BACKGROUND:The natural history and pathophysiology of diverticular disease (DD) are still uncertain. An ex-vivo human complicated DD (cDD) model has recently shown a predominant transmural oxidative imbalance. The present study aims to evaluate whether the previously described alterations may precede the symptomatic form of the disease. METHODS:Colonic surgical samples obtained from patients with asymptomatic diverticulosis (DIV), complicated DD, and controls were systematically and detailed morphologically and molecularly analyzed. Therefore, histologic, histomorphometric, immunohistochemical evaluation, and gene and protein expression analysis were performed to characterize colonic muscle changes and evaluate chronic inflammation, oxidative imbalance, and hypoxia. Functional muscle activity was tested on strips and isolated cells in response to contractile and relaxant agents. KEY RESULTS:Compared with controls, DD showed a marketed increase in muscle layer thickness, smooth muscle cell syncytium disarray, and increased interstitial fibrosis; moreover, the observed features were more evident in the cDD group. These changes mainly affected longitudinal muscle and were associated with altered contraction-relaxation dynamics and fibrogenic switch of smooth muscle cells. Chronic lymphoplasmacytic inflammation was primarily evident in the mucosa and spared the muscle. A transmural increase in carbonylated and nitrated proteins, with loss of antioxidant molecules, characterized both stages of DD, suggesting early oxidative stress probably triggered by recurrent ischemic events, more pronounced in cDD, where HIF-1 was detected in both muscle and mucosa. CONCLUSION & INFERENCES:The different DD clinical scenarios are part of a progressive process, with oxidative imbalance representing a new target in the management of DD.

The pathophysiology of diverticular disease (DD) is not well outlined. Recent studies performed on the DD human ex vivo model have shown the presence of a predominant transmural oxidative imbalance whose origin remains unknown. Considering the central role of mitochondria in oxidative stress, the present study evaluates their involvement in the alterations of DD clinical phenotypes. Colonic surgical samples of patients with asymptomatic diverticulosis, complicated DD, and controls were analyzed. Electron microscopy, protein expression, and cytofluorimetric analyses were performed to assess the contribution of mitochondrial oxidative stress. Functional muscle activity was tested on cells in response to contractile and relaxant agents. To assess the possibility of reverting oxidative damages, N-acetylcysteine was tested on an in vitro model. Compared with the controls, DD tissues showed a marketed increase in mitochondrial number and fusion accompanied by the altered mitochondrial electron transport chain complexes. In SMCs, the mitochondrial mass increase was accompanied by altered mitochondrial metabolic activity supported by a membrane potential decrease. Ulteriorly, a decrease in antioxidant content and altered contraction–relaxation dynamics reverted by N-acetylcysteine were observed. Therefore, the oxidative stress-driven alterations resulted in mitochondrial impairment. The beneficial effects of antioxidant treatments open new possibilities for tailored therapeutic strategies that have not been tested for this disease.

Diverticular disease (DD) management is impaired by its pathogenesis, which is still not completely defined, with an unmet clinical need for improved therapies. Ex vivo DD human models demonstrated the presence of a transmural oxidative imbalance that supports an ischemic pathogenesis. This study aimed to assess, with the use of circulating biomarkers, insights into DD pathogenesis and possible therapeutic targets. Nox2-derived peptide, H2O2, antioxidant capacity, isoprostanes, thromboxanes, TNF-α, LPS and zonulin were evaluated by ELISA in healthy subjects (HS) and asymptomatic and symptomatic DD patients. Compared to HS, DD patients presented low antioxidant capacity and increase in sNox2-dp, H2O2 and isoprostanes paralleled to a TNFα increase, lower than that of oxidative markers. TxB2 production correlated to Nox2 and isoprostanes, suggesting platelet activation. An increase in zonulin and LPS highlighted the role of gut permeability and LPS translocation in DD pathogenesis. The increase of all the markers statistically correlated with DD severity. The present study confirmed the presence of a main oxidative imbalance in DD and provides evidence of platelet activation driven by LPS translocation. The use of circulating biomarkers could represent a new clinical tool for monitoring disease progression and validate therapeutic strategies never tested in DD as antioxidant supplementation.

