Publications by authors named "Roberto Delfini"

151 Publications

Ruptured Brain Arteriovenous Malformations: Surgical Timing and Outcomes-A Retrospective Study of 25 Cases.

J Neurosci Rural Pract 2021 Jan 4;12(1):4-11. Epub 2020 Nov 4.

Department of Neurological Sciences, Neurosurgery, "La Sapienza" University of Rome, Rome, Italy.

 One important problem in treatment of ruptured brain arteriovenous malformations (bAVMs) is surgical timing. The aim of the study was to understand which parameters affect surgical timing and outcomes the most.  Between January 2010 and December 2018, 25 patients underwent surgery for a ruptured bAVM at our institute. Intracerebral hemorrhage (ICH) score was used to evaluate hemorrhage severity, while Spetzler-Martin scale for AVM architecture. We divided patients in two groups: "early surgery" and "delayed surgery." The modified Rankin Scale (mRS) evaluated the outcomes.   Eleven patients were in the "early surgery" group: age 38 ± 18 years, Glasgow Coma Scale (GCS) 7.64 ± 2.86, ICH score 2.82 ± 0.71, hematoma volume 45.55 ± 23.21 mL. Infratentorial origin of hemorrhage was found in 27.3% cases; AVM grades were I to II in 82%, III in 9%, and IV in 9% cases. Outcome at 3 months was favorable in 36.4% cases and in 54.5% after 1 year. Fourteen patients were in the "delayed surgery" group: age 41 ± 16 years, GCS 13.21 ± 2.39, ICH score 1.14 ± 0.81, hematoma volume 29.89 ± 21.33 mL. Infratentorial origin of hemorrhage was found in 14.2% cases; AVM grades were I to II in 50% and III in 50%. Outcome at 3 months was favorable in 78.6% cases and in 92.8% after 1 year.  The early outcome is influenced more by the ICH score, while the delayed outcome by Spetzler-Martin grading. These results suggest that it is better to perform surgery after a rest period, away from the hemorrhage when possible. Moreover, this study suggests how in young patient with a high ICH score and a low AVM grade, early surgery seems to be a valid and feasible therapeutic strategy.
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http://dx.doi.org/10.1055/s-0040-1716792DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7857959PMC
January 2021

Outcome Features Analysis in Intramedullary Tumors of the Cervicomedullary Junction: A Surgical Series.

J Neurol Surg A Cent Eur Neurosurg 2021 May 4;82(3):225-231. Epub 2021 Feb 4.

Department of Neurology and Psychiatry, Endovascular Neurosurgery/Interventional Neuroradiology, "Sapienza" University of Rome, Rome, Italy.

Object:  The aim of this study is to investigate the impact of surgery for different cervicomedullary lesions on symptomatic pattern expression and postoperative outcome. We focused on specific outcome features of the early and late postoperative assessments. The former relies on surgery-related transient and permanent morbidity and feasibility of radicality in eloquent areas, whereas the latter on long-term course in lower grade tumors and benign tumorlike lesions (cavernomas, etc.).

Material And Methods:  We retrospectively analyzed 28 cases of intramedullary tumors of the cervicomedullary junction surgically treated at our institution between 1990 and 2018. All cases were stratified for gender, histology, macroscopic appearance, location, surgical approach, and presence of a plane of dissection (POD). Mean follow-up was 5.6 years and it was performed via periodic magnetic resonance imaging (MRI) and functional assessments (Karnofsky Performance Scale [KPS] and modified McCormick [MC] grading system).

Results:  In all, 78.5% were low-grade tumors (or benign lesions) and 21.5% were high-grade tumors. Sixty-one percent underwent median suboccipital approach, 18% a posterolateral approach, and 21% a posterior cervical approach. Gross total resection was achieved in 54% of cases, near-total resection (>90%) in 14%, and subtotal resection (50-90%) in 32% of cases. Early postoperative morbidity was 25%, but late functional evaluation in 79% of the patients showed KPS > 70 and MC grade I; only 21% of cases showed KPS < 70 and MC grades II and III at late follow-up. Mean overall survival was 7 years in low-grade tumors or cavernomas and 11.7 months in high-grade tumors. Progression-free survival at the end of follow-up was 71% (evaluated mainly on low-grade tumors).

