A light on the dark side: In vivo endoscopic anatomy of the posterior third ventricle and its variations in hydrocephalus

Objective: Despite the technological advancements of neurosurgery, the posterior part of the third ventricle has always been the "dark side"of the ventricle. However, flexible endoscopy offers the opportunity for a direct, in vivo inspection and detailed description of the posterior third ventricle in physiological and pathological conditions. The purposes of this study were to describe the posterior wall of the third ventricle, detailing its normal anatomy and surgical landmarks, and to assess the effect of chronic hydrocephalus on the anatomy of this hidden region. Methods: The authors reviewed the video recordings of 59 in vivo endoscopic explorations of the posterior third ventricle to describe every identifiable anatomical landmark. Patients were divided into 2 groups based on the absence or presence of a chronic dilation of the third ventricle. The first group provided the basis for the description of normal anatomy. Results: The following anatomical structures were identified in all cases: adytum of the cerebral aqueduct, posterior commissure, pineal recess, habenular commissure, and suprapineal recess. Comparing the 2 groups of patients, the authors were able to detect significant variations in the shape of the adytum of the cerebral aqueduct and in the thickness of the habenular and posterior commissures. Exploration with sodium fluorescein excluded the presence of any fluorescent area in the posterior third ventricle, other than the subependymal vascular network. Conclusions: The use of a flexible scope allows the complete inspection of the posterior third ventricle. The anatomical variations caused by chronic hydrocephalus might be clinically relevant, in light of the commissure functions

Visualization, navigation, augmentation. The ever-changing perspective of the neurosurgeon

Introduction: The evolution of neurosurgery coincides with the evolution of visualization and navigation. Augmented reality technologies, with their ability to bring digital information into the real environment, have the potential to provide a new, revolutionary perspective to the neurosurgeon. Research question: To provide an overview on the historical and technical aspects of visualization and navigation in neurosurgery, and to provide a systematic review on augmented reality (AR) applications in neurosurgery. Material and methods: We provided an overview on the main historical milestones and technical features of visualization and navigation tools in neurosurgery. We systematically searched PubMed and Scopus databases for AR applications in neurosurgery and specifically discussed their relationship with current visualization and navigation systems, as well as main limitations. Results: The evolution of visualization in neurosurgery is embodied by four magnification systems: surgical loupes, endoscope, surgical microscope and more recently the exoscope, each presenting independent features in terms of magnification capabilities, eye-hand coordination and the possibility to implement additional functions. In regard to navigation, two independent systems have been developed: the frame-based and the frame-less systems. The most frequent application setting for AR is brain surgery (71.6%), specifically neuro-oncology (36.2%) and microscope-based (29.2%), even though in the majority of cases AR applications presented their own visualization supports (66%). Discussion and conclusions: The evolution of visualization and navigation in neurosurgery allowed for the development of more precise instruments; the development and clinical validation of AR applications, have the potential to be the next breakthrough, making surgeries safer, as well as improving surgical experience and reducing costs

Sporadic and hereditary hemangioblastoma: The role of endothelial cells

Hemangioblastomas HBs are benign, highly vascularized tumors of the central nervous system. Approximately 75 of HBs are sporadic, while 25 are associated with von Hippel Lindau disease. HBs consist of two main components: A rich capillary network composed of vascular endothelia and pericytes, within large vacuolated stromal cells, which harbor the genetic defect

Longitudinal Neuropsychological Assessment of Symptomatic Edema after Subthalamic Nucleus Deep Brain Stimulation Surgery: A Case Series Study

