Publications by authors named "Angelo Franzini"

153 Publications

Characteristics of Patients Returning to Work After Brain Tumor Surgery.

Front Hum Neurosci 2020 3;14:609080. Epub 2021 Feb 3.

Neurology, Public Health and Disability Unit, Fondazione IRCSS Istituto Neurologico Carlo Besta, Milan, Italy.

To investigate the differences between patients returning to work and those who did not after brain tumor surgery. Patients were evaluated before surgery and after 3 months. The Montreal Cognitive Assessment test, Trail-Making Test (parts A and B), 15-word Rey-Osterrieth Word List (immediate and delayed recall), F-A-S tests, and Karnosfky Performance Status were used to assess cognitive status, attention, executive functions, memory, word fluency, and functional status. Patient-reported outcome measures (PROMs) used to evaluate emotional distress and disability were the Hospital Anxiety and Depression Scale and World Health Organization Disability Assessment Schedule. Clinical and work-related variables, PROMs, and cognitive tests were compared using chi-squared, -test or Mann-Whitney test. Sixty patients were included. Patients returning to work were 61.3 and 31.0% among people with meningioma and glioma, respectively. They reported lower postoperative disability and lesser home-to-work travel time. Patients with meningioma also showed better preoperative and postoperative attention and executive functions, better postoperative functional and cognitive status, and lower frequency of treatments. These variables should be considered in a clinical context to plan interventions for people who need support during return to work and in future research to investigate preoperative and postoperative predictive factors of going back to work.
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http://dx.doi.org/10.3389/fnhum.2020.609080DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7886680PMC
February 2021

Holmes tremor: a delayed complication after resection of brainstem cavernomas.

J Neurosurg 2020 Dec 11:1-11. Epub 2020 Dec 11.

1Neurosurgery, Great Metropolitan Hospital Niguarda, Milan.

Objective: In this paper, the authors aimed to illustrate how Holmes tremor (HT) can occur as a delayed complication after brainstem cavernoma resection despite strict adherence to the safe entry zones (SEZs).

Methods: After operating on 2 patients with brainstem cavernoma at the Great Metropolitan Hospital Niguarda in Milan and noticing a similar pathological pattern postoperatively, the authors asked 10 different neurosurgery centers around the world to identify similar cases, and a total of 20 were gathered from among 1274 cases of brainstem cavernomas. They evaluated the tremor, cavernoma location, surgical approach, and SEZ for every case. For the 2 cases at their center, they also performed electromyographic and accelerometric recordings of the tremor and evaluated the post-operative tractographic representation of the neuronal pathways involved in the tremorigenesis. After gathering data on all 1274 brainstem cavernomas, they performed a statistical analysis to determine if the location of the cavernoma is a potential predicting factor for the onset of HT.

Results: From the analysis of all 20 cases with HT, it emerged that this highly debilitating tremor can occur as a delayed complication in patients whose postoperative clinical course has been excellent and in whom surgical access has strictly adhered to the SEZs. Three of the patients were subsequently effectively treated with deep brain stimulation (DBS), which resulted in complete or almost complete tremor regression. From the statistical analysis of all 1274 brainstem cavernomas, it was determined that a cavernoma location in the midbrain was significantly associated with the onset of HT (p < 0.0005).

Conclusions: Despite strict adherence to SEZs, the use of intraoperative neurophysiological monitoring, and the immediate success of a resective surgery, HT, a severe neurological disorder, can occur as a delayed complication after resection of brainstem cavernomas. A cavernoma location in the midbrain is a significant predictive factor for the onset of HT. Further anatomical and neurophysiological studies will be necessary to find clues to prevent this complication.
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http://dx.doi.org/10.3171/2020.7.JNS201352DOI Listing
December 2020

Design and Operation of the Lombardy Parkinson's Disease Network.

Front Neurol 2020 26;11:573. Epub 2020 Jun 26.

Department of Neurology, IRCCS Humanitas Research Hospital, Rozzano, Italy.

Parkinson's disease (PD) is one of the most common chronic neurological conditions leading to disability and social burden. According to the 2016 Italian National Plan on Chronic Diseases, regional health authorities are implementing dedicated networks to manage neurological diseases, including PD. A panel of experts representing health-care providers in Lombardy reached consensus on the organization of a patient-centered regional PD healthcare network. The panel proposed a structure and organization implementing a hub-and-spoke PD network model. Three levels of neurological services were identified: General Neurologist, PD Clinic, PD Center. This model was applied to health service providers currently accredited in Lombardy, yielding 12 candidate PD Centers, each serving an area of ~1,000-2,000 km, and not less than 27 PD Clinics. The panel agreed on uniform diagnostic and staging criteria for PD, and on a minimum common clinical data set, on PD patient management by the network at initial and follow-up assessments, on the cadence of follow-up visits, on patient referrals, and on outcome measures for the assessment of network activities. The implementation of disease-centered networks for chronic neurological diseases provides an innovative opportunity to improve patient management, facilitate research and education.
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http://dx.doi.org/10.3389/fneur.2020.00573DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7332852PMC
June 2020

Deep brain stimulation versus pallidotomy for status dystonicus: a single-center case series.

J Neurosurg 2019 Dec 20:1-11. Epub 2019 Dec 20.

1Neurosurgery Department, Functional Neurosurgery Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta.

