Mr Angelo Pichierri

Italy-trained Neurosurgeon, CCT equivalent completed in 2009. 2009-2012 PhD in Clinical Neurosciences on dye-guided resection of intrinsic brain lesions. Moved to the UK in 2014 and joined the Specialist Register (Surgical Neurology, no. 7464349). 2014 Endoscopic Pituitary and skull base Fellow at the QEH NHS Foundation Trust, Birmingham 2015 Minimally invasive spine surgery Fellow at the QEH NHS Foundation Trust, Birmingham 2016 -2017 RCS Senior Clinical Fellowship in Neuro-oncology 2017- 2018 Senior Epilepsy Fellow in Southmead Hospital and in the internationally renowned Centre of Epilepsy Surgery “C. Munari”, Milan, Italy. Consultant Neurosurgeon at Neuro / Muscoloskeletal Department in Southmead Hospital (North Bristol Trust) since December 2018, with a special interest in Epilepsy Surgery and Neuro-oncology. Elective operations include: - Diagnostic stereo-EEGs (sEEG). Pre-surgical planning requires a high-field MRI with special sequences that are subsequently processed to detail the three-dimensional cortical and vascular anatomy of the brain enabling a precise and safe placement of the depth electrodes. Post-operative 3D reconstructions are also used to analyse the EEG data and identify the exact position of each recording contact within the brain in order to define the epileptogenic zone (EZ) with more accuracy. - sEEG-guided radiofrequency thermocagulation (RFTC). If the EZ is small enough or if critical nodes are identified, a lesioning of these areas can be done at the patient’s bedside. This procedure often leads to a temporary improvement in seizures’ frequency and/or intensity. In fewer cases, the improvement can be permanent and spares the patient a more invasive operation. Currently, the RFTC is mainly used as a prognostic factor for the subsequent resective surgery: the better is the response to RFTC the more are the chances surgery will lead to permanent improvement / cure from seizures. - Resections for lesional epilepsy Most cases of intractable epilepsy can be caused by a benign or malignant brain tumour, a cavernoma (venous malformation), an AVM (arteriovenous malformation), a cortical dysplasia or rarer developmental or acquired anomalies of the brain. In most of these cases, the resection of the lesion succeeds in controlling the seizures. For particularly challenging lesions, a multidisciplinary team can be consulted and involved in the treatment (vascular neurosurgeon / interventional neuroradiologist, neuro-oncologist, radiotherapist). - Anterior temporal lobectomy. Temporal lobe epilepsy is the most common type of epilepsy. It is generally controllable with medications, but it can become intractable in a minority of patients. The surgical option leads to good outcomes in the major part of cases, especially in patients with hippocampal sclerosis (~70% chances of permanent seizure control / cure). Potential damage to the visual fibers (in particular to the Meyer loop) could lead to a visual field impairment: if large enough, the DVLA will reject application for a driver licence, even if patient would be seizure free. To minimise this risk, our neuroradiology service provides a three-dimensional reconstruction of the patients’ visual system individual anatomy. All the dataset is then sent to the optical surgical neuronavigation system which works like a SatNav and helps identifying key vessels and no-touch zones during surgery. Using this method, the rate of our symptomatic visual field deficit is 7% (compared to 33% of the Literature). - Cortectomies Removal of the epileptogenic zone (EZ) from various areas of the brain. After the appropriate set of investigations has been performed (scalp and/or stereo-EEG, MRI, fMRI, PET/SPECT, MEG, Wada testing, neuropsychology testing) a thorough review of the electro-clinical data and imaging leads to the identification of the EZ. In case the EZ is identified nearby or even within eloquent areas (i.e. monomodal sensory, language, or motor areas) further intraoperative aids can be used (ECoG, awake surgery) for maximising the resection of the malfunctioning tissue without interfering with the function of that specific brain lesion. - Disconnections In case of large malfunctioning tissue or in some cases of network epilepsy, disconnecting the region of the brain triggering seizures may be a better alternative to the resection, because of the lower risk of post-operative complications and similar results in terms of efficacy. The disconnection of large areas of the brain is inevitably burdened from high risks of neurological dysfunction, especially in adults. Hence, a benefit/risk discussion must be carried out in order to set realistic expectations. - Vagus nerve stimulator (VNS) There are cases where the epileptogenic zone (EZ) cannot be treated surgically (bilateral, multifocal and/or generalised epilepsies), or where the EZ is so extensive that a disconnection is deemed not appropriate. These patients may still benefit from the insertion of a VNS: a relevant reduction in seizure’s frequency is achieved in about half of the cases, and is particularly effective in reducing the incidence of drop attacks. Modern stimulators can be extensively programmed and have sophisticated generators self-activating during the early phases of a seizure. The patient or carer can also activate the implant swiping a wrist-held magnet on the generator, located near the left axillar region.