Microvascular decompression in supinated position for trigeminal neuralgija treatment

Cilj: Prikazati operacijsku tehniku i učinkovitost mikrovaskularne dekompresije trigeminusa provedene u supinacijskom položaju bolesnika. Bolesnici i metode: Tijekom 2009., 2010. i 2011. godine na Zavodu za neurokirurgiju KB “Dubrava” operirano je 48 bolesnika s neuralgijom trigeminusa; učinjena im je mikrovaskularna dekompresija živca trigeminusa. Operirana su 22 muškarca i 26 žena, prosječne starosti od 56 godina i prosječnog trajanja bolesti 7 godina; kod 16 bolesnika bol je bio lokaliziran u području inervacije jedne grane trigeminusa, kod 25 bolesnika u području inervacije dviju grana, a kod 7 bolesnika u području inervacije svih triju grana trigeminusa. Rezultati: Kod 43 bolesnika nađen je jasan neurovaskularni konflikt. Početni uspjeh operacijskog liječenja (potpuni nestanak bolova ili prisutni značajno blaži bolovi) zabilježen je kod 42 bolesnika. Rasprava i zaključak: Mikrovaskularna dekompresija koja predstavlja jedino uzročno liječenje neuralgije trigeminusa dobra je i učinkovita metoda liječenja te bolesti te se uspješno može provesti u supinacijskom položaju bolesnika.Aim: To describe the operating technique and efficacy of microvascular decompression of trigeminus done in patients in supinated position. Patients and methods: During 2009, 2010 and 2011 in Department of neurosurgery University hospital Dubrava microvascular decompression was performed on 48 patients with trigeminal neuralgia. There were 22 male and 26 female patients with average age 56 years and average duration of pain 7 years. A total of 16 patients had pain distribution in only one trigeminal branch, 25 had pain in two branches and 7 in three branches. Results: A total of 43 patients had a clear neurovascular conflict intraoperatively and 42 patients had initial pain improvement. Discussion and conslusion: Microvascular decompression is the only treatment of trigeminal neuralgia that affects the cause of the illnes and is a good and effective method performed in the supinated position

Intracranial mature teratoma in an adult patient: a case report

Introduction: Primary intracranial teratoma is a subtype of germ cell tumors, classified into three subtypes. They occur very rarely, with only several reported individual cases in adults. ----- Case Description: We present a patient with an intermittent headache in the right frontal region. Magnetic resonance imaging (MRI) revealed a right sided high frontal parasagittal mass that compressed the falx, the right lateral ventricle, as well as the brain parenchyma. Patient underwent surgical treatment. Histopathological analysis described mature teratoma. Four months after the surgical treatment there were no signs of residual intracranial mass or relapse. ----- Discussion: Primary intracranial teratoma in adults has a nonspecific clinical presentation. MRI reveals a solitary irregular mass with multilocularity and mixed signals derived from different tissues. The patients age, biochemical markers, and patohistological analysis are necessary to confirm the diagnosis. ----- Conclusion: Teratoma treatment strategy still remains controversial. It includes radical resection whenever possible. Since the residual portion of mature teratoma may contain part of immature or malignant tissue, tumor recurrence after surgical removal is possible. Also, new tumor mass could occur at other sites intracranial after the initial one was removed. Thus, although patients usually recover, they should be followed-up for a long period of time

Primary dural lymphoma mimicking meningioma: a clinical and surgical case report

INTRODUCTION: Primary central nervous system lymphoma and its subtype, primary dural lymphoma, are types of non-Hodgkin's lymphoma that only occur in the central nervous system without any dissemination. They are extremely rare cases of extra nodal lymphomas accounting for 1--5% of intracranial tumors. ----- CASE REPORT: We present a patient diagnosed with primary dural lymphoma in right frontal brain region who underwent surgical resection. Histopathological analysis revealed diffuse B-type large cell non-Hodgkin lymphoma. Patient underwent four cycles of R-CHOP and intrathecal methotrexate protocol. Six months postoperative, no signs of newly onset infiltration were present. ----- DISCUSSION: Primary dural lymphoma most likely presents with unusual radiological signs, which can easily be mistaken for meningioma, the main differential diagnosis. A thorough immunological, histopathological and clinical patients profile should be conducted in order to establish the certainty of diagnosis. Although there are few treatment options: surgery, radiotherapy or chemotherapy, there is no established treatment protocol