Objective: First-line pharmacological therapies have shown limited efficacy in status dystonicus (SD), while surgery is increasingly reported as remediable in refractory cases. In this context, there is no evidence regarding which neurosurgical approach is the safest and most effective. The aim of this study was to assess the clinical outcomes and surgery-related complications of globus pallidus internus deep brain stimulation (GPi DBS) and pallidotomy for the treatment of drug-resistant SD.

Methods: The authors reviewed the records of patients with drug-resistant SD who had undergone GPi DBS or pallidotomy at their institution between 2003 and 2017. The severity of the dystonia was evaluated using the Barry-Albright Dystonia (BAD) Scale. Surgical procedures were performed bilaterally in all cases.

Results: Fourteen patients were eligible for inclusion in the study. After surgery, the mean follow-up was 40.6 ± 30 months. DBS ended the dystonic storm in 87.5% of cases (7/8), while pallidotomy had a success rate of 83.3% (5/6). No significant differences were observed between the two techniques in terms of failure rates (risk difference DBS vs pallidotomy -0.03, 95% CI -0.36 to 0.30), SD mean resolution time (DBS 34.8 ± 19 days, pallidotomy 21.8 ± 20.2 days, p > 0.05), or BAD scores at each postoperative follow-up (p > 0.05). The long-term hardware complication rate after DBS was 37.5%, whereas no surgery-related complications were noted following pallidotomy.

Conclusions: The study data suggest that DBS and pallidotomy are equally safe and effective therapies for drug-resistant SD. The choice between the two techniques should be tailored on a case-by-case basis, depending on factors such as the etiology and evolution pattern of the underlying dystonia and the clinical conditions at the moment of SD onset. Given the limitation of the low statistical power of this study, further multicentric investigations are needed to confirm its findings.
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http://dx.doi.org/10.3171/2019.10.JNS191691DOI Listing
December 2019

A prospective international multi-center study on safety and efficacy of deep brain stimulation for resistant obsessive-compulsive disorder.

Mol Psychiatry 2019 Oct 29. Epub 2019 Oct 29.

KU Leuven and/or UZ Leuven and/or UPC KU Leuven, Leuven, Belgium.

Deep brain stimulation (DBS) has been proposed for severe, chronic, treatment-refractory obsessive-compulsive disorder (OCD) patients. Although serious adverse events can occur, only a few studies report on the safety profile of DBS for psychiatric disorders. In a prospective, open-label, interventional multi-center study, we examined the safety and efficacy of electrical stimulation in 30 patients with DBS electrodes bilaterally implanted in the anterior limb of the internal capsule. Safety, efficacy, and functionality assessments were performed at 3, 6, and 12 months post implant. An independent Clinical Events Committee classified and coded all adverse events (AEs) according to EN ISO14155:2011. All patients experienced AEs (195 in total), with the majority of these being mild (52% of all AEs) or moderate (37%). Median time to resolution was 22 days for all AEs and the etiology with the highest AE incidence was 'programming/stimulation' (in 26 patients), followed by 'New illness, injury, condition' (13 patients) and 'pre-existing condition, worsening or exacerbation' (11 patients). Sixteen patients reported a total of 36 serious AEs (eight of them in one single patient), mainly transient anxiety and affective symptoms worsening (20 SAEs). Regarding efficacy measures, Y-BOCS reduction was 42% at 12 months and the responder rate was 60%. Improvements in GAF, CGI, and EuroQol-5D index scores were also observed. In sum, although some severe AEs occurred, most AEs were mild or moderate, transient and related to programming/stimulation and tended to resolve by adjustment of stimulation. In a severely treatment-resistant population, this open-label study supports that the potential benefits outweigh the potential risks of DBS.
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http://dx.doi.org/10.1038/s41380-019-0562-6DOI Listing
October 2019

Ablative brain surgery: an overview.

Int J Hyperthermia 2019 10;36(2):64-80

Department of Neurological Surgery, University of Virginia Health System , Charlottesville , VA , USA.

Ablative therapies have been used for the treatment of neurological disorders for many years. They have been used both for creating therapeutic lesions within dysfunctional brain circuits and to destroy intracranial tumors and space-occupying masses. Despite the introduction of new effective drugs and neuromodulative techniques, which became more popular and subsequently caused brain ablation techniques to fall out favor, recent technological advances have led to the resurgence of lesioning with an improved safety profile. Currently, the four main ablative techniques that are used for ablative brain surgery are radiofrequency thermoablation, stereotactic radiosurgery, laser interstitial thermal therapy and magnetic resonance-guided focused ultrasound thermal ablation. To review the physical principles underlying brain ablative therapies and to describe their use for neurological disorders. The literature regarding the neurosurgical applications of brain ablative therapies has been reviewed. Ablative treatments have been used for several neurological disorders, including movement disorders, psychiatric disorders, chronic pain, drug-resistant epilepsy and brain tumors. There are several ongoing efforts to use novel ablative therapies directed towards the brain. The recent development of techniques that allow for precise targeting, accurate delivery of thermal doses and real-time visualization of induced tissue damage during the procedure have resulted in novel techniques for cerebral ablation such as magnetic resonance-guided focused ultrasound or laser interstitial thermal therapy. However, older techniques such as radiofrequency thermal ablation or stereotactic radiosurgery still have a pivotal role in the management of a variety of neurological disorders.
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http://dx.doi.org/10.1080/02656736.2019.1616833DOI Listing
October 2019

Deep brain stimulation of the posterior limb of the internal capsule in the treatment of central poststroke neuropathic pain of the lower limb: case series with long-term follow-up and literature review.

