases of association between MA with either tooth pathologies or dental surgical procedures and our case is the only one originating from PICA. Therefore an extensive literature analysis was performed. Hence if we observe a patient with a fusiform aneurysm in posterior intracranial circulation and clinical history of fever and/or persistent neck swelling after dental pathologies, it is mandatory to consider the possibility of a MA, for a correct differential diagnosis. If the diagnosis is confirmed, it is necessary to research the origin of infection and to set the specific antibiotics therapy.