Normal Pressure Hydrocephalus as an Unusual Presentation of Supratentorial Extraventricular Space-Occupying Processes: Report on Two Cases

Normal pressure hydrocephalus (NPH) is a clinical and radiographic syndrome characterized by ventriculomegaly, abnormal gait, urinary incontinence, and dementia. The condition may occur due to a variety of secondary causes but may be idiopathic in approximately 50% of patients. Secondary causes may include head injury, subarachnoid hemorrhage, meningitis, and central nervous system tumor. Here, we describe two extremely rare cases of supratentorial extraventricular space-occupying processes: meningioma and glioblastoma multiforme, which initially presented with NPH

Long-Term Survival of a Patient with Giant Cell Glioblastoma: Case Report and Review of the Literature

Glioblastoma multiforme (GBM) is the most common glial tumor of the central nervous system. Overall survival is less than a year in most of the cases in spite of multimodal treatment approaches. A 45-year-old female with histologically confirmed giant cell GBM was treated at our institution. Subtotal excision of the lesion situated in the right precentral area was performed during the initial stay in August 2005. The patient improved after the procedure with no hypertension and additional neurological deficit. Radiotherapy plus concomitant and adjuvant temozolomide was performed. The patient was symptom-free for 35 months after initial surgery. From July 2008 the patient developed partial motor seizures in the left side of the body and progressive hemiparesis. Local tumor progression was demonstrated on the neuroimaging studies. In December 2008, a second operative intervention was performed with subtotal excision of the tumor. Forty-five months after the initial diagnosis the patient is still alive with moderate neurological deficit. Microarray analysis of the tumor found the following numeric chromosomal aberrations: monosomy 8, 10, 13, 22, and trisomy 21, as well as amplifications in 4q34.1, 4q28.2, 6q16.3, 7q36.1, 7p21.3, and deletions in 1q42.12, 1q32.2, 1q25.2, 1p33, 2q37.2, 18q22.3, 19p13.2, Xq28, and Xq27.3. GBMs seem to be a heterogeneous group of glial tumors with different clinical course and therapeutic response. Microarray analysis is a useful method to establish a number of possible molecular predictors

Navigational guidance in transsphenoidal pituitary adenoma surgery

Objective: To assess whether frameless stereotaxy can further increase safety and efficacy of transsphenoidal microsurgery.Methods: We conducted a retrospective analysis of 29 patients with pituitary adenomas (10 recurrent, 12 micro, 17 macro), who had undergone image guided endonasal transsphenoidal surgery during an 18-month period in the Department of Neurosurgery, Medical University - Sofia, Bulgaria. In the preoperative planning process, the adenoma volume and both carotid arteries were segmented in a MRI/CT-3 D dataset (T1-weighted, 3 D FLASH after Gadolinium). An optical infrared-based neuronavigation system (Vector Vision, BrainLAB®, Heimstetten, Germany) was used in all cases for frameless guidance. Using Z-touch infrared markerless or landmark registration (in 3 cases) a mean calculated accuracy of 1.47±0.4 mm was achieved; intraoperative accuracy was checked every 10 min. Intraoperative records were reviewed with attention to the utility of the navigational guidance.Results: The time requirements for set-up, registration and navigational control were minimal (<16 min). In none of the cases the system did interfere with surgical manipulations. True accuracy at surgery was obtained in 29/30 cases. A mean calculated accuracy of 1.47±0.4 mm was achieved during co-registration (1.45±0.69 mm for MRI-based NN and 1.53±0.64 mm for CT-based guidance), which is in concordance with the data from the literature, using similar navigational system , . The frameless technique was used to determine the midline, the depth and trajectory of the approach, as well as to reduce safely working area (in 29/29); in later stages, it provided fast and correct anatomical orientation in relation to the perisellar structures (24/29). Guidance was especially useful in asymmetrical/atypical microsella (in 9/9 pts), in conchal type of sella (3/3 cases), and helpful in locating accurately eccentric microlesions. Conclusions: We found frameless guidance during transsphenoidal surgery useful in certain occasions: misleading sphenoidal sinus anatomy, narrow/asymmetrical sella, eccentric adenomas with perisellar extension/distortion and re-operations for recurrent/residual tumors with obscured bony landmarks. In macroadenomas, however, the accuracy and reliability of the technique are compromised after debulking due to movements of the adenoma capsule

Long-Term Survival with Primary Glioblastoma Multiforme: A Clinical Study in Bulgarian Patients

Glioblastoma multiforme (GBM) is the most common and aggressive primary brain tumor with an extremely poor prognosis in spite of multimodal treatment approaches. The estimated median survival in cases with GBM is about 12–16 months. Those patients who survive ≧3 years after the initial diagnosis are defined as long-term survivors. In this study, we retrospectively analyze 50 consecutive cases of Bulgarian patients with newly diagnosed GBM surgically treated at our institution for a period of 1 year. Four of them survived for more than 36 months after the initial intervention. The histological re-examination revealed features typical of primary GBM in 3 of these cases, which are described in detail in the present paper. A brief review of the relevant literature is also given