J Neurosurg 2019 Aug 16:1-9. Epub 2019 Aug 16.

1Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milano, Italy.

Objective: Central poststroke neuropathic pain is a debilitating syndrome that is often resistant to medical therapies. Surgical measures include motor cortex stimulation and deep brain stimulation (DBS), which have been used to relieve pain. The aim of this study was to retrospectively assess the safety and long-term efficacy of DBS of the posterior limb of the internal capsule for relieving central poststroke neuropathic pain and associated spasticity affecting the lower limb.

Methods: Clinical and surgical data were retrospectively collected and analyzed in all patients who had undergone DBS of the posterior limb of the internal capsule to address central poststroke neuropathic pain refractory to conservative measures. In addition, long-term pain intensity and level of satisfaction gained from stimulation were assessed. Pain was evaluated using the visual analog scale (VAS). Information on gait improvement was obtained from medical records, neurological examination, and interview.

Results: Four patients have undergone the procedure since 2001. No mortality or morbidity related to the surgery was recorded. In three patients, stimulation of the posterior limb of the internal capsule resulted in long-term pain relief; in a fourth patient, the procedure failed to produce any long-lasting positive effect. Two patients obtained a reduction in spasticity and improved motor capability. Before surgery, the mean VAS score was 9 (range 8-10). In the immediate postoperative period and within 1 week after the DBS system had been turned on, the mean VAS score was significantly lower at a mean of 3 (range 0-6). After a mean follow-up of 5.88 years, the mean VAS score was still reduced at 5.5 (range 3-8). The mean percentage of long-term pain reduction was 38.13%.

Conclusions: This series suggests that stimulation of the posterior limb of the internal capsule is safe and effective in treating patients with chronic neuropathic pain affecting the lower limb. The procedure may be a more targeted treatment method than motor cortex stimulation or other neuromodulation techniques in the subset of patients whose pain and spasticity are referred to the lower limbs.
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http://dx.doi.org/10.3171/2019.5.JNS19227DOI Listing
August 2019

Is Deep Brain Stimulation still an option for tremor recurrence after Focused Ultrasound thalamotomy? A case report.

J Clin Neurosci 2019 Oct 18;68:344-346. Epub 2019 Jul 18.

Department of Clinical Neurosciences, Movement Disorders Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.

With the development of MRI-guided focused ultrasound (FUS), there is an ongoing renewal of interest for ablative procedures as a surgical option for tremor disorders. One of the main criticisms regarding FUS thalamotomy is the potential recurrence of tremor symptoms during follow-up. In case of tremor reappearance, repeating the ultrasound ablation may represent a reasonable option. However, tremor is often perceived as a highly disabling condition and patients may be reluctant to undergo the same unsuccessful treatment again. In this context, few data are available about the feasibility of Deep Brain Stimulation (DBS) in case of tremor recurrence after FUS. Moreover, concerns exist that FUS lesioning could preclude or limit the effectiveness of future DBS. Here we present the case of a 73-year-old right-handed man with a disabling, right-hand, mixed tremor recurring after initial successful FUS thalamotomy and that was properly managed in the end with thalamic Deep Brain Stimulation. Our case suggests that DBS and FUS thalamotomy are not mutually exclusive, but rather they represent complementary tools in the surgical approach to tremor.
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http://dx.doi.org/10.1016/j.jocn.2019.07.035DOI Listing
October 2019

Dorsal anterior cingulate cortex (ACC) deep brain stimulation (DBS): a promising surgical option for the treatment of refractory thalamic pain syndrome (TPS).

Acta Neurochir (Wien) 2019 08 17;161(8):1579-1588. Epub 2019 Jun 17.

Neurosurgery Department, Functional Neurosurgery Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Giovanni Celoria 11, 20133, Milan, Italy.

Background: Neuroimaging evidences and previous successful case series of cingulotomy for cancer pain have disclosed the key-role of the dorsal anterior cingulate cortex (ACC) in the generation of the empathic and affective dimension of pain. The aim of this study is to assess the effectiveness and safety of ACC neuromodulation for the treatment of the thalamic pain syndrome (TPS), a chronic neuropathic disease often complicated by severe affective and emotional distress in the long term.

Method: From January 2015 to April 2017, 5 patients with pure drug-refractory TPS underwent ACC deep brain stimulation (DBS) at our institution. Quantitative assessment of pain and health-related quality of life were performed 1 day before surgery and postoperatively at 6 and 18 months by using the numeric rating scale (NRS), the 36-item short-form health survey (SF-36), and the McGill pain and the EuroQol5-domain questionnaires.

Results: Mean age at surgery was 56.2 years (range, 47-66). NRS score improved by 37.9% at 6 months (range, - 22.2 to - 80%) and by 35% at 18 months (range, - 11.1 to - 80%). At the last follow-up, one patient reported a relevant pain reduction (NRS 2), only complaining of mild pain poorly interfering with activities of daily living. Concomitant improvements in the McGill and EuroQol5-domain pain questionnaires, SF-36 total and sub-item scores were also noticed at each follow-up. No surgical or stimulation-related complications occurred during the study period.