Severe non-infectious or non-haemorrhagic brain edema surrounding the electrode represents a rare complication of subthalamic nucleus deep brain stimulation (STN-DBS) surgery. The aim of this study is to report three patients with advanced Parkinson's Disease (PD) who developed symptomatic brain edema after STN-DBS surgery treated with intravenous steroids with a specific profile of reversible cognitive alterations. Patients were both assessed with a comprehensive neuropsychological battery including attention, memory, visuo-spatial and executive tasks. They were also briefly assessed for emotional and behavioural alterations, and for possible limitations in the activities of daily living. Normative data for an Italian population were available for all neuropsychological tests. The patients were firstly assessed before the surgery (baseline) as soon as they became symptomatic for the post-surgery edema and a few more times in follow-up up to ten months. In all patients we observed the resolution of cognitive deficits within six months after surgery with the corresponding reabsorption of edema at brain CT scans. The appearance of post-DBS edema is a fairly frequent and clinically benign event. However, in some rare cases it can be very marked and lead to important clinical-albeit transient-disturbances. These events can compromise, at least from a psychological point of view, the delicate path of patients who undergo DBS and can prolong the post-operative hospital stay. In this setting it could be helpful to perform a brain CT scan in 2-3 days with the aim of detecting the early appearance of edema and treating it before it can constitute a relevant clinical problem

New national and regional bryophyte records, 69

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A systematic review of tests of empathy in medicine

Abstract Background Empathy is frequently cited as an important attribute in physicians and some groups have expressed a desire to measure empathy either at selection for medical school or during medical (or postgraduate) training. In order to do this, a reliable and valid test of empathy is required. The purpose of this systematic review is to determine the reliability and validity of existing tests for the assessment of medical empathy. Methods A systematic review of research papers relating to the reliability and validity of tests of empathy in medical students and doctors. Journal databases (Medline, EMBASE, and PsycINFO) were searched for English-language articles relating to the assessment of empathy and related constructs in applicants to medical school, medical students, and doctors. Results From 1147 citations, we identified 50 relevant papers describing 36 different instruments of empathy measurement. As some papers assessed more than one instrument, there were 59 instrument assessments. 20 of these involved only medical students, 30 involved only practising clinicians, and three involved only medical school applicants. Four assessments involved both medical students and practising clinicians, and two studies involved both medical school applicants and students. Eight instruments demonstrated evidence of reliability, internal consistency, and validity. Of these, six were self-rated measures, one was a patient-rated measure, and one was an observer-rated measure. Conclusion A number of empathy measures available have been psychometrically assessed for research use among medical students and practising medical doctors. No empathy measures were found with sufficient evidence of predictive validity for use as selection measures for medical school. However, measures with a sufficient evidential base to support their use as tools for investigating the role of empathy in medical training and clinical care are available.</p

Autoamputation of a large pedunculated colon polyp.

A 49-year old man was referred for colonoscopy due to positive fecal occult blood test. Laboratory tests and physical examination were unrevealing. A large pedunculated polyp was found in the sigmoid colon (Figures 1A-1B). Due to inadequate bowel cleansing, polypectomy was not performed at that time. Upon repeat colonoscopy, 120 days later, bowel cleansing was excellent. The exam was performed by an expert endoscopist, achieving a good vision with a good colonic distension and without blind angulations. However, despite every effort, he was unable to find the polyp. A second expert endoscopist was asked to repeat the exam in the same session. Although he had reached the cecum twice, he couldn’t detect the polyp as well. Interestingly, both endoscopists described a prolapsed normal mucosa with a scar on its edge, in the site previously described as the polyp location (Figure 3). On close inspection, no adenomatous tissue was visible. We hypothesized a case of polyp autoamputation, with the prolapsed mucosa being the remnant of the stalk of the missing polyp. Indeed, the patient reported having suffered of a passage of bright red material and clots per rectum a few weeks before, without relevant consequences. To our knowledge only 3 cases of polyp autoamputation have been reported in the colon - ; autoamputation has been described also in the stomach and in the duodenum. It has been linked mainly with pedunculated type of polyps, which are subject to higher mechanical traction and torsion of the stalk. This is the first case documented with endoscopic images both before and after the event. Autoamputation can be either asymptomatic or accompanied by abdominal pain and bleeding, eventually leading to hospitalization.4 No fatalities have been reported. Intrinsic limitations of colonoscopy usually represent the first cause of missed polyps. Nevertheless, in case of pedunculated polyps that are not found anymore in subsequent colonoscopies, autoamputation is a possibility that gastroenterologists should take into account