Background It is still a matter of debate if neuromuscular alterations reflect a primary event in diverticular disease (DD). Aims This study aimed to assess colonic wall layers from both stenotic and non-stenotic complicated DD, bio-phenotypic alterations, inflammatory and oxidative status. Methods A systematic analysis of colonic specimens obtained from stenotic and non-stenotic DD specimens was conducted and compared with controls. Biological activity and qPCR analysis were performed on longitudinal and circular muscles. Western blot analysis was performed throughout colonic wall layers to quantify oxidative and inflammatory markers. Results A homogenous increase in oxidative stress was observed through all the layers, which were more sharpened in the longitudinal muscle for a loss in antioxidant defenses. In both stenotic and non-stenotic colon, the longitudinal muscle presented an impaired relaxation and a cellular phenotypic switch driven by transforming growth factor-β with an increase in mRNA expression of collagen Iα and a decrease in myosin heavy chain. The circular muscle, as the mucosa, was less affected by molecular alterations. No peculiar increase in inflammatory markers was observed. Conclusion A longitudinal colonic myopathy is present in DD, independently from the disease stage associated with an oxidative imbalance that could suggest new therapeutic strategies.

BACKGROUND: Acute subdural hematoma represents an important cause of disability and mortality. Its surgical treatment takes advantage of two surgical procedures: craniotomy and decompressive craniectomy, nevertheless the effectiveness of one procedure rather than the other is still debated. This study was conducted to identify which of the surgical procedures could provide better neurological outcome after traumatic acute subdural hematoma; as a secondary endpoint, the study tries to settle preoperative prognostic factors useful to identify the most appropriate surgical technique for every specific patient and kind of trauma. METHODS: A retrospective analysis was performed on patients who underwent craniotomy or decompressive craniectomy between January 2010 and July 2017 at the Department of Neurosurgery of Umberto I Hospital in Rome. Ninety-four patients were selected and reviewing clinical records, preoperative and postoperative's data were collected (e.g., GCS, mechanism of trauma, CT findings, mortality rate, neurological outcome at discharge, mRS at 12 months). Data were analyzed using x2 test and the F test. The multivariate analysis was performed using a stepwise logistic regression. The analysis was carried out using SPSS software and a P value <0.05 was considered significant. RESULTS: In 94 patients, 46.8% underwent decompressive craniectomy and 53.2% underwent craniotomy. The mortality rate was (53.2%); it was shown to be related to a GCS 8 (P=0.033) and to age 60 years old (P=0.0001). Decompressive craniectomy was performed most frequently for high energy trauma (P=0.006); the mean GCS at admission was 7.91 for decompressive craniectomy and 9.64 for craniotomy (P=0.05). Patients who underwent decompressive craniectomy and survived surgery showed a better neurological outcome compared to those who underwent craniotomy (P=0.009). The evaluation of mRS after 12 months did not show a statistically significant difference between the two groups. CONCLUSIONS: In case of high energy trauma and GCS<8 different neurosurgeons decided to perform most frequently decompressive craniectomy rather than craniotomy. Furthermore, even if not related to survival rate, decompressive craniectomy showed a better neurological outcome especially in patients with GCS<8 at admission. In conclusion, even if prospective studies are required, these results depict the current attitude about the choice between craniotomy and decompressive craniectomy. (Cite this article as: Ruggeri AG, Cappelletti M, Tempestilli M, Fazzolari B, Delfini R. Surgical management of acute subdural hematoma: a comparison between decompressive craniectomy and craniotomy on patients treated from 2010 to the present in a single center. J Neurosurg Sci 2022;66:22-7.