Conclusions: ACC DBS may be a safe and promising surgical option to alleviate discomfort and improve the overall quality of life in a patient affected by drug-resistant TPS. Further prospective, larger, and randomized studies are needed to validate these findings.
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http://dx.doi.org/10.1007/s00701-019-03975-5DOI Listing
August 2019

Antibiotic Impregnated Catheter Coating Technique for Deep Brain Stimulation Hardware Infection: An Effective Method to Avoid Intracranial Lead Removal.

Oper Neurosurg (Hagerstown) 2020 03;18(3):246-253

Neurosurgery Department, Functional Neurosurgery Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.

Background: Few studies have proposed alternative salvage methods of deep brain stimulation (DBS) intracranial lead once the infection has already occurred.

Objective: To assess the effectiveness of antibiotic impregnated catheter coverage of DBS leads in case of hardware infection.

Methods: Patients with a hardware infection and consequent partial removal of extension and internal pulse generator (IPG) were reviewed. To diagnose an infection, criteria provided by the Guideline for Prevention of Surgical Site Infection were used. We compared the intracranial lead salvage rate between the group that underwent antibiotic catheter lead protection (group A) and the group that did not (group B).

Results: A total of 231 DBS surgeries and 339 IPG replacements were performed from January 2012 to January 2017. Twenty-three hardware-related infections (4%) were identified. Nineteen patients (82.6%) underwent partial hardware removal with an attempt to spare intracranial lead. Of these, 8 patients (42.1%) had antibiotic catheter lead coverage (group A) while 11 patients (57.9%) did not receive any antibiotic protection (group B). At 6-mo follow-up, 6 patients had the extension and IPG successfully re-implanted in group A, whereas only 1 patient was successfully re-implanted in group B (75 vs 9.1%; P < .001).

Conclusion: The antibiotic impregnated catheter coating technique seems to be effective in avoiding intracranial lead removal in case of IPG or DBS extension-lead junction infection. This method does not require any surgical learning curve, it is safe and relatively inexpensive. Randomized, prospective, larger studies are needed to validate our results.
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http://dx.doi.org/10.1093/ons/opz118DOI Listing
March 2020

Two-Staged Frontal Bone Defect Reconstruction: Perioperative Assessment of Scalp Vascularization Using Near-Infrared Indocyanine Green Video Angiography (Visionsense Iridium).

World Neurosurg 2019 Jun 20;126:502-507. Epub 2019 Mar 20.

Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.

Background: Head trauma and neurosurgical-related osteomyelitis are common causes of cranial bone defect. Even though cranioplasty is considered a safe and well-consolidated procedure, there are still some issues about the flap's vascularization assessment. In this paper we describe a 2-staged cranioplasty procedure, focusing on the perioperative evaluation of the skin flap vascularization. Our goal is to assess if the skin flap's perfusion measurement with indocyanine green fluorescence can be considered a reliable method to predict good outcome in cranioplasties.

Case Description: A 50-year-old patient presented with a wide frontal bone defect due to a prior surgery-related osteomyelitis. During the first operation, a tissue expander was placed under the scalp in order to grant an appropriate skin stretching. During the second operation the defect was repaired with a custom-made prosthesis after tissue expander removal. During all procedures, vascular integrity of the skin flap was intraoperatively assessed by means of indocyanine green fluorescence.

Conclusions: Surgical procedures were well tolerated; at 1 year of follow-up the cosmetic defect was unremarkable. Indocyanine green fluorescence can be a good aid to predict the probability of the skin flap survival by measuring its perfusion.
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http://dx.doi.org/10.1016/j.wneu.2019.02.247DOI Listing
June 2019

The neurosurgical treatment of craniofacial pain syndromes: current surgical indications and techniques.

Neurol Sci 2019 May;40(Suppl 1):159-168

Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy.

Craniofacial pain syndromes are comprised of multiple pathological entities resulting in pain referred to the scalp, face, or deeper cranial structures. In a small subset of patients affected by those syndromes, pharmacological and physical therapies fail in alleviating pain. In some of those refractory patients surgical procedures aimed at relieving pain are indicated and have been adopted with variable results and safety profiles. In this review, the authors describe craniofacial pain syndromes that most commonly fail to respond to pharmacological therapies and may be amenable to tailored surgical procedures. In particular, trigeminal, glossopharyngeal, and occipital neuralgias are considered, as well as some primary headache syndromes such as cluster headache, short unilateral neuralgiform headache with conjunctival injection and tearing/short unilateral neuralgiform headache with autonomic symptoms, and migraine. Surgical techniques, including the implantation of deep brain or peripheral nerve electrodes with subsequent chronic stimulation, microvascular decompression of neurovascular conflicts, and percutaneous lesioning of neural structures are described. Finally, surgical indications, outcomes, and safety of these procedures are presented.
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http://dx.doi.org/10.1007/s10072-019-03789-4DOI Listing
May 2019

Deep Brain Stimulation of the Caudal Zona Incerta and Motor Thalamus for Postischemic Dystonic Tremor of the Left Upper Limb: Case Report and Review of the Literature.

World Neurosurg 2019 05 8;125:191-197. Epub 2019 Feb 8.

Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.