Conclusions:  The surgical goal should be to achieve maximal cytoreduction and minimal postoperative neurologic damage. Functional outcome is influenced by the presence of a POD, radicality, histology, preoperative status, and employment of advanced neuroimaging planning and intraoperative monitoring.
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http://dx.doi.org/10.1055/s-0040-1719080DOI Listing
May 2021

Microsurgical Treatment of Anterior Communicating Artery Aneurysms: A 20-year Single-institution Experience.

J Neurol Surg A Cent Eur Neurosurg 2020 Jan 23;81(1):33-43. Epub 2019 Sep 23.

NESMOS Department, "Sapienza" University of Rome, Rome, Italy.

Background:  Anterior communicating artery (AComA) aneurysms are the most frequent intracranial aneurysms. They have a high risk of rupture, morbidity, and mortality following rupture. Surgical treatment is complex because of their deep location, proximity to the perforators, and their different projections and relations with the parent vessels. This retrospective study reports our experience in the surgical management of AComA aneurysms, describing how the microsurgical strategy is influenced by their projection and size, the orientation of the AComA complex, and the location and caliber of the parent vessels.

Methods:  We reviewed all the patients treated surgically at our institution from September 1995 to March 2015 for ruptured and unruptured AComA aneurysms. Operative reports, neuroimages, and intraoperative videos were analyzed, and the surgical technique was examined. Illustrative cases are also included.

Results:  A complete documentation was available for 223 (75.3%) of the 296 treated patients. Medium-size (55.1%) and superiorly projecting (31.8%) aneurysms were the most represented; 158 patients (70.9%) had different A1 diameters. A left- or right-sided pterional approach was performed in 85 patients (38.1%) and 138 patients (61.9%), respectively. A complete occlusion was documented in 185 patients (83%).

Conclusions:  Posterior and superior projections are the most complex to deal with because of the difficult dissection of the perforators and the contralateral A2, respectively. Approaching from the side of the dominant A1 ensures a prompt proximal control. Searching preoperatively for an eventual rotation of the AComA complex and for the location of the A2s can be very helpful for intraoperative orientation.
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http://dx.doi.org/10.1055/s-0039-1685507DOI Listing
January 2020

Proposal of Standardization of Closure Techniques After Endoscopic Pituitary and Skull Base Surgery Based on Postoperative Cerebrospinal Fluid Leak Risk Classification.

J Craniofac Surg 2019 Jun;30(4):1027-1032

Department of Neurosciences-Neurosurgery Unit.

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.
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http://dx.doi.org/10.1097/SCS.0000000000005540DOI Listing
June 2019

Recurrent lumbar disc herniation: Is there a correlation with the surgical technique? A multivariate analysis.

J Craniovertebr Junction Spine 2018 Oct-Dec;9(4):260-266

Department of Neurology and Psychiatry, Division of Neurosurgery, "Sapienza" University of Rome, Rome, Italy.

Purpose: The recurrence of a lumbar disc herniation (LDH) is a common cause of poor outcome following lumbar discectomy. The aim of this study was to assess a potential relationship between the incidence of recurrent LDH and the surgical technique used. Furthermore, we tried to define the best surgical technique for the treatment of recurrent LDH to limit subsequent recurrences.

Materials And Methods: A retrospective study was conducted on 979 consecutive patients treated for LDH. A multivariate analysis tried to identify a possible correlation between (1) the surgical technique used to treat the primary LDH and its recurrence; (2) technique used to treat the recurrence of LDH and the second recurrence; and (3) incidence of recurrence and clinical outcome. Data were analyzed with the Pearson's Chi-square test for its significance.

Results: In 582 cases (59.4%), a discectomy was performed, while in 381 (40.6%), a herniectomy was undertaken. In 16 cases, a procedure marked as "other" was performed. Among all patients, 110 (11.2%) had a recurrence. Recurrent LDH was observed in 55 patients following discectomy (9.45%), in 45 following herniectomy (11.8%), and in 10 (62.5%) following other surgery. Our data showed that 90.5% of discectomies and 88.2% of the herniectomies had a good clinical outcome, whereas other surgeries presented a recurrence rate of 62.5% (Pearson's χ< 0.001). No statistical differences were observed between discectomy or herniectomy, for the treatment of the recurrence, and the incidence for the second recurrences ( > 0.05). A significant statistical correlation emerged between the use of other techniques and the incidence for the second recurrences ( < 0.05).