AIM: To assess the feasibility of using an endoscopic-assisted lateral supraorbital (LSO) approach and an endoscopic endonasal transclival approach (EETA) for basilar apex (BAX) aneurysms. MATERIAL and METHODS: Ten cases with LSO approaches, with or without posterior clinoidectomy and endoscopic assistance, and 10 cases with EETA, with or without drilling of the dorsum sellae, were performed on 20 cadaveric heads. Anatomical exposure and surgical freedom at the BAX were evaluated. RESULTS: Anatomical exposure provided by the LSO approach was limited to the BAX and ipsilateral posterior cerebral artery (PCA) and increased with a mean value of 5.0 mm after posterior clinoidectomy; the basilar artery, contralateral PCA, and superior cerebellar arteries (SCAs) were visualized in all cases. Accordingly, surgical freedom was larger. Endoscopic assistance provided a significant increase in basilar artery exposure; however, surgical freedom did not increase markedly. The main advantage of EETA was the greatest exposure of the basilar artery. With drilling of the dorsum sellae, anatomical exposure increased by a mean value of 3.4 mm, and provided the greatest amount of surgical freedom and visualization of the basilar artery terminal bifurcation and of the SCAs in all cases. CONCLUSION: The endoscopic-assisted LSO approach and the EETA may represent a feasible approach for treatment of BAX aneurysms lying within 5.0 mm below and within 3.4 mm above the dorsum sellae.

Accumulating evidence shows that oxidative stress plays an essential role in the pathogenesis and progression of many diseases. The imbalance between the production of reactive oxygen species (ROS) and the antioxidant systems has been extensively studied in pulmonary, neurodegenerative cardiovascular disorders; however, its contribution is still debated in gastrointestinal disorders. Evidence suggests that oxidative stress affects gastrointestinal motility in obesity, and post-infectious disorders by favoring the smooth muscle phenotypic switch toward a synthetic phenotype. The aim of this review is to gain insight into the role played by oxidative stress in gastrointestinal pathologies (GIT), and the involvement of ROS in the signaling underlying the muscular alterations of the gastrointestinal tract (GIT). In addition, potential therapeutic strategies based on the use of antioxidants for the treatment of inflammatory gastrointestinal diseases are reviewed and discussed. Although substantial progress has been made in identifying new techniques capable of assessing the presence of oxidative stress in humans, the biochemical-molecular mechanisms underlying GIT mucosal disorders are not yet well defined. Therefore, further studies are needed to clarify the mechanisms through which oxidative stress-related signaling can contribute to the alteration of the GIT mucosa in order to devise effective preventive and curative therapeutic strategies

OBJECTIVE: The endoscopic technique is in many cases the technique of choice for the removal of pituitary adenomas. Extended endoscopic approaches make it possible to remove lesions with suprasellar and parasellar extension and fibrous consistency. We identify some characteristics that might point to the adoption of an expanded approach in the preoperative phase. METHODS: We considered 66 consecutive cases treated for pituitary macroadenomas. All patients underwent preoperative magnetic resonance imaging and computed tomography, as well as postoperative magnetic resonance imaging. From the analysis of surgical reports and preoperative radiologic investigations, we extracted data related to size, extension, morphologic characteristics, consistency, and type of approach used (sellar or expanded). The degree of removal was judged to be total, near total, subtotal, or partial. RESULTS: The data showed that in some cases it is possible to assume in advance that there is a need for an expanded endoscopic approach. The features that led to an extended approach for extracapsular dissection of the lesion were the size of the tumor; an hourglass/dumbbell shape; lateral extension to the suprasellar carotid artery; Knosp degree 3 or 4; contrast enhancement heterogeneity; intratumoral hemorrhage, erosion, or discontinuity of the sellar floor; and increased sellar depth, which predicts increased thickness. CONCLUSIONS: The ability to predict the consistency of pituitary adenomas allows the surgeon to design a surgical procedure tailored to the patient. This approach has advantages concerning the extent of resection and allows a radical strategy with a single surgical procedure to be pursued.