Background: Dystonic tremor is defined as a tremor occurring in a body region affected by dystonia. The pathophysiologic mechanisms behind dystonic tremor supposedly involve anomalies affecting the pallidothalamic-receiving area (for the dystonic component) and the ventralis intermedius-cortical loop (for the tremor component). Interest in posterior subthalamic area stimulation for various types of involuntary abnormal movements has arisen owing to positive results in patients affected by tremor refractory to ventralis intermedius deep brain stimulation.

Case Description: A 23-year-old man, with a 15-year history of left upper limb dystonic tremor due to a stroke in the right thalamus, underwent deep brain stimulation with a single electrode passing through the right ventralis oralis anterior/ventralis oralis posterior nuclei and caudal zona incerta. Objective movement outcomes were assessed through the Unified Dystonia Rating Scale and Fahn-Tolosa-Marin Clinical Rating Scale for Tremor. The impact of tremor on activities of daily living was assessed with the ADL-T24 questionnaire, and quality of life was assessed with the Quality of Life Scale. All questionnaires were administered before deep brain stimulation and at 5-year follow-up. Unified Dystonia Rating Scale and Fahn-Tolosa-Marin Clinical Rating Scale for Tremor scores decreased from 14.5 to 4.5 and from 46 to 7, respectively. ADL-T24 score decreased from 19 to 3, whereas Quality of Life Scale score increased from 49 to 82.

Conclusions: Stimulation of motor thalamus and caudal zona incerta could be a viable treatment for patients affected by tremor of various origins, including dystonic tremor, refractory to medical therapy.
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http://dx.doi.org/10.1016/j.wneu.2019.01.183DOI Listing
May 2019

Lumbar epidural blood patch: effectiveness on orthostatic headache and MRI predictive factors in 101 consecutive patients affected by spontaneous intracranial hypotension.

J Neurosurg 2019 Feb 8;132(3):809-817. Epub 2019 Feb 8.

1Functional Neurosurgery Unit.

Objective: Although epidural blood patch (EBP) is considered the gold-standard treatment for drug-resistant orthostatic headache in spontaneous intracranial hypotension (SIH), no clear evidence exists regarding the best administration method of this technique (blind vs target procedures). The aim of this study was to assess the long-term efficacy of blind lumbar EBP and predictors on preoperative MRI of good outcome.

Methods: Lumbar EBP was performed by injecting 10 ml of autologous venous blood, fibrin glue, and contrast medium in 101 consecutive patients affected by SIH and orthostatic headache. Visual analog scale (VAS) scores for headache were recorded preoperatively, at 48 hours and 6 months after the procedure, and by telephone interview in July 2017. Patients were defined as good responders if a VAS score reduction of at least 50% was achieved within 48 hours of the procedure and lasted for at least 6 months. Finally, common radiological SIH findings were correlated with clinical outcomes.

Results: The median follow-up was 60 months (range 8-135 months); 140 lumbar EBPs were performed without complications. The baseline VAS score was 8.7 ± 1.3, while the mean VAS score after the first EBP procedure was 3.5 ± 2.2 (p < 0.001). The overall response rate at the 6-month follow-up was 68.3% (mean VAS score 2.5 ± 2.4, p < 0.001). Symptoms recurred in 32 patients (31.7%). These patients underwent a second procedure, with a response rate at the 6-month follow-up of 78.1%. Seven patients (6.9%) did not improve after a third procedure and remained symptomatic. The overall response rate at the last follow-up was 89.1% with a mean VAS score of 2.7 ± 2.3 (p < 0.001). The only MRI predictors of good outcome were location of the iter > 2 mm below the incisural line (p < 0.05) and a pontomesencephalic angle (PMA) < 40° (p < 0.05).

Conclusions: Lumbar EBP may be considered safe and effective in cases of drug-refractory SIH. The presence of a preprocedural PMA < 40° and location of the iter > 2 mm below the incisural line were the most significant predictors of good outcome. Randomized prospective clinical trials comparing lumbar with targeted EBP are warranted to validate these results.
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http://dx.doi.org/10.3171/2018.10.JNS181597DOI Listing
February 2019

Prefrontal Cortical Stimulation in Tourette Disorder: Proof-of-concept Clinical and Neuroimaging Study.

Mov Disord Clin Pract 2018 Sep-Oct;5(5):499-505. Epub 2018 Oct 3.

Department of Neurology Catholic University of the Sacred Heart Milan Italy.

Background: The benefits of neurosurgery in Tourette Syndrome (TS) are still incompletely understood. Prefrontal cortical electrical stimulation offers a less invasive alternative to deep brain stimulation.

Objective: To perform a pilot assessment on safety and efficacy of prefrontal cortical bilateral electrical stimulation in TS using clinical and brain metabolic assessments.

Methods: Four adult TS patients underwent tic assessment using the Yale Global Tic Severity Scale and the Rush Video Rating Scale at baseline and 1, 3, 6, and 12-months after implant; whereas FDG-PET scans were acquired at baseline and after 6 and 12 months.

Results: Tic clinical scores were improved at 6 months after implant, meanwhile they showed a tendency to re-emerge at the 12-month follow-up. There was a correlation between FDG-PET and tics, mainly consisting in a reduction of baseline brain hypermetabolism, which paralleled tic score reduction.

