iUS was highly sensitive in detecting all types of pathology, was safe and precise in planning trajectories to intraparenchymal lesions (including minimally mini-invasive approaches), and was accurate in checking extent of resection in more than 80% of cases. iUS is a versatile and feasible tool; it could improve safety and its use may be considered in routine intracranial surgery.

Background: The aim of this study was to compare the results of two different titanium cranioplasties for reconstructing skull defects: standard precurved mesh versus custom-made prostheses. Methods: Retrospective analysis of 23 patients submitted to titanium cranioplasty between January 2014 and January 2019. Ten patients underwent delayed cranioplasty using custom-made prostheses; and 13 patients were treated using precurved titanium mesh (ten delayed cranioplasties, and three single-stage resection- reconstructions). Demographic, clinical, and radiological data were recorded. Results and complications of the two methods were compared, including duration of surgery, cosmetic results (visual analog scale for cosmesis [VASC]), and costs of the implants. Results: Complications: one epidural hematoma in the custom-made group, one delayed failure in precurved group due to wound dehiscence with mesh exposure. There were no infections in either group. All custom-made prostheses perfectly fitted on the defect; eight of 13 precurved mesh prostheses incompletely covered the defect. Custom-made cranioplasty obtained better cosmetic results (average VASC 94 vs. 68), shorter surgical time (141min vs. 186min), and -fewer screws was needed to fix the prostheses in place (6 vs. 15). However, satisfactory results were obtained using precurved mesh in cases of small defects and in single-stage reconstruction. Precurved mesh was found to be cheaper (€1,500 vs. €5,500). Conclusion: Custom-made cranioplasty obtained better results and we would suggest that this should be a first choice, particularly for young patients with a large cranial defect. Precurved mesh was cheaper and useful for single-stage resection-reconstruction. Depending on the individual conditions, both prostheses have their place in cranioplasty therapies.

Background Resection of tumors adjacent to motor pathways carries risks of both postoperative motor deficit and incomplete resection. Our aim was to assess usefulness and limitations of a multimodal strategy that combines intraoperative ultrasound (iUS) guided resection with intraoperative neurophysiology. Methodology This is a prospective study of 25 patients with brain lesions adjacent to motor areas who underwent intracranial surgery with assistance of the iUS guidance system and intraoperative neurophysiological monitoring and mapping. Pathologies treated included 19 gliomas, 3 metastases, 1 anaplastic meningioma, 1 arteriovenous malformation (AVM), and 1 ependymoma. The iUS-guided lesion removal accuracy and the extent of resection were estimated and compared with a 30-day postoperative brain MRI. The results were assessed considering the extent of resection related to 6-month motor function outcome. Results iUS was accurate in checking the extent of resection in 17 patients, whereas in 8 cases the decline of the iUS images quality did not allow a valuable assessment. Positive mapping was obtained in 16 patients. Gross total resection was achieved in 16 patients. In five of nine cases with subtotal resection, surgery was stopped because a functional area was reached. In four patients, tumor removal was limited due to the difficulty of identifying neoplastic tissue. Motor function worsening was transient in six patients and permanent in two. Conclusions The integrated use of intraoperative neuromonitoring to identify motor areas and iUS to identify tumor–tissue interface could help increase the rate of radical resection respecting the eloquent areas.

Introduction: There are no guidelines about the management of glioblastoma multiforme (GBM) during pregnancy: treatment of these patients presents therapeutic and ethical challenges. Case Description: Two patients, respectively, 28 years old at the 14th week of gestation with a thalamic GBM and 38 years old at the 28th week of gestation with fronto-mesial GBM. Patients and their relatives were deeply informed about the natural history of GBM and potential risks and benefits of surgery, radiotherapy (XRT), and chemotherapy (CTX) for both, mother and fetus. The first patient’s will was to preserve her fetus from any related, even minimal, risk of XRT, and CTX until safe delivery despite progression of GBM, accepting only surgery (tumor debulking and shunting of hydrocephalus). The second one asked to deliver the baby as soon as possible (despite the risks of prematurity) to receive the standard treatments of GBM. The two patients survived, respectively, 16 and 46 months after delivery. The first patient’s son is in good clinical conditions; the second one suffered problems linked to prematurity. Conclusions: Standard treatment of GBM in a pregnant woman could improve the mother’s survival but can expose the fetus to several potential risks. Ethically, relatives should understand that mother has anyway a poor prognosis and, at the same time, fetus prognosis depends on mother’s condition and therapy. It is not possible to warrant absence of risk for both. Considering the absence of guidelines and the relatively poor current data available about management of GBM in a pregnant woman, after a deep explanation of the situation, we think that the will of the mother and her relatives should prevail.

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Background: DLGNT is a rare tumor, commonly diagnosed in pediatric age; in most cases, the pathology presents a slow and indolent evolution. We present a case report of a young adult affected by DLGNT characterized by aggressive and atypical behavior. Case Description: A 21-year-old male presented with mild paraparesis and hypoesthesia with a D2 level. MRI scan of the brain and spine showed a dorsal intramedullary lesion; a diffuse craniospinal leptomeningeal thickening was also present. After a week, the neurological status deteriorated rapidly with paraparesis worsening and onset of acute hydrocephalus. The patient underwent external ventricular drain positioning; a C7-D4 laminectomy was subsequently performed with partial tumor resection. Histological examination revealed a DLGNT with aggressive aspects (Ki67 30%). Postoperatively, the patient showed an immediate mild worsening of the lower limbs deficit. After a few days, severe further neurological deterioration occurred with progressive motor deficit to the upper limbs and ultimately respiratory failure. Mechanical ventilation was necessary and the patient was transferred to the ICU; during the following weeks, he developed tetraplegia and underwent ventriculoperitoneal shunt positioning. By the time, the histological diagnosis was available, the clinical status would not allow radiotherapy or chemotherapy. The patient deceased approximately 90 days after hospitalization due to respiratory complications. Conclusion: DLGNT is a rare tumor; diagnosis requires a high index of suspicion and confirmation with biopsy. Although most cases have an indolent course, some patients may have aggressive forms. High proliferation index, hydrocephalus occurrence, and massive craniospinal leptomeningeal spread appear to be associated with worse prognosis.