Conclusions: The recurrence of an LDH is one of the most feared complications following surgery. Although the standard discectomy has been considered more protective toward the recurrence compared to herniectomy, our data suggest that there is no significant correlation between the surgical technique and the risk of LDH recurrence.
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http://dx.doi.org/10.4103/jcvjs.JCVJS_94_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6364357PMC
February 2019

Chiari Malformations.

Acta Neurochir Suppl 2019;125:89-95

Department of Neurology and Psychiatry, Division of Neurosurgery, "Sapienza" University of Rome, Rome, Italy.

Background: Chiari malformations (CM) represent a group of anomalies characterized by descent of the cerebellar tonsils or vermis into the cervical spinal canal. These malformations can be associated with abnormalities such as hydrocephalus, spina bifida, hydromyelia, syringomyelia, curvature of the spine (kyphosis and scoliosis) and tethered cord syndrome. Hereditary syndromes and other disorders that affect growth and bone formation-such as craniosynostosis, Ehlers-Danlos syndromes and Klippel-Feil syndrome-can also be associated with CM.

Methods: The literature concerning treatment is large, and an extensive range of therapeutic protocols have been described. The literature is inclined in favour of surgery; however, there is controversy over when to perform surgery and which procedure is most appropriate. Lately, the indications for stabilization have been under discussion.

Results And Conclusion: In this paper we review the literature and discuss the historical background, anatomical forms, pathophysiology, clinical presentation, relationships with other diseases and diagnostic procedures for these abnormalities.
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http://dx.doi.org/10.1007/978-3-319-62515-7_13DOI Listing
August 2019

Fibrous Pituitary Macroadenomas: Predictive Role of Preoperative Radiologic Investigations for Proper Surgical Planning in a Cohort of 66 Patients.

World Neurosurg 2019 Jan 27;121:e449-e457. Epub 2018 Sep 27.

Department of Neurology and Psychiatry-Neurosurgery Unit, "Sapienza" University of Rome, Rome, Italy.

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.
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http://dx.doi.org/10.1016/j.wneu.2018.09.137DOI Listing
January 2019

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 2018 Sep 25. Epub 2018 Sep 25.

DPT of Neurology and Psychiatry, Neurosurgery Unit, "Sapienza" University of Rome, Rome, Italy.

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 pre-operative 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. Ninty-four patients were selected and reviewing clinical records, pre-operative and post-operative'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: On 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 didn't 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.
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http://dx.doi.org/10.23736/S0390-5616.18.04502-2DOI Listing
September 2018

Delayed surgery in neurologically intact patients affected by thoraco-lumbar junction burst fractures: to reduce pain and improve quality of life.

J Spine Surg 2018 Jun;4(2):397-402

Department of Neurology and Psychiatry, "Sapienza" University of Rome, Rome, Italy.

Background: This is a retrospective study on 18 patients affected by thoraco-lumbar junction burst fractures (TLJBF) A3 or A4 at computed tomography (CT) scan who referred to our hospital. To assess the surgical results in terms of pain and quality of life in a series of neurologically intact patients affected by TLJBF who underwent surgery after 3-4 months from the injury. In literature there is controversy if pain could be an indication for surgery in TLJBF and series of patients conservatively managed with success have been reported.

Methods: A retrospective study on 18 patients is reported. Patients included in this series were neurologically intact and affected by a TLJBF A3 or A4 at CT scan, the height of the burst vertebral body was >50%, spinal canal invasion was <30% and kyphosis deformity <30 degrees. Pain and quality of life were evaluated using graphic rating scale (GRS) and EuroQol (EQ-5D) scores on admission, at the clinical follow-up and in post-surgical period.

Results: Comparing pre- and post-operative EQ-5D, the scores had a statistically significant decrease after the operation (P<0.001) [pre-surgery EQ-5D was 2.60 (SD =0.67), post-surgery EQ-5D was 1.37 (SD =0.41)]. Also analyzing the EQ5D-VAS scores, the t-test revealed that surgery (P<0.01) improved the quality of life with statistically significance (EQ5D-VAS pre =43.89, SD =12.43 and EQ5D-VAS post =73.33, SD =10.84). Analyzing pre- and post-surgical GRS scores, the pain decreased significantly with the maximum mean difference among the 2nd and 3rd month before surgery and at 12 months after surgery (respectively D =5.444, P<0.001 and D =5.167, P<0.001).