Postoperative cerebrospinal fluid (CSF) leak still represents the main limitation of endonasal endoscopic surgery. The aim of the study is to classify the risk of postoperative leak and to propose a decision-making protocol to be applied in the preoperative phase based on radiological data and on intraoperative findings to obtain the best closure.One hundred fifty-two patients were treated in our institution; these patients were divided into 2 groups because from January 2013 the closure technique was standardized adopting a preoperative decision-making protocol. The Postoperative CSF leak Risk Classification (PCRC) was estimated taking into account the size of the lesion, the extent of the osteodural defect, and the presence of intraoperative CSF leak (iCSF-L). The closure techniques were classified into 3 types according to PCRC estimation (A, B, and C).The incidence of the use of a nasoseptal flap is significantly increased in the second group 80.3% versus 19.8% of the first group and the difference was statistically significant P < 0.0001. The incidence of postoperative CSF leak (pCSF-L) in the first group was 9.3%. The incidence of postoperative pCSF-L in the second group was 1.5%. An analysis of the pCSF-L rate in the 2 groups showed a statistically significant difference P = 0.04.The type of closure programmed was effective in almost all patients, allowing to avoid the possibility of a CSF leak. Our protocol showed a significant total reduction in the incidence of CSF leak, but especially in that subgroup of patients where a leak is usually unexpected.

Since the introduction of endoscopic surgery for the treatment of skull base lesions, one of the main issues has been the CSF leak. The implementation of efficient reconstructive techniques has reduced the post-operative CSF leak rate. However, none of the techniques for closure has proved to be totally effective in preventing CSF leakage. We propose a possible solution to this problem. Two patients underwent surgery for suprasellar meningioma via an expanded endoscopic endonasal approach and subsequently presented post-operative CSF leakage. They were treated via injections of autologous fibrin glue at the patients' bedside. The autologous fibrin glue was obtained using the automated Vivostat (R) system, that prepares 5 ml of autologous fibrin sealant from 120 ml of the patient's own blood. In both patients, we obtained the permanent closure of the small defects and the interruption of the leakage. The application of autologous fibrin glue made it possible to successfully treat these two cases of postoperative CSF leak without the need of a second operation. The advantage of using autologous fibrin glue is probably related to the high biological activity of such material in promoting a faster healing, it might be a solution in selected cases.

BACKGROUND: Ependymoma accounts for 3%-9% of all neuroepithelial tumors. Giant cell ependymoma (GCE) is a rare and distinct variant, with only 22 cases described in the literature. The 2007 World Health Organization classification first acknowledged this rare subtype. The cytologic features of GCE include the presence of pleomorphic giant cells with several cellular atypias, which at intraoperative frozen diagnosis may appear to be high-grade glial lesions. Despite its apparently malignant histology, GCE seems to be a neoplasm with a relatively good prognosis. Extended tumor removal is the gold standard without adjuvant treatment. CASE DESCRIPTION: We describe the first case, to our knowledge, of GCE situated at the cervicomedullary junction in a 62-year-old patient. Surgery was performed with combined intraoperative monitoring of motor evoked potentials and somatosensory evoked potentials. Intraoperative frozen diagnosis revealed a high-grade glial neoplasm; however, gross total resection was achieved. The definitive diagnosis was GCE. At follow-up evaluation 11 years after surgery, the patient did not present with any tumor recurrence. CONCLUSIONS: As the intraoperative diagnosis can be misleading, whenever a cleavage plane is recognized, it is essential to perform a gross total resection with the aid of intraoperative neurophysiologic monitoring, to improve prognosis and neurologic outcome. Data reported in the literature show that prognosis is mainly influenced by grade of resection.

