Glioblastoma are the most common primary malignant brain tumors with a highly infiltrative behavior. The extent of resection of the enhancing component has been shown to be correlated to survival. Recently, it has been proposed to move the resection beyond the contrast-enhanced portion into the MR hyper intense tissue which typically surrounds the tumor, the so-called supra marginal resection (SMR). Though it should be associated with better overall survival (OS), a potential harmful resection must be avoided in order not to create new neurological deficits. Through this work, we aimed to perform a critical review of SMR in patients with Glioblastoma. A Medline database search and a pooled meta-analysis of HRs were conducted; 19 articles were included. Meta-analysis revealed a pooled OS HR of 0.64 (p = 0.052). SMR is generally considered as the resection of any T1w gadolinium-enhanced tumor exceeding FLAIR volume, but no consensus exists about the amount of volume that must be resected to have an OS gain. Equally, the role and the weight of several pre-operative features (tumor volume, location, eloquence, etc.), the intraoperative methods to extend resection, and the post-operative deficits, need to be considered more deeply in future studies.
Acute brain plasticity during resection of central lesions has been recently described. In the cases reported, perilesional latent networks, useful to preserve the neurological functions, were detected in asymptomatic patients. In this paper, we presented a case of acute functional reactivation (AFR) of the language network in a symptomatic patient. Tumor resection allowed to acutely restore the neurological deficit. Intraoperative direct cortical stimulation (DCS) and functional neuroimaging showed new epicentres of activation of the language network after tumor excision. DCS in awake surgery is mandatory to reveal AFR needful to improve the extent of resection preserving the quality of life.
Abstract BACKGROUND The behavior of meningiomas under influence of progestin therapy remains unclear. OBJECTIVE To investigate the relationship between growth kinetics of intracranial meningiomas and usage of the progestin cyproterone acetate (PCA). METHODS This study prospectively followed 108 women with 262 intracranial meningiomas and documented PCA use. A per-meningioma analysis was conducted. Changes in meningioma volumes over time, and meningioma growth velocities, were measured on magnetic resonance imaging (MRI) after stopping PCA treatment. RESULTS Mean follow-up time was 30 (standard deviation [SD] 29) mo. Ten (4%) meningiomas were treated surgically at presentation. The other 252 meningiomas were followed after stopping PCA treatment. Overall, followed meningiomas decreased their volumes by 33% on average (SD 28%). A total of 188 (72%) meningiomas decreased, 51 (20%) meningiomas remained stable, and 13 (4%) increased in volume of which 3 (1%) were surgically treated because of radiological progression during follow-up after PCA withdrawal. In total, 239 of 262 (91%) meningiomas regressed or stabilized during follow-up. Subgroup analysis in 7 women with 19 meningiomas with follow-up before and after PCA withdrawal demonstrated that meningioma growth velocity changed statistically significantly ( P = .02). Meningiomas grew (average velocity of 0.25 mm 3 /day) while patients were using PCA and shrank (average velocity of −0.54 mm 3 /day) after discontinuation of PCA. CONCLUSION Ninety-one percent of intracranial meningiomas in female patients with long-term PCA use decrease or stabilize on MRI after stopping PCA treatment. Meningioma growth kinetics change significantly from growth during PCA usage to shrinkage after PCA withdrawal.
Incidence of chronic subdural hematomas (cSDH) is expected to progressive rise in the next decades. There is no univocal indication of the approach to be used. Furthermore, there is no data about the efficacy of twist drill craniostomy (TDC) in hematomas with membranes. To describe our modified technique for TDC in patients affected by cSDH with membranes and in treatment with antiplatelets. We analyzed a group of 37 patients, affected by cSDH with membrane (type D laminar membrane and type G trabecular membrane according to Nakaguchi classification), treated with mushroom TDC using a modified technique. After surgery the average maximum thickness of the common postoperative liquoral subdural collection decreased from 18.8 to 6.21 mm. We documented one acute subdural hematoma (2.7%), asymptomatic and not treated, and one recurrence of cSDH (2.7%) after 2 months that needed re-intervention with single burr hole. We presented a modified twist drill technique, characterized by the introduction of an application of a new device that optimizes both surgical results, clinical outcome and surgical procedure time. The presence of membrane type D and G does not affect the efficacy of drainage, that is negatively related to the presence of clots or acute hematoma. This modified technique is safe, fast, effective and represents a valid first line treatment of an unstable and unpredictable pathology such as cSDH. We suggest performing such technique on a larger patients' cohort to further validate its effectiveness.