Conclusions: Conservatively managed patients affected by TLJBF require a strict clinical follow-up since pain sometimes is present in the following months and it affects the quality of life. Surgery should be considered for these cases.
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http://dx.doi.org/10.21037/jss.2018.05.02DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6046318PMC
June 2018

Considerations regarding supplementary motor area syndrome after surgery for parasagittal meningiomas.

Acta Neurochir (Wien) 2018 08 22;160(8):1555-1556. Epub 2018 Jun 22.

Department of Neurology and Psychiatry, "Sapienza" University of Rome, viale dell'Università 121, Rome, Italy.

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http://dx.doi.org/10.1007/s00701-018-3604-yDOI Listing
August 2018

Emerging Strategies and Future Perspective in Neuro-Oncology Using Transcranial Focused Ultrasonography Technology.

World Neurosurg 2018 Sep 8;117:84-91. Epub 2018 Jun 8.

Endovascular Neurosurgery, Policlinico Umberto I, Rome, Italy. Electronic address:

Background: Despite the progress achieved in recent years, the prognosis of patients with primary brain tumors remains poor. Research efforts have therefore focused on identifying more effective and minimally invasive treatment methods. Magnetic resonance-guided transcranial focused ultrasonography (MRgFUS) is a consolidated minimally invasive therapeutic technique, which has recently acquired a role also in the treatment of some nononcologic intracranial diseases.

Methods: We reviewed the latest studies to take stock of the potential of MRgFUS.

Results: The objective of the research in the last decade was to apply FUS also to the treatment of intracranial neoplastic diseases, using both the thermal effects (thermal ablation) and, above all, the ability to permeabilize the blood-brain barrier and modify the tumor microenvironment. This strategy may allow the use of drugs that are poorly active on the central nervous system or active selectively at high doses, minimize the side effects, and substantially modify the prognosis of patients affected by these diseases.

Conclusions: In the future, targeted drug delivery, immunotherapy, and gene therapy will probably become main players in the treatment of brain neoplasms, with the aid of MRgFUS. In this way, it will be possible to directly intervene on tumor cells and preserve healthy tissue.
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http://dx.doi.org/10.1016/j.wneu.2018.05.239DOI Listing
September 2018

Total en-bloc spondylectomy through a posterior approach: technique and surgical outcome in thoracic metastases.

Acta Neurochir (Wien) 2018 07 28;160(7):1373-1376. Epub 2018 May 28.

Department of Neurology and Psychiatry, University of Rome, Rome, Italy.

Background: In 1981, Roy-Camille et al. have firstly reported the total en-bloc spondylectomy (TES) through a posterior approach for cases of malignant spine tumors in order to reduce the local recurrence and to increase the patient's survival. By then, this surgery has been increasingly gaining recognition. However, it requires a high level of technical ability and knowledge of spinal anatomy, physiology, and biomechanics.

Method: Herein, we report the patient's selection and technique to execute the TES for cases of thoracic metastasis.

Conclusion: This surgery is technically demanding so the patient's selection requires a careful pre-operative evaluation. However, it can be suggested for patients affected by intracompartmental lesions with a good prognosis since the tumor's progression is "limited" by local barriers as demonstrated by histological studies.
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http://dx.doi.org/10.1007/s00701-018-3572-2DOI Listing
July 2018

Giant Cell Ependymoma of Cervicomedullary Junction: A Case Report of a Long-Term Survivor and Literature Review.

World Neurosurg 2018 Aug 14;116:121-126. Epub 2018 May 14.

Division of Neurosurgery, Department of Neurology and Psychiatry, "Sapienza" University of Rome, Rome, Italy.

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.
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http://dx.doi.org/10.1016/j.wneu.2018.05.040DOI Listing
August 2018

Isolated Pediatric Intramedullary Schwannoma: Case Report and Review of Literature.

World Neurosurg 2018 Jul 9;115:417-420. Epub 2018 May 9.

Division of Neurosurgery A, Department of Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy.

Background: Intramedullary (IM) schwannomas are rare entities representing 0.3%-1% of intramedullary tumors and 1.1% of spinal schwannomas. Beside many theories proposed, their rare occurrence might be related to the absence of Schwann cells in the spinal cord. Pediatric IM schwannomas are uncommon, and in the absence of neurofibromatosis they are extremely rare. To date, few cases have been reported in the literature.