Conclusion: Epidural stimulation in TS is safe and yields a modulation of tics, paralleled by FDG-PET metabolic modulation.
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http://dx.doi.org/10.1002/mdc3.12648DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6207124PMC
October 2018

Suitability of Administrative Databases for Durotomy Incidence Assessment: Comparison to the Incidence Associated With Bone-Removal Devices, Calculated Using a Systemic Literature Review and Clinical Data.

Int J Spine Surg 2018 Aug 31;12(4):498-509. Epub 2018 Aug 31.

Israel Spine Center, Assuta Medical Center, Tel Aviv, Israel.

Background: Durotomy is a major complication of spinal surgery, potentially leading to additional clinical complications, longer hospitalization, and increased costs. A reference durotomy incidence rate is useful for the evaluation of the safety of different surgical aspects. However, the literature offers a wide range of incidence rates, complicating this comparison. Theoretically, a reference incidence value can be extracted from administrative databases, containing a large number of procedures. However, it is suspected that these databases suffer from underreporting of complications. This study aims to evaluate durotomy incidence using several large-scale databases and to assess the ability to use it as a reference by comparison to durotomy incidences directly associated with 4 bone removal devices, including the commonly used high-speed drill.

Methods: Durotomy overall incidence was estimated from several administrative databases using different methods in order to achieve minimal and maximal estimations. Durotomy incidences for 3 bone removal devices were derived using literature meta-analysis, and the incidence for the fourth device was calculated using clinical data.

Results: The incidence range of durotomy according to the databases was 2.8-3.5%. The calculated incidence of durotomy for the studied devices was 0.4-2.91%. The highest rate, 2.91%, is associated with the commonly used high-speed drill combined with Kerrison Rongeur and bone punches. Since bone-removal devices are just one of the possible causes of dural tears, the general incidence is expected to be higher than the incidence associated with the devices, yet even the maximal estimation, 3.5%, was only slightly higher, suggesting that the speculation of underreporting of dural tears to these databases is probably true, as also supported by the mostly higher incidences reported in the literature.

Conclusions: Hospital administrative databases seem to show a lower-than-reasonable incidence of durotomy, suggesting possible underreporting. Researchers should therefore use this tool with caution. Reduction of the absolute durotomy incidence by approximately 2.5% can be achieved by improving the safety of bone-removal devices.
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http://dx.doi.org/10.14444/5061DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6159638PMC
August 2018

An unusual surgical indication for cerebral tuberculosis: status dystonicus. Case report.

Acta Neurochir (Wien) 2018 07 15;160(7):1355-1358. Epub 2018 May 15.

Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133, Milan, Italy.

Actual indications for surgery in tuberculosis are limited to obtaining a diagnosis, acquiring tissue for culture studies, treating hydrocephalus, aspiring a brain abscess, and reducing intracranial pressure in patients with multiple tuberculomas. Tuberculosis-related movement disorders are usually treated pharmacologically. We report on a child affected by post-tubercular generalized dystonia, who progressed to status dystonicus (SD) and underwent stereotactic bilateral pallidotomy. After surgery, SD resolved, and drugs were rapidly tapered. The successful reversal of SD and the motor improvement observed in our patient demonstrate the safety, feasibility, and clinical efficacy of pallidotomy in post-tuberculous-meningoencephalitis dystonia and SD.
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http://dx.doi.org/10.1007/s00701-018-3561-5DOI Listing
July 2018

Deep brain stimulation for trigeminal autonomic cephalalgias.

Expert Rev Neurother 2018 May 19;18(5):421-426. Epub 2018 Apr 19.

Functional Neurosurgery Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.

: Deep brain stimulation (DBS) of the posterior hypothalamic region (pHyr) has been shown to be efficacious for more than a half of patients suffering from trigeminal autonomic cephalalgias (TACs); nonetheless, controversies about the mechanisms of action and the actual site of stimulation have arisen in recent years.: Firstly, a review of the most recent literature on the subject is presented, stressing the critical points that could, in the future, make a difference for optimal management of patients afflicted by these life-threating diseases. Hypothalamic functional anatomy, experimental data and pathophysiological hypotheses are reported.: About 32% of patients who underwent DBS for TACs are pain-free. The determination of the pHyr region seems to be crucial for the generation of pain attack in these pathologies, although other structures are involved in complex mechanisms and circuits that interact with each other. Neurophysiological data, combined with more advanced experimental models, are of primary importance regarding our understanding of what the real target is, and how to overcome the issue of refractory patients.
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http://dx.doi.org/10.1080/14737175.2018.1462702DOI Listing
May 2018

Piezoelectric Surgery for Dorsal Spine.

World Neurosurg 2018 Jun 10;114:58-62. Epub 2018 Mar 10.

Department of Neurosurgery, IRCCS Foundation Carlo Besta Neurological Institute, Milan, Italy.

Background: Laminoplasty and laminectomy are 2 common surgical procedures used in treating degenerative and neoplastic diseases of the spinal canal. Routinely used instruments, such as the Kerrison rongeur and high-speed drill, can result in potentially serious complications, such as dural injury and thermal and mechanical damage to neurovascular structures. We adopted piezoelectric bone surgery, which permits a selective cut of mineralized tissues, to perform posterior procedures on the thoracic spine, where the relationship between bone and the spinal cord is critical. The aim of this article was to evaluate the use of piezoelectric surgery for performing dorsal spine laminectomy and laminoplasty.