OBJECTIVE Neurosurgical management of many vascular and neoplastic lesions necessitates control of the internal carotid artery (ICA). The aim of this study was to investigate the feasibility of achieving control of the ICA through the endoscopic endonasal approach by temporary occlusion with a Fogarty balloon catheter. METHODS Ten endoscopic endonasal paraseptal approaches were performed on cadaveric specimens. A Fogarty balloon catheter was inserted through a sellar bony opening and pushed laterally and posteriorly extraarterially along the paraclival carotid artery. The balloon was then inflated, thus achieving temporary occlusion of the vessel. The position of the catheter was confirmed with CT scans, and occlusion of the ICA was demonstrated with angiography. The technique was performed in 2 surgical cases of pituitary macroadenoma with cavernous sinus invasion. RESULTS Positioning the Fogarty balloon catheter at the level of the paraclival ICA was achieved in all cadaveric dissections and surgical cases through a minimally invasive, quick, and safe approach. Inflation of the Fogarty balloon caused interruption of blood flow in 100% of cases. CONCLUSIONS Temporary occlusion of the paraclival ICA performed through the endoscopic endonasal route with the aid of a Fogarty balloon catheter may be another maneuver for dealing with intraoperative ICA control. Further clinical studies are required to prove the efficacy of this method.

OBJECTIVE: To analyze outcomes of patients surgically treated for calcified spinal meningiomas and to determine factors associated with surgical morbidity.METHODS: Between January 2000 and June 2013, a total of 54 patients underwent surgical resection of a spinal meningioma: 37 of these cases showed various degrees of calcification, confirmed by histopathologic analysis. The clinical evaluation was performed according to the American Spinal Injury Association Impairment Scale. At the last follow-up, neurologic status improved in 19 cases and remained unchanged in 20 cases; just 1 case worsened. According to the American Spinal Injury Association Impairment Scale, neurologic status was classified into 3 levels: poor (A D B), fair (C), and good (D D E). Neurologic status improvement (NSI) during postoperative time (considered as a transition from one lower level to the higher) was analyzed in relationship to the patient's age, length of clinical history, spine level, meningioma's position inside the spinal canal, and its degree of calcification.RESULTS: A statistically significant relationship between NSI and the degree of ossification of the meningioma was observed. in particular, a direct relationship with microcalcified meningiomas and an inverse relationship with ossified meningiomas. No relationship was observed between NSI and patient's age, length of clinical history, and the site of the lesion into the vertebral canal.CONCLUSIONS: The univariate analysis confirms that the degree of calcification affects the outcome, because extensive tumor calcification is associated with an increased surgical morbidity probably.

In this retrospective study, we analyzed 105 cases of ruptured MCAAs, admitted from January 2001 to December 2015 at Neurosurgical Department of Umberto I University Hospital of Rome, Italy. Predictive factors evaluated are: patient’s features (age, sex, co-morbidities), aneurysmal location (proximal, bifurcation or distal) and size of aneurysmal dome (small, large or giant); surgical timing (ultra-early, early, delayed), and Intracerebral Hemorrhage (ICH) volume. For each parameter we calculated mean and standard deviation, covariance and relation coefficient (through the linear regression model).

BACKGROUND: Traditionally, the surgical removal of tuberculum sellae meningioma (TSM) and olfactory groove meningioma (OGM) requires transcranial approaches and microsurgical techniques, but in the last decade endoscopic expanded endonasal approaches have been introduced: transcribriform for OGMs and transtuberculum-transplanum for TSM. A comparative analysis of the literature concerning the two types of surgical treatment of OGMs and TSM is, however, difficult.METHODS: We conducted a literature search using the PubMed database to compare data for endoscopic and microsurgical techniques in the literature. We also conducted a retrospective analysis of selected cases from our series presenting favorable characteristics for an endoscopic approach, based on the criteria of operability of these lesions as generally accepted in the literature, and we compared the results obtained in these patients with those in the endoscopic literature.RESULTS: We believe that making the sample more homogeneous, the difference between microsurgical technique and endoscopic technique is no longer so striking. A greater radical removal rate, a reduced incidence of cerebrospinal fluid fistula and, especially, the possibility of removing lesions of any size are advantages of transcranial surgery; a higher percentage of improvement in visual outcome and a lower risk of a worsening of a pre-existing deficit or onset of a new deficit are advantages of the endoscopic technique.CONCLUSION: At present, the microsurgical technique is still the gold standard for the removal of the anterior cranial fossa meningiomas of all sizes, and the endoscopic technique remains a second option in certain cases.