Case Description: We describe the case of an 8-year-old female affected by a progressive paraparesis. Neuroradiologic investigations showed an oval-shaped mass at the level of T10-T11. The patient underwent surgery, performed under neurophysiologic monitoring. The patient was operated on with complete removal of the lesion. The postoperative course was uneventful.

Conclusions: The clinical, neuroradiologic, and intraoperative findings are presented, along with a review of the literature. Despite the number of lesions potentially compressing the spinal cord, IM schwannoma is rare but should be taken into account in the differential diagnosis.
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http://dx.doi.org/10.1016/j.wneu.2018.04.220DOI Listing
July 2018

Spinal epidural lipomatosis: a rare condition with unclear etiology.

J Neurosurg Sci 2019 06 9;63(3):352-354. Epub 2018 May 9.

Department of Neurology and Psychiatry, "Sapienza" University of Rome, Rome, Italy.

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http://dx.doi.org/10.23736/S0390-5616.17.04129-7DOI Listing
June 2019

UAIS: Unruptured Aneurysms Italian Study.

J Neurosurg Sci 2019 Dec 23;63(6):697-701. Epub 2018 Feb 23.

Sacred Heart Catholic University, Rome, Italy -

Background: Unruptured intracranial aneurysms (UIAs) are increasingly identified and are an important health-care burden; in the past they were commonly treated by surgical clipping, but nowadays endovascular coil embolization is increasingly employed as an alternative.

Methods: The Unruptured Aneurysms Italian Study (UAIS) is a multicentric cooperative prospective study aimed to delineate the "State of the Art" of UIAs treatment in Italy. 51 Italian Neurosurgical and Neuroradiological Units, representatives of all 20 Italian regions are involved in the Study.

Results: UAIS started on June 2003 and ended on July 2007. 1138 patients were collected by that date, but 181 were ruled-out due to severe violation of the protocol; 957 had complete data and could be statistically evaluated.

Conclusions: UAIS demonstrates that the treatment of UAs, as performed in Italy as a Nation, is effective in improving long-term outcome vs. natural history, particularly in aneurysms larger than 7 mm.
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http://dx.doi.org/10.23736/S0390-5616.18.04337-0DOI Listing
December 2019

Non-obstructive hydrocephalus in a giant hemorrhagic prolactinoma.

J Neurosurg Sci 2019 12 23;63(6):748-749. Epub 2018 Feb 23.

Division of Neurosurgery, Department of Neurology and Psychiatry, Sapienza University, Rome, Italy.

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http://dx.doi.org/10.23736/S0390-5616.18.04317-5DOI Listing
December 2019

Quality of Life After Craniovertebral Junction Meningioma Resection: Shaping the Real Neurologic and Functional Expectancies About These Surgeries in a Contemporary Large Multicenter Experience.

World Neurosurg 2018 Feb;110:583-591

Policlinico Umberto I, Division of Neurosurgery, Rome, Italy.

Objective: Craniovertebral junction (CVJ) meningiomas are one of the most surgically complex conditions in neuro-oncologic surgery. The aim of this work is to correlate our data with clinical outcome to outline factors leading to a worse functional prognosis.

Methods: We analyzed sex, age, clinical presentation, topography, surgical approach, Simpson grade resection, postoperative lower cranial nerve deficits, consistency, histology, site of origin, presence of a capsule, and radiologic and clinical follow-up at 1, 6, and 12 months of 61 patients affected by CVJ meningiomas, operated on in our institution from 1992 to 2014.

Results: 78.7% of patients were women (mean age, 52.85 years); the onset symptom was pain in 65.5% of cases. The mean preoperative Nurick grade of the sample was 3.78; the most frequent histologic type was endotheliomatous (42.8%). We treated 22 patients with a posterior median approach (5 with lateral and 17 with posterolateral axial topography); in 39 cases (30 anterolateral and 9 anterior) we performed a posterolateral approach. Gross total removal was achieved in 85.2% of cases. We recorded a final follow-up step overall neurologic improvement in the cohort (average preoperative Nurick grade, 3.81, and at 12 months, 2.13). Twenty-nine patients presented with lower cranial nerve deficit (permanent or transient) and no statistically significant association was found between surgical approach and temporary or permanent postoperative complications.