Methods: The Mectron piezosurgery device was developed for cutting bone with microvibrations that are created by the piezoelectric effect. This instrument allows a safe and precise bone cut, and it is characterized by no heat generation, thus avoiding thermal injury to bone and soft tissues. We used this device to perform 8 laminoplasties for tumors of the dorsal spine and 2 laminectomies for thoracic spinal stenosis in 10 patients.

Results: There were no procedure-related intraoperative complications, such as dural injury or damage to neural structures.

Conclusions: The piezoelectric device showed excellent results in terms of safety and precise bone cutting properties when performing posterior surgical procedures in the dorsal spine, where thermal injury produced by the conventionally used drill may damage the spinal cord closer to bony elements.
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http://dx.doi.org/10.1016/j.wneu.2018.03.026DOI Listing
June 2018

Conservative treatment for bilateral subdural hematomas.

J Neurosurg Sci 2020 Feb 23;64(1):124-125. Epub 2018 Feb 23.

Department of Neurosurgery, Carlo Besta Institute of Neurology, IRCCS and Foundation, Milan, Italy.

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http://dx.doi.org/10.23736/S0390-5616.18.04332-1DOI Listing
February 2020

Boomerang-shaped hemorrhage of the splenium of corpus callosum after mild brain injury: an unusual case of delayed hematoma.

J Neurosurg Sci 2019 Oct 4;63(5):611-612. Epub 2017 Dec 4.

Department of Neurosurgery III, Fondazione IRCCS Istituto, Neurologico Carlo Besta, Milan, Italy.

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http://dx.doi.org/10.23736/S0390-5616.17.04270-9DOI Listing
October 2019

Staged pallidotomy: MRI and clinical follow-up in status dystonicus.

Br J Neurosurg 2019 Apr 28;33(2):184-187. Epub 2017 Nov 28.

a Functional Neurosurgery Unit , Fondazione IRCCS Istituto Neurologico Carlo Besta , Milan , Italy.

Purpose: We report on a patient affected by Status Distonicus who was treated with Deep Brain Stimulation electrodes implanted in the Globus Pallidus internus (Gpi) and used for serial radiofrequency lesions.

Materials And Methods: The evolution of radiofrequency lesions was monitored by post-operative and late Magnetic Resonance Imaging (MRI). After the first lesion the patient did improve, though not in a significant fashion. Therefore, three further radiofrequency lesions were delivered 2, 4 and 6 days respectively after surgery with subsequent improvement of dystonic movements.

Results: MRI scans performed at 8 days, 3 months, and 6 months after surgery showed a diffuse T2-hyperintense and T1-hypointense GPi signal alteration which progressively decreased over time.

Conclusion: We confirm that the possibility to stage pallidotomies over time using a couple of new contacts is a safe and efficacious procedure in treating SD patients where the lesions themselves are limited by the appearance of side effects, or in patients showing a poor response to a single lesion. As far as we know, this is the first description of MRI evolution and monitoring of a staged pallidotomy.
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http://dx.doi.org/10.1080/02688697.2017.1409875DOI Listing
April 2019

Correction to:"Careful" reprogramming of baclofen intrathecal programmable synchromed infusion pumps at their replacement in a series of 156 patients.

Acta Neurochir (Wien) 2017 12;159(12):2449

Department of Neurosurgery, Fondazione Istituto Nazionale Neurologico "C. Besta", Milan, Italy.

The original version of this article unfortunately contained mistakes. The names of all authors are inadvertently inverted and are now corrected in the authorgroup of this article.
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http://dx.doi.org/10.1007/s00701-017-3364-0DOI Listing
December 2017

Surgical "Fat Patch" Improves Secondary Intracranial Hypotension Orthostatic Headache Associated with Lumbosacral Dural Ectasia.

World Neurosurg 2017 Nov 1;107:1053.e7-1053.e10. Epub 2017 Sep 1.

Department of Neurosurgery Fondazione IRCCS Istituto Neurologico "C. Besta", Milan, Italy.

Background: Secondary intracranial hypotension is a clinical syndrome associated with reduction of cerebrospinal fluid volume and dural continuity violation. The main symptoms are orthostatic headache associated with nausea, vomiting, diplopia, dizziness, and tinnitus. The treatment is usually nonspecific.

Case Description: A 37-year-old woman developed secondary intracranial hypotension caused by lumbosacral iatrogenic dural ectasia following detethering surgery. An orthostatic headache was the mainstay of her clinical picture, and it was confirmed by intracranial pressure monitoring. Conservative treatment including spinal blood patch improved symptoms for a limited amount of time (<1 month). Altered compliance of the dural spinal sac was suspected. Therefore thecal sac remodeling by placing autologous fat at the level of the dural ectasia was performed, improving the symptoms for 2 years.

Conclusion: Volumetric reduction of the epidural space may be considered as a valuable therapeutic option in case of intracranial hypotension that is unresponsive to medical treatments and spinal blood patch, as well as when an altered compliance of the dural sac is hypothesized.
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http://dx.doi.org/10.1016/j.wneu.2017.08.145DOI Listing
November 2017

Exploring the brain through posterior hypothalamus surgery for aggressive behavior.

Neurosurg Focus 2017 Sep;43(3):E14

Neurosurgery Unit, Department of Neuroscience and Neurorehabilitation, IRCCS Bambino Gesù Children's Hospital, Rome; and.