Pneumonia caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a newly recognized illness that has spread rapidly from Wuhan to other provinces in the People's Republic of China and around the world. Italy was one of the most affected countries. From February 2020, Lombardy (northern Italy) was the most affected region by the coronavirus disease 2019 (COVID-19) infection, with a total number of 93,990 positive cases and a total number of 16,302 deaths (data as of July 2, 2020). In particular, Brescia was 1 of the provinces of Lombardy most affected by the pandemic. Data on the clinical characteristics and outcomes of patients having asthma with SARS-CoV-2 infection are scarce but are of paramount importance to evaluate the relationship between COVID-19 and asthma. Given the characteristics of the virus, one would expect to observe an increased prevalence of asthma and wheezing exacerbations in patients having COVID-19 with allergy and asthma comorbidity—a typical consequence in the case of a viral respiratory infection.1Jartti T. Bønnelykke K. Elenius V. Feleszko W. Role of viruses in asthma.Semin Immunopathol. 2020; 42: 61-74Crossref PubMed Scopus (119) Google Scholar In this single-center, observational study, we investigated patients with asthma with confirmed SARS-CoV-2 pneumonia who were admitted to our hospital (Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy), which is 1 of the designated hospitals to treat patients with SARS-CoV-2 pneumonia. We retrospectively evaluated the data of patients with asthma, from February 20, 2020 to April 20, 2020, who had been diagnosed as having SARS-CoV-2 pneumonia. Asthma was identified as diagnosed by physicians and by the standard criterion used for several real-life studies; in most of our cases, the diagnosis was supported by the results of previous historical standard spirometry with reversibility test with albuterol or methacholine challenge. We evaluated a total of 1043 hospitalized patients who received a positive test result for COVID-19 (men, 704; women, 339; age range, 14-91 years) with only 20 patients with asthma (men, 8; women, 12; age range, 41-77 years). None of the 20 patients were smokers or ex-smokers, and only 1 was an immigrant (woman, aged 47 years from Ghana; arrived in Italy 10 years before with no previous history of sensitization to aeroallergens and/or nasal polyposis). Of the 20 patients with asthma, 6 (30%) had no other comorbidities. The most frequent comorbidity was systemic hypertension (40% of the total cases) (Fig 1). The percentage distribution of lung parenchyma involvement derived from the computed tomography imaging data was as follows: (1) less than 25% (9 patients); (2) 25% to 50% (7 patients); (3) 50% to 75% (2 patients), and (4) greater than 75% (2 patients). None of the 20 patients had an evident exacerbation of asthma symptoms or objective evidence of bronchospasm on chest auscultation. With regard to antiasthmatic therapies taken by patients before admission to the hospital, we have documented the following treatments: (1) 15 patients (75%) took a preestablished association with long-acting β-agonists plus inhaled corticosteroids ICS; (2) 2 patients (10%) took inhaled steroid only and short-acting β-agonist on demand; (3) 4 patients (20%) took oral steroid at low doses (prednisone, 5-7.5 mg/d); and (4) 4 patients took (20%) montelukast (10 mg/d). No patients were taking tiotropium, biological agents, or allergen-specific immunotherapy. Of the 20 patients, 3 were transferred to the intensive care unit from the internal medicine area owing to worsening of the clinical picture and respiratory failure. A total of 2 fatal cases (2 women, aged 66 and 77 years, respectively) were recorded, both of whom were not related to the clinical condition of asthma. Both were moved to the intensive care unit and died from acute respiratory distress syndrome. Compared with the control group of patients without asthma hospitalized for COVID-19, the mortality in patients with asthma was much lower (10% vs 22.6%). The prevalence of asthma in our hospitalized patients with COVID-19 was particularly low (1.92%) when compared with the prevalence of asthma in the general population of Italy (6.1% men and 5.49% women, 6.64% total)2Cazzola M. Puxeddu E. Bettoncelli G. et al.The prevalence of asthma and COPD in Italy: a practice-based study.Respir Med. 2011; 105: 386-391Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar or Europe (4%-7%).3Gibson G.J. Loddenkemper R. Lundbäck B. Sibille Y. Respiratory health and disease in Europe: the new European Lung White Book.Eur Respir J. 2013; 42: 559-563Crossref PubMed Scopus (235) Google Scholar This observation is surprising if we consider the following: (1) the chronic inflammatory infiltration and the airway dysfunction characterizing asthma; (2) the close association between asthma and respiratory viral infections; (3) the increased frequency and severity of lower respiratory tract infections in patients with asthma; and (4) the influenza-related increased morbidity and community-acquired pneumonia. We can speculate that patients with a chronic respiratory disease such as asthma should be at increased risk of SARS-CoV-2 infection with worse clinical outcomes, but data, thus far, do not support this. In a study performed in Wuhan, electronic medical records including demographics, clinical manifestation, comorbidities, laboratory data, and radiology reports of 140 hospitalized patients with a confirmed result of SARS-CoV-2 viral infection were extracted and analyzed, and it was noted that asthma or other allergic diseases were not reported by any of the patients.4Zhang J.-J. Dong X. Cao Y.-Y. et al.Clinical characteristics of 140 patients infected by SARS-CoV-2 in Wuhan, China.Allergy. 