Conclusions: We selected, in our experience, some predictors of worse outcome: preoperative sphincter impairment, absence of a capsule, cranial site of origin, a poor preoperative functional status, and firm consistency of the tumor.
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http://dx.doi.org/10.1016/j.wneu.2017.05.177DOI Listing
February 2018

Revision surgery for degenerative spinal deformity: a case report and review of the literature.

Spinal Cord Ser Cases 2017 30;3:17085. Epub 2017 Nov 30.

1Department of Neurosurgery, Sapienza University, Viale del Policlinico 115, 00161, Rome, Italy.

Introduction: Management of spinal degenerative deformities always represents a challenge for the spinal surgeon.

Case Presentation: We report a case of revision surgery for adult scoliosis, focusing of most common errors in pre-surgical management and criteria for reoperation. We analyzed the spino-pelvic parameters on the standing whole-spine X-ray and the role of sagittal balance. To restore 45° of lumbar lordosis, we performed a L3 Pedicle Subtraction Osteotomy (PSO), along with L2-L3 and L3-L4 eXtreme Lateral Interbody Fusion (XLIF).

Discussion: In cases of adult scoliosis, careful preoperative planning is necessary in an attempt to avoid difficult, expensive, and high-risk additional procedures.
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http://dx.doi.org/10.1038/s41394-017-0008-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5798913PMC
November 2017

Spontaneous Spinal Discitis and Spondylodiscitis: Clinicotherapeutic Remarks.

J Neurosci Rural Pract 2017 Oct-Dec;8(4):642-646

Department of Neurology and Psychiatry, Division of Neurosurgery, Sapienza University of Rome, Rome, Italy.

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http://dx.doi.org/10.4103/jnrp.jnrp_67_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5709891PMC
December 2017

Spinal Nerves Schwannomas: Experience on 367 Cases-Historic Overview on How Clinical, Radiological, and Surgical Practices Have Changed over a Course of 60 Years.

Neurol Res Int 2017 18;2017:3568359. Epub 2017 Sep 18.

Department of Neurological Sciences, Neurosurgery, University of Rome "Sapienza", Rome, Italy.

Background: Spinal schwannomas are common benign spinal tumors. Their treatment has significantly evolved over the years, and preserving neurological functions has become one of the main treatment goals together with tumor resection.

Study Design And Aims: Retrospective review focused on clinical assessment, treatment techniques, and outcomes.

Methods: A retrospective study on our surgical series was performed. Clinical and operative data were analyzed. In regard to neurophysiologic monitoring, patients were retrospectively divided into two groups comparing the outcomes before and after introduction of routine intraoperative neurophysiology tests.

Results: From 1951 to 2010, 367 patients overall were treated. Diagnosis was obtained using angiography and/or myelography (pre-CT era), MRI, or CT scan. A posterior spinal approach was used for most patients; complex approaches were adopted for treatment of giant/dumbbell tumors. A trend of neurophysiology monitoring decreasing the rate of post-op neurological deficits was observed but was not statistically significant enough to draft evidence-based conclusions.

Conclusions: Clinical and radiological assessment of spinal schwannomas has markedly changed over the course of 50 years. Diagnostic tools have improved, and detection of recurrence has become way more sensitive. Neurophysiologic monitoring has become a useful intraoperative tool to guide resection and prevent post-op neurological impairment.
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http://dx.doi.org/10.1155/2017/3568359DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5624174PMC
September 2017

Lumbar ganglion cyst: Nosology, surgical management and proposal of a new classification based on 34 personal cases and literature review.

World J Orthop 2017 Sep 18;8(9):697-704. Epub 2017 Sep 18.

Department of Neurological and Psychiatric, Sapienza University of Rome, 00185 Rome, Italy.

Aim: To analyze different terms used in literature to identify lumbar extradural cysts and propose a common scientific terminology; to elaborate a new morphological classification of this pathology, useful for clinical and surgical purposes; and to describe the best surgical approach to remove these cysts, in order to avoid iatrogenic instability or treat the pre-existing one.

Methods: We retrospectively reviewed 34 patients with symptomatic lumbar ganglion cysts treated with spinal canal decompression with or without spinal fixation. Microsurgical approach was the main procedure and spinal instrumentation was required only in case of evident pre-operative segmental instability.