Neurological surgery offers an opportunity to study brain functions, through either resection or implanted neuromodulation devices. Pathological aggressive behavior in patients with intellectual disability is a frequent condition that is difficult to treat using either supportive care or pharmacological therapy. The bulk of the laboratory studies performed throughout the 19th century enabled the formulation of hypotheses on brain circuits involved in the generation of emotions. Aggressive behavior was also studied extensively. Lesional radiofrequency surgery of the posterior hypothalamus, which peaked in the 1970s, was shown to be an effective therapy in many reported series. As with other surgical procedures for the treatment of psychiatric disorders, however, this therapy was abandoned for many reasons, including the risk of its misuse. Deep brain stimulation (DBS) offers the possibility of treating neurological and psychoaffective disorders through relatively reversible and adaptable therapy. Deep brain stimulation of the posterior hypothalamus was proposed and performed successfully in 2005 as a treatment for aggressive behavior. Other groups reported positive outcomes using target and parameter settings similar to those of the original study. Both the lesional and DBS approaches enabled researchers to explore the role of the posterior hypothalamus (or posterior hypothalamic area) in the autonomic and emotional systems.
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http://dx.doi.org/10.3171/2017.6.FOCUS17231DOI Listing
September 2017

The role of radiosurgery in trigeminal neuralgia.

Neurol Sci 2017 May;38(Suppl 1):63-65

Neurosurgery Department, Neurological Institute "Carlo Besta" IRCCS Foundation, Milan, Italy.

A short review of clinical use of radiosurgery in trigeminal neuralgia is offered.
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http://dx.doi.org/10.1007/s10072-017-2892-yDOI Listing
May 2017

Treatments of glossopharyngeal neuralgia: towards standard procedures.

Neurol Sci 2017 May;38(Suppl 1):51-55

Neurosurgery Department, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133, Milan, Italy.

The degree of disability due to glossopharyngeal neuralgia (GN) refractory to conservative treatments justifies surgical procedures as second-line treatments. Since the first description of this facial pain disorders, many surgical options have been described either via a percutaneous or an open surgical way. Actually, when a neurovascular conflict on root entry zone (REZ) or cisternal portion of the ninth and tenth cranial nerves is identified, microvascular decompression (MVD) is the first surgical option to consider. Many studies have demonstrated its efficacy and safety for the treatment of GN. Recently, stereotactic radiosurgery has gained space in the treatment of selected cases of GN. We provide an overview of the surgical procedures for the treatment of GN and of our own experience.
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http://dx.doi.org/10.1007/s10072-017-2909-6DOI Listing
May 2017

Letter: Thalamotomy-Like Effects From Partial Removal of a Ventral Intermediate Nucleus Deep Brain Stimulator Lead in a Patient With Essential Tremor: Case Report.

Neurosurgery 2017 05;80(5):E254-E255

Department of Experimental Biomedicine and Clinical Neuroscience Neurosurgical Unit University hospital Palermo, Italy.

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http://dx.doi.org/10.1093/neuros/nyx066DOI Listing
May 2017

Restoring Neurological Physiology: The Innovative Role of High-Energy MR-Guided Focused Ultrasound (HIMRgFUS). Preliminary Data from a New Method of Lesioning Surgery.

Acta Neurochir Suppl 2017 ;124:55-59

Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, Neurosurgical Clinic, University of Palermo, Via del Vespro 129, Palermo, 90100, Italy.

Background: Tremor is a disabling condition, common to several neurodegenerative diseases. Lesioning procedures and deep brain stimulation, respectively, of the ventralis intermedius nucleus for intentional tremor, and of the subthalamic nucleus for parkinsonian resting tremor, have been introduced in clinical practice for patients refractory to medical treatment. The combination of high-energy focused ultrasound (HIFUS) with sophisticated magnetic resonance (MR) instrumentation, together with accurate knowledge of the stereotactic brain coordinates, represents a revolution in neuromodulation.

Methods: At the Neurosurgical Clinic and the Radiology Department of the University of Palermo,, two patients affected by severe and refractory forms of intentional tremor were treated by MRI-guided FUS (MRgFUS) with a unique 1.5 T MR scanner prototype that uses FUS. This apparatus is the only one of its type in the world."

Findings: This is the first Italian experience, and the second in Europe, of treatment with MRI-gFUS for intentional tremor. But this is the very first experience in which a 1.5 T MRI apparatus was used. In both patients, the treatment completely abolished the tremor on the treated side, with results being excellent and stable after 7 and 5 months, respectively; no side effects were encountered.

Conclusion: MRgFUS, recently introduced in clinical practice, and widely used at several clinical centers, has been shown to be a valid therapeutic alternative in the treatment of tremor in several neurodegenerative diseases. It is virtually safe, noninvasive, and very efficacious. We report this technique in which a 1.5 T MR scanner was used. Further investigations with long-term follow up and larger clinical series are needed.
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http://dx.doi.org/10.1007/978-3-319-39546-3_9DOI Listing
November 2017

Painful Rosacea as a Warning Sign of Intracranial Metastasis of Squamous Cell Carcinoma.

Headache 2016 Oct 16;56(9):1514-1516. Epub 2016 Sep 16.

Private practice, Dermatology & STD, Milan, Italy, formerly Consulting Dermatologist, Carlo Besta Neurological Institute, Milan, Italy.

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http://dx.doi.org/10.1111/head.12956DOI Listing
October 2016