OBJECTIVEIn the last 2 decades, the endoscopic endonasal approach in the treatment of clival chordomas has evolved to be a viable strategy to achieve maximal safe resection of this tumor. Here, the authors present a multicentric national study, intending to analyze the evolution of this approach over a 20-year time frame and its contribution in the treatment of clival chordomas.METHODSClival chordoma cases surgically treated between 1999 and 2018 at 10 Italian neurosurgical departments were included in this retrospective study. Clinical, radiological, and surgical findings, adjuvant therapy, and outcomes were evaluated and compared according to classification in the treatment eras from 1999 to 2008 and from 2009 to 2018.RESULTSOne hundred eighty-two surgical procedures were reviewed, with an increase in case load since 2009. The endoscopic endonasal transclival approach (EETA) was performed in 151 of 182 cases (83.0%) and other approaches were performed in 31 cases (17%). There was an increment in the use of EETA, neuronavigation, and Doppler ultrasound after 2008. The overall postoperative complication rate was 14.3% (26 of 182 cases) consisting of 9 CSF leaks (4.9%), 7 intracranial hemorrhages (3.8%), 5 cases of meningitis (2.7%), and 5 cerebral ischemic injuries (2.7%). Gross-total resection (GTR) was achieved in 93 of 182 cases (51.1%). Extent of resection (EOR) improved in the second era of the study. Signs and/or symptoms at presentation worsened in 27 cases (14.8%), and the Katz Index worsened in 10 cases (5.5%). Previous treatment, dural involvement, EETA, and intraoperative Doppler ultrasound correlated with GTR. Patients received adjuvant proton beam radiation in 115 of 182 cases (63.2%), which was administered more in the latter era. Five-year progression-free survival (PFS) and overall survival (OS) were 62.3% and 73.5%, respectively. GTR, EETA, proton beam therapy, and the chondroid subtype correlated with a better survival rate. The mean follow-up was 62 months.CONCLUSIONSThrough multicentric data collection, this study encompasses the largest series in the literature of clival chordomas surgically treated through an EETA. An increase in the use of this approach was found among Italian neurosurgical departments together with an improved extent of resection over time. The satisfactory rate of GTR was marked by low surgical morbidity and the preservation of patient quality of life. Surgical outcome was reinforced, in terms of PFS and OS, by the use of proton beam therapy, which was increasingly performed along the period of study.

5-ALA surgery assisted by functional mapping makes high HGG resection in eloquent areas feasible , through a reasonable rate of late morbidity. This emerges even more remarkably for selected patients.

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C alCulation is based on distinct neural networks, which can be reproducibly identified in different subjects. 2,3,24 A pivotal role in calculation is played by the parietal lobe. In the past 2 decades, neuroimaging and neuropsychological evidence was collected about the innermost mechanisms of calculation, and 3 main parietal circuits 4 have been proposed as the basis of calculation processing. According to this model, intraparietal areas are bilaterally associated with core quantity organization, the left angular gyrus is associated with verbal processing of numbers, and the posterior superior parietal system is associated with spatial and nonspatial attention. In particular, a crucial role in quantity processing has been proposed for the horizontal segment of the intraparietal sulcus. With regard to electrostimulation mapping of calculation, some experiences have been reported on left parietal lobe mapping, 7,13-15,21,23 while data on right parietal mapping are anecdotal and discordant. 20,25 This difference may be due to the much greater attention given to language mapping so far; however, impairment of mathematical skills can be the cause of serious personal and social difficulties. For this reason, the ability to perform calculation tasks ought to be regarded as a fundamental function. The parietal lobe is not only a frequent location of different neurosurgical conditions (such as gliomas, arteriovenous malformations, and others) but it is also a key area for the surgical approach of deeply seated lesions such as intraventricular or periventricular lesions. 10,12,16 The potential clinical repercussions of new data providing evidence of the right parietal lobe as an eloquent area for calculation are therefore obvious in left-dominant patients, in whom the right, nondominant side is generally considered a reasonably safe surgical approach.In this report, we present the results of intraoperative Object. The role of parietal areas in number processing is well known. The significance of intraoperative functional mapping of these areas has been only partially explored, however, and only a few discordant data are available in the surgical literature with regard to the right parietal lobe. The purpose of this study was to evaluate the clinical impact of simple calculation in cortical electrostimulation of right-handed patients affected by a right parietal brain tumor.Methods. Calculation mapping in awake surgery was performed in 3 right-handed patients affected by highgrade gliomas located in the right parietal lobe. Preoperatively, none of the patients presented with calculation deficits. In all 3 cases, after sensorimotor and language mapping, cortical and intraparietal sulcus areas involved in singledigit multiplication and addition calculations were mapped using bipolar electrostimulation.Results. In all patients, different sites of the right parietal cortex, mainly in the inferior lobule, were detected as being specifically related to calculation (multiplication or addition). In 2 patients the intraparietal s...

Despite the small number of patients, our study shows that ICG videoangiography could play a crucial role in guiding surgery of parasagittal meningioma occluding the SSS. Further studies are needed to define the role of this technique on functional and oncological outcome of these patients.

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The endoscope-assisted subtemporal approach can be useful in visualizing tumor in the posterior fossa. It can help the surgeon in planning further surgical steps through consideration of the size, extension, and adherence of the tumor to surrounding structures. The endoscope-assisted Kawase approach permits maximum anatomic exposure of the posterior cranial fossa, although the deepest neurovascular structures could be better addressed with more direct approaches.