Results: The complete cystectomy with histological examination was performed in all cases. All patients presented an improvement of clinical conditions, evaluated by Visual Analogic Scale and Japanese Orthopaedic Association scoring.

Conclusion: Spinal ganglion cysts are generally found in the lumbar spine. The treatment of choice is the microsurgical cystectomy, which generally does not require stabilization. The need for fusion must be carefully evaluated: Pre-operative spondylolisthesis or a wide joint resection, during the operation, are the main indications for spinal instrumentation. We propose the terms "ganglion cyst" to finally identify this spinal pathology and for the first time its morphological classification, clinically useful for all specialists.
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http://dx.doi.org/10.5312/wjo.v8.i9.697DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5605355PMC
September 2017

A case of cervical tuberculosis with severe kyphosis treated with a winged expandable cage after double corpectomy.

J Spine Surg 2017 Jun;3(2):304-308

Division of Neurosurgery, Department of Neurology and Psychiatry, "Sapienza" University of Rome, Rome, Italy.

In this case report, we demonstrate that the use of a winged expandable cage was able to obtain good clinical and radiological results in a case of cervical tuberculosis with severe kyphosis. However, case series will be necessary to affirm its validity as a stand-alone device for similar cases with high risk of instability.
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http://dx.doi.org/10.21037/jss.2017.06.02DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5506313PMC
June 2017

C5 palsy after insertion of a winged expandable cervical cage: a case report and literature review.

J Spine Surg 2017 Jun;3(2):300-303

Department of Neurology and Psychiatry, "Sapienza" University of Rome, Rome, Italy.

C5 nerve root palsy is a well-known complication after anterior or posterior cervical decompression. Many theories have been proposed but the etiology is still unclear. The use of a winged expandable cage after single or multiple corpectomy is among the used techniques in reconstructing the cervical spine. Herein we report a case of C5 palsy after a three-level corpectomy and reconstruction using this device for the treatment of cervical spondylosis. In our case the preexisting foraminal stenosis, wide anterior decompression and partial improvement of cervical alignment were factors supposed contributing to the palsy.
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http://dx.doi.org/10.21037/jss.2017.06.03DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5506319PMC
June 2017

Static and dynamic cervical MRI: two useful exams in cervical myelopathy.

J Spine Surg 2017 Jun;3(2):212-216

1Department of Neurology and Psychiatry, 2Department of Psychology, "Sapienza" University of Rome, Rome, Italy.

Background: Cervical magnetic resonance imaging (MRI) is the gold standard exam in the assessment of patients affected by cervical myelopathy and is very useful in planning the operation. Herein we present a series of patients affected by long tract symptoms who underwent dynamic MRI in addition to the static exam.

Methods: In the period between March 2010 and March 2012, three-hundred-ten patients referred to our department since affected by neck/arm pain or symptoms related to cervical myelopathy. Thirty-eight patients complained "long-tract symptoms" related to cervical myelopathy. This series of patients was enrolled in the study. All patients underwent clinical and neurological exam. In all the cases, a static and dynamic cervical MRI was executed using a 3.0-T superconducting MR unit (Intera, Philips, Eindhoven, Netherlands). The dynamic exam was performed with as much neck flexion and extension the patient could achieve alone. On T2-weigthed MRI each level was assessed independently by two neuroradiologists and Muhle scale was applied.

Results: According to Muhle's classification of spinal cord compressions, static MRI demonstrated 156 findings: 96 (61.54%) anterior and 60 (38.46%) posterior. Dynamic MRI showed 186 spinal cord compressions: 81 (43.5%) anterior and 105 (56.5%) posterior. The anterior compressions were: grade 1 in 23 cases (28.4%), grade 2 in 52 cases (64.2%), grade 3 in 6 cases (7.4%). The posterior compressions were: 32 (30.48%) of grade 1, 60 (57.14%) of grade 2, 13 (12.38%) of grade 3.

Conclusions: The dynamic MRI demonstrated a major number of findings and spinal cord compressions compared to the static exam. Finally, we consider the dynamic exam able to provide useful information in these patients, but we suggest a careful evaluation of the findings in the extension exam since they are probably over-expressed.
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http://dx.doi.org/10.21037/jss.2017.06.01DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5506301PMC
June 2017

Aneurysms of the Intracranial Segment of the Ophthalmic Artery Trunk: Case Report and Systematic Literature Review.