Application accuracy of RONNA robotic system in stereotactic neurosurgery

UVOD: Robotski sustav RONNA je robotski sustav za stereotaktičku navigaciju koji je konstruiran u suradnji s Fakultetom strojarstva i brodogradnje i Kliničkom bolnicom Dubrava. Donosimo prospektivnu studiju robotskih biopsija izvedenih robotskim sustavom RONNA s detaljnom analizom točnosti primjene i usporedbom s drugim robotskim sustavima iz literature i stereotaktičkim biopsijama izvedenim Leksell okvirom. Donosimo i rezultate in vitro testiranja robotskoga sustava RONNA na antropomorfnom fantomu u robotskom laboratoriju. MATERIJALI I METODE: Svaka skupina se sastoji od 32 pacijenta, u jednoj skupini su obavljene biopsije bez okvira robotskim sustavom RONNA, a u drugoj skupini obavljene su biopsije Leksellovim okvirom. Grupa koja je operirana robotskim sustavom RONNA uključivala je 32 uzastopna bolesnika i to 11 žena (34,38%) i 21 muškarca (65,62%); prosječna dob u skupini žena bila je 68 ± 12,91 godina (raspon 40 - 83 godine), dok je prosječna dob u skupini muškaraca bila 64 ± 12,68 godina (raspon 34 - 79 godina). Skupinu bolesnika kojima je učinjena stereotaktička biopsija pomoću Leksellovog okvira čine 32 bolesnika, 12 žena (37,5%) i 20 muškaraca (62,5%); prosječna dob u skupini žena bila je 60 ± 10,10 godina (raspon 50 - 80 godina), dok je prosječna dob u skupini muškaraca bila 62,5 ± 15,49 godina (raspon 24 - 79 godina). Postoperativni CT i MR pregledi snimljeni su i korišteni za precizno mjerenje i izračunavanje pogreške ciljne točke (GCT) i pogreške ulazne točke (GUT) za robotske biopsije. Obje su skupine uspoređivane prema svim relevantnim antropološkim i kliničkim značajkama, kao što su spol, dob, trajanje bolesti, lokacija tumora, boravak u bolnici, PHD dijagnoza, komplikacije. Također, za robotske biopsije analizirano je trajanje postupaka i utjecaj kuta putanje bioptičke sonde na kost lubanje na točnost. REZULTATI: Nije bilo postoperativnog mortaliteta, morbiditeta ili infekcija. U skupini bolesnika koji su operirani robotskim sustavom RONNA trajanje operacije iznosilo je 57,5 ± 19,1 (raspon 41 - 128 min), dok je prosječni boravak bolesnika u bolnici bio 4 ± 1,08 dana (raspon 3 - 6 dana). U skupini bolesnika kod kojih je učinjena stereotaktička biopsija pomoću Leksell okvira trajanje operativnog zahvata, odnosno vrijeme od trenutka ulaska bolesnika u operacijsku salu do završetka operativnog zahvata iznosilo je 38 ± 12,28 (raspon 21 - 57 min), dok je prosječni boravak bolesnika u bolnici bio 7 ± 6,46 dana (raspon 2 - 30 dana). U obje skupine rezultati samo jedne patohistološke dijagnoze bili su nejasni, stoga je dijagnostička točnost robotskog sustava RONNA i okvira Leksell 96,87% (31/32). Pogreška ciljne točke (GCT), pogreška ulazne točke (GUT), kut putanje u odnosu na površinsku kost i duljina putanje temeljito su analizirani za robotske biopsije. Prosječna vrijednost GCT je 1,95 ± 1,11 (raspon 0,39 - 5,58 mm), prosječna vrijednost GUT je 1,42 ± 0,74 (raspon 0,35 - 3,36 mm), prosječni kut prema površini kosti je 15,30 ± 9,60° (raspon 2,70 - 38,10), dok je prosječna duljina putanje 45,73 ± 17,41 mm (raspon 15,50 – 86,10). Linearna regresija pokazala je statističku značajnost između GCT i GUT i kuta putanje na kosti lubanje. Trajanje postupka za robotske biopsije smanjivalo se s vremenom (p<0,0001, r = 0,69, R2 = 0,478), statistička značajnost zapisa bila je između prvih deset i zadnjih deset obavljenih operacija (p = 0,0007), pokazujući strmu krivulja učenja. ZAKLJUČAK: Robotski sustav RONNA G4 precizan je i vrlo precizan autonomni neurokirurški asistent za izvođenje biopsije mozga bez okvira, precizan je kao i drugi robotski sustavi opisani u literaturi te siguran i učinkovit kao stereotaktički Leksell sustav.INTRODUCTION: We bring a prospective study of robotic biopsies performed with RONNA robotic system compared to biopsies performed with the Leksell frame. MATERIALS AND METHODS: Patients are divided into two groups of 32 patients, in one group frameless biopsies with RONNA robotic system were performed and in another group framebased biopsies with Leksell frame were performed. Post-operative CT and MRI scans were assessed to precisely measure and calculate target point error (TPE) and entry point error (EPE) for robotic biopsies. Both groups were compared by all relevant anthropological and clinical features. RESULTS: There was no postoperative mortality, morbidity or infections. In both groups the results of only one pathohistological diagnosis were unclear, therefore the diagnostic accuracy of the RONNA robotic system and Leksell frame is 96.87% (31/32, The average value of TPE is 1.95 ± 1.11 (range 0.39 - 5.58 min), the average value of EPE is 1.42 ± 0.74 (range 0.35 - 3.36 min), the average angle to the bone surface is 15.30 ± 9.60° (range 2.70 - 38.10), while the average length of trajectory is 45.73 ± 17.41 mm (range 15.50 – 86.10). Linear regression showed statistical significance between the TPE and EPE and the angle of the trajectory on the skull bone. The duration of the procedure showed statistical significance between the first ten and the last ten performed operations (p = 0.0007). CONCLUSION: The RONNA G4 robotic system is a precise and highly accurate autonomous neurosurgical assistant for performing frameless brain biopsies