Objective: Identify potential advantages in endonasal surgical aspiration of this kind of lesion, considering several cases from our transcranial series, which could have been treated also by endoscopic route. Study Design: Midline anterior skull base meningiomas have been traditionally treated via transcranial approaches. Recently, the endoscopic endonasal approach has been introduced for the surgical treatment of such lesions. The actual advantages of the latter approach in terms of outcome are not clear yet. Methods: We analyzed a series of 94 patients treated for olfactory groove or tuberculum sellae meningiomas during the past 13 years. We selected 25 cases who had radiological characteristics that suggest resectability by endoscopic route. Inclusion criteria for the use of expanded endoscopic endonasal approaches are: size less than 4 cm; absence of carotid encasement, or cavernous sinus invasion; no optical nerves involvement, absence of optical canal invasion; extension not above the middle orbital line; anterior limits crista galli and frontal sinus; predominant midline location. We took into consideration several parameters regarding the postoperative course of our patients. Results: Transcranial microsurgical approaches are still the first choice for treatment of midline anterior skull base meningiomas because they allow treating lesions with any characteristics. Conclusion: Transcranial route offer a greater chance of complete removal and lower risk of CSF fistula.

Objective: Demonstrate within this group the existence of distinct patterns, which could influence the type of treatment. Study Design: Planum sphenoidalis, tuberculum sellae, and diaphragma sellae meningiomas are usually considered as the same entity, known as TSM (tuberculum sellae meningiomas). TSM can origin from dura covering the planum sphenoidalis, limbus sphenoidalis, chiasmatic sulcus, tuberculum sellae, or diaphragma sellae. Methods: In the last 13 years, at our department have been treated 44 TSM. The majority of these cases have been treated by transcranial route. Most of the surgical interventions were performed by pterional approach. Data collection has been based on anatomical characteristics, radiological appearance, and clinical patterns, distinguishing some categories. Results: We suspect that some features could determine the treatment of these lesions: position of nearest vessels (hypophyseal arteries); optic nerves and chiasm position; pituitary stalk displacement; cavernous sinus invasion. Size of lesion is also important for surgical decision-making, including anteroposterior extension and laterolateral diameter. Conclusion: From our analysis, we conclude that some lesions are better approached by transcranial route, respect to diaphragma sellae meningiomas, which could be easily and safely treated by endoscopic approach.

Male 29 years, treated surgically for a traumatic fracture of L2, was referred to us about a year after for the onset of worsening paraparesis, anesthesia in his left arm and trunk, urgent incontinence, hyperhydrosis. An MRI of the spinal cord showed the presence of a holocord syrinx, extending to the filum terminale. The patient underwent surgery via L2 laminectomy, with lysis of the arachnoidal adhesions and resection of the filum terminale. After 14 months, MRI control highlighted the reduction of the syrinx and the improvement of symptoms. In post-traumatic syringomyelia the most effective surgical strategy is a combined treatment.

Ballism consists of violent flinging limb movements due to nvoluntary, arrhythmic proximal muscles contractions, usually nvolving only upper extremities of one side of the body (hemibalism). The arm is thrown into space and projected forward and ideways with flexion and rotation on its axis. Like the chorea, the emiballism generates phasic discharges and short synchronous otor unit potentials in the agonist muscles without activation of he antagonists. It is generally caused by injuries to the subthalamic ucleus of Luys or, more extensively, to the basal ganglia such as schemic or hemorrhagic infarctions, diencephalic tumors, inflamations and metabolic paraneoplastic syndromes [1]. Hemiballism esponds in part to neuroleptics. Primary or secondary cortical or subcortical brain tumors usully provoke seizures, focal neurological deficits, higher functions mpairments, or headache [2]. Cortical masses responsible for xtrapyramidal symptoms are not known in the literature. Rarely, arge intracranial lesions may cause movement disorders through mechanism of direct mechanical compression or torsion of the asal ganglia [1,2]. Two cases of small convexity meningiomas just bove the pre-motor cortex causing tremors which disappeared fter tumor removal have been reported [3].