J Neurol Surg A Cent Eur Neurosurg 2018 May 25;79(3):257-261. Epub 2017 Jul 25.

Department of Neurology and Psychiatry, Endovascular Neurosurgery, University of Rome "Sapienza," Rome, Italy.

Aneurysms arising from the ophthalmic artery trunk (OAT) are very rare, particularly in the artery's intracranial course. The onset of a subarachnoid hemorrhage (SAH) from a ruptured OAT aneurysm in this segment is extremely rare. We present a case and discuss the anatomy, clinical significance, and therapeutic options for an aneurysm at this site. We also retrospectively analyzed the record of a patient with a ruptured aneurysm of the intracranial segment of the OAT and conducted a comprehensive and systematic review of the PubMed and Scopus databases for literature on this pathology. Only one case report of SAH from an aneurysm of the intracranial segment of the OAT was published in the literature. Only in our case was the intracranial OAT segment aneurysm discovered in the acute phase of SAH. Conventional angiography with three-dimensional acquisition may help detect aneurysms at this level. Detailed knowledge of the anatomy of the OAT is of paramount importance for both surgical and endovascular approaches. Surgical treatment is complex because of difficulties in accessing the orbital region and the risk of optic nerve and vascular injuries. Endovascular treatment, when feasible, could be a good alternative to reduce the risk of loss of vision related to surgical manipulation.
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http://dx.doi.org/10.1055/s-0037-1604268DOI Listing
May 2018

Comment on "Controversies about Interspinous Process Devices in the Treatment of Degenerative Lumbar Spine Diseases: Past, Present, and Future".

Biomed Res Int 2017 11;2017:6545361. Epub 2017 May 11.

Department of Neurology and Psychiatry, Division of Neurosurgery A, Sapienza University of Rome, Rome, Italy.

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http://dx.doi.org/10.1155/2017/6545361DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5444032PMC
November 2018

Factors Leading to a Poor Functional Outcome in Spinal Meningioma Surgery: Remarks on 173 Cases.

Neurosurgery 2017 04;80(4):602-609

Neurosurgery Division, NESMOS Department, Sapienza University, Roma, Italy.

Background: Spinal meningiomas are common spinal tumors, in most cases benign and with a good surgical prognosis. However, specific location, infiltration of spinal cord, vascular encasement, or spinal root involvement can bring a less favorable prognosis.

Objective: To correlate these data with clinical/functional outcome.

Methods: Two hundred twenty-four consecutive patients with spinal meningiomas treated from 1976 to 2013 in our institution were analyzed; among these, 51 were excluded for incomplete clinical data or follow-up. The remaining 173 cases were classified in regards to sex, age, symptoms, axial location, Simpson grade resection, and functional pre-/postoperative status.

Results: Most recurring onset symptoms were pain (32.9%) and motor deficit (31.8%); thoracic spine was the most severely affected (69.8%). Functional improvement on the follow-up was observed in 86.7% of cases; 6.4% of patients resulted stable and 6.9% worsened. A low functional grade before surgery was connected to a lesser improvement after. Anterolateral meningiomas were the most represented (42.2%); a gross total resection (Simpson grades I and II) was conducted in 98.8%, and a macroscopically complete removal without dural resection or coagulation (Simpson grade III) was performed in 1.2%. Of the meningiomas, 98.3% were classified as WHO grade I. Recurrence rate was 2.3%, and 7 cases presented complications (4 of 7 required surgical procedure).

Conclusion: We can affirm that negative prognostic factors in our study were anterior or anterolateral axial location, prolonged presentation before diagnosis, WHO grade >I, Simpson grade resections II and III, sphincter involvement, and worse functional grade at onset.
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http://dx.doi.org/10.1093/neuros/nyw092DOI Listing
April 2017

Calcified Spinal Meningiomas.

World Neurosurg 2017 Jun 18;102:406-412. Epub 2017 Mar 18.

Department of Neurology and Psychiatry, Neurosurgery Unit, Sapienza University of Rome, Rome, Italy.

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 + B), fair (C), and good (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.
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http://dx.doi.org/10.1016/j.wneu.2017.03.045DOI Listing
June 2017
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