2020; 75: 1730-1741Crossref PubMed Scopus (2534) Google Scholar Moreover, Yang et al5Yang J. Zheng Y. Gou X. et al.Prevalence of comorbidities in the novel Wuhan coronavirus (COVID-19) infection: a systematic review and meta-analysis.Int J Infect Dis. 2020; 94: 91-95Abstract Full Text Full Text PDF PubMed Scopus (2681) Google Scholar conducted a systematic review of studies to evaluate the prevalence of comorbidities in patients diagnosed as having COVID-19 and the presence of underlying diseases in severe patients compared with nonsevere patients. A total of 46,248 participants were included in this meta-analysis. The most prevalent comorbidities were hypertension and diabetes, followed by cardiovascular diseases and respiratory system diseases (2%). Overall, given that the prevalence of asthma in the People's Republic of China is 4.2%, these early studies found that asthma is not a risk factor for SARS-CoV-2 infection. Furthermore, Richardson et al6Richardson S. Hirsch J.S. Narasimhan M. et al.Presenting characteristics, comorbidities, andoutcomes among 5700 patients hospitalized with COVID-19 in the New York City area.JAMA. 2020; 323: 2052-2059Crossref PubMed Scopus (6379) Google Scholar evaluated characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in New York City and found no increase in hospitalizations among patients with asthma; indeed, the reported percentage (9%) is in line with the annual American data. Beyond the People's Republic of China and the United States, looking at the recent data from Italy, among the 355 patients who died because of SARS-CoV-2, asthma was not listed as a relevant comorbidity.7Onder G, Rezza G, Brusaferro S. Case-fatality rate and characteristics of patients dying in relation to COVID-19 in Italy [e-pub ahead of print]. JAMA. https://doi.org/10.1001/jama.2020.4683, accessed march 23, 2020.Google Scholar Our data seem even more impressive if we consider that the COVID-19 pandemic in northern Italy coincided with the start of the new pollen season, and therefore, with the periodic annual increase in the cases of seasonal allergic asthma. An intriguing hypothesis is that having asthma protects against SARS-CoV-2, perhaps through a different pattern of immune response elicited by the chronic disease itself.8Halpin D.M.G. Faner R. Sibila O. Badia J.R. Agusti A. Do chronic respiratory diseases or their treatment affect the risk of SARS-CoV-2 infection?.Lancet Respir Med. 2020; 8: 436-438Abstract Full Text Full Text PDF PubMed Scopus (281) Google Scholar More recently, Jackson et al9Jackson D.J. Busse W.W. Bacharier L.B. et al.Association of respiratory allergy, asthma, and expression of the SARS-CoV-2 receptor ACE2.J Allergy Clin Immunol. 2020; 146 (e3): 203-206Abstract Full Text Full Text PDF PubMed Scopus (418) Google Scholar reported that respiratory allergy and controlled allergen exposures are each associated with significant reductions in the angiotensin-converting enzyme 2 expression; it is noteworthy that nonatopic asthma was not associated with reduced angiotensin-converting enzyme 2 expression. Another possibility is that therapies used by patients with asthma can reduce the risk of infection. Recently, inhaled corticosteroids alone or in combination with bronchodilators have been reported to suppress coronavirus replication and cytokine production.10Yamaya M. Nishimura H. Deng X. et al.Inhibitory effects of glycopyrronium, formoterol, and budesonide on coronavirus HCoV-229E replication and cytokine production by primary cultures of human nasal and tracheal epithelial cells.Respir Investig. 2020; 58: 155-168Crossref PubMed Scopus (193) Google Scholar In conclusion, according to our data, it seems that asthma is not a relevant risk factor in the development of COVID-19 infection. This study confirms that asthma is not in the top 10 comorbidities associated with COVID-19 fatalities, the more common of which were obesity, diabetes, and chronic heart disease. The authors thank Paolo Matricardi (Department of Pediatrics, Division of Pulmonology, Immunology, and Critical Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany), and Diego Bagnasco (Allergy and Respiratory Diseases, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Martino, University Of Genoa, Genoa, Italy) for their valuable suggestions and contribution to the revision of this article.
Background: The increasing complexity of transnasal endoscopic skull base surgery has led to a significant increase in operating times and, therefore, to the demand for an endoscope holder. A robotic endoscope holder might provide various advantages in transnasal endoscopic skull base surgery, but only recently the first clinical evaluations of robotic systems have been published. Objective: A systematic review of the literature was performed to provide a comprehensive critical overview of robotic systems developed for transnasal endoscopic skull base surgery and evaluated in a clinical setting. Methods: A systematic review was performed on PubMed and Scopus databases, using different keywords. The retrieved papers were analyzed, recording the following features: name of the robotic system, function of the robotic system, number of treated patients, and key findings. Results: Clinical studies included in the review were divided into the following categories: transoral robotic skull base surgery with free-hand endoscopic transnasal approach; robotic armrest (iArms); robotic endoscope holders (ENDOFIXexo; Endoscope Robot®). Each category has specific advantages and limitations. Clinical experiences are increasingly reported but they still remain limited. Conclusions: A few clinical applications of robotic endoscopic skull base surgery have been described. To improve the present results, the need for close collaboration with the industry and engineering research centers is evident and of paramount importance for future developments.