A biphasic tumor in posterior cranial fossa and the pineal region in young adult

Background: Biphasic tumors of the central nervous system are rarely described and mainly consisted out of the glial and mesenchymal component. The tumor originated out of both astrocytes and pinealocytes, best to our knowledge, has not been described. We present a case of a brain tumor consisted out of pilocytic astrocytoma (PA) and pineocytoma as components situated in the pineal region and posterior cranial fossa in young adult. ----- Case Description: We present a 21-year-old patient with a history of intermittent headache, followed by nausea and vomiting, double vision, and dextropulsion. Magnetic resonance imaging revealed an extensive cystic-solid expansive formation in the posterior cranial fossa with a solid part in the area of the pineal gland. The patient underwent surgical resection. The pathohistological analysis showed two types of tumor cells; the major part of tumor showed features of PA, while minor part corresponded to pineocytoma. ----- Conclusion: PA accounts for 5% of all gliomas and is most common in children and young adults. It usually occurs in the cerebellum, the optic pathway, third ventricular region, etc. Pineocytomas are rare, accounting up to 1% of all intracranial tumors. Since tumors origin is different, there must be complex molecular events or mutations that can lead to cell rearrangements and generation of two histologically different tissues in the same tumor mass. The course of treatment options is different for PA and pineocytoma; therefore, the case of brain mass consisted out of two different tissues can be helpful when deciding about the treatment of tumors in posterior cranial fossa and pineal region

Spontaneous spinal subdural hematoma in COVID-19 patient: Croatian national COVID hospital experience

Background: Spontaneous spinal subdural hematoma (SSDH) is a rare condition and causes of acute spinal cord compression, with symptoms varying from mild to severe neurological deficit. SSDH could occur as a consequence of posttraumatic, iatrogenic, or spontaneous causes, including underlying arteriovenous malformations, tumors, or coagulation disorder. Due to its rarity, it is difficult to establish standardized treatment. We present a rare case of SSDH in COVID-19 patient and course of treatment in COVID hospital. ----- Case description: A 71-year-old female patient was admitted due to instability, weakness of the left leg, and intensive pain in the upper part of thoracic spine as well as mild respiratory symptoms of COVID-19. She was not on pronounced anticoagulant therapy and her coagulogram at admission was within normal range. MRI revealed acute subdural hematoma at the level C VII to Th III compressing the spinal cord. The patient underwent a decompressive Th I and Th II laminectomy and hematoma evacuation. Post-operative MRI revealed a satisfactory decompression and re-expansion of the spinal cord. COVID-19 symptoms remained mild. ----- Conclusion: SSDH represents a neurological emergency, possibly leading to significant deficit and requires urgent recognition and treatment. One of the main difficulties when diagnosing is to consider such condition when there is no history of anticoagulant treatment or previous trauma. Since high incidence of coagulation abnormalities and thromboembolic events was described COVID-19 patients, when considering the pathology of the central nervous system, the bleeding within it due to COVID-19 should be taken into account, in both brain and spine

Structural changes in brains of patients with disorders of consciousness treated with deep brain stimulation

Disorders of consciousness (DOC) are one of the major consequences after anoxic or traumatic brain injury. So far, several studies have described the regaining of consciousness in DOC patients using deep brain stimulation (DBS). However, these studies often lack detailed data on the structural and functional cerebral changes after such treatment. The aim of this study was to conduct a volumetric analysis of specific cortical and subcortical structures to determine the impact of DBS after functional recovery of DOC patients. Five DOC patients underwent unilateral DBS electrode implantation into the centromedian parafascicular complex of the thalamic intralaminar nuclei. Consciousness recovery was confirmed using the Rappaport Disability Rating and the Coma/Near Coma scale. Brain MRI volumetric measurements were done prior to the procedure, then approximately a year after, and finally 7 years after the implementation of the electrode. The volumetric analysis included changes in regional cortical volumes and thickness, as well as in subcortical structures. Limbic cortices (parahippocampal and cingulate gyrus) and paralimbic cortices (insula) regions showed a significant volume increase and presented a trend of regional cortical thickness increase 1 and 7 years after DBS. The volumes of related subcortical structures, namely the caudate, the hippocampus as well as the amygdala, were significantly increased 1 and 7 years after DBS, while the putamen and nucleus accumbens presented with volume increase. Volume increase after DBS could be a result of direct DBS effects, or a result of functional recovery. Our findings are in accordance with the results of very few human studies connecting DBS and brain volume increase. Which mechanisms are behind the observed brain changes and whether structural changes are caused by consciousness recovery or DBS in patients with DOC is still a matter of debate