Cerebral revascularization: direct versus indirect bypass: Case presentation and review

Since 1985 when the EC-IC bypass study results were published and less procedures were performed for cerebral ischemia, the EC-IC bypass even high or low flow and the IC-IC bypass as flow replacement procedures gain acceptance for many neurosurgical pathologies, from extrinsic and intrinsic tumors requiring large vessels sacrifice to large giant and fusiform aneurysms. In recent years, after the results of Carotid Occlusion Surgery Study (COSS) and the Japanese EC-IC trial published their results the indications for extracranial-intracranial (EC-IC) by-pass expanded, including both extracranial carotid artery occlusive disease and intracranial atherosclerotic disease. The authors make a literature review of the indications for cerebral revascularization, with focus on the direct STA-MCA and indirect (EDAMS) revascularization techniques as a treatment for ischemic stroke. They present two cases of Moyamoya disease one treated with combined approaches and one with indirect approach and discuss the technical skills the surgeon should acquire in order to perform an anastomosis, focusing on the details of STA-MCA bypass, concluding that a combined approach gives better neurological results visible shortly after the surgery

Image-guided stereotactic biopsy of infiltrative, multicentric and deep-seated supratentorial cerebral gliomas

Infiltrative cerebral gliomas remain a neurosurgical challenge despite the latest achievements in neuroimaging techniques and microsurgical approaches. In this paper the authors present their experience in 85 cases of stereotactic biopsies performed for infiltrative, multicentric and deep-seated cerebral gliomas. The stereotactic and neuroimagistic tools used for these procedures included the Leksell stereotactic system and the software: Stereotactic Planning System (SPS), NTPS 8.2. The histopatological results (according to World Health Organization (WHO) classification) were: 51 cases of glioblastomas (grade IV) (60%), 7 cases of anaplastic astrocytomas (grade III) (8,2%), 13 cases of grade II diffuse astrocytomas (15,3%), 6 cases of grade I astrocytomas (7,1%), one case of grade II oligodendroglioma (1,2%), 3 cases of anaplastic oligodendrogliomas (grade III) (3,5%), one case of grade I ganglioglioma (1,2%), one case of anaplastic ganglioglioma (grade III) (1,2%), and 2 cases of anaplastic ependymomas (grade III) (2,3%). In 21 cases (24,7%) the immunohistochemistry has been performed in order to obtain an accurate histopathological result. In this series, the early postoperative mortality was 0%, with no cases of clinically significant hemorrhages after biopsy procedures. Temporary increase of neurological deficits has been noticed in 7 patients (8,2%). In conclusion, image-guided stereotactic biopsy represents now a safe and accurate diagnostic method for cerebral gliomas, which can favorably influence the therapeutic management of the patients

Severe TBI with complex craniofacial fractures followed by cranioorbitar reconstruction

Young age is associated with better outcome in patients with severe traumatic brain injury (TBI). Still the reported mortality rate in patients that present in profound coma Glasgow Coma Scale (GCS) -3 pts is very high, even approaching 100% in the presence of fixed and dilated pupils in some series. We report a case of a 25 years old patient with a severe TBI in a car crush and presented in severe coma with a bilateral frontal and right temporal brain laceration with extended posttraumatic subarachnoid hemorrhage and a complex cominutive right frontal, maxillary and zygomatic fracture corresponding to Le Fort III fracture. After a difficult postoperative course with complications of tracheostomy like candidosis and bronchopneumony, then after a slowly progressive recovery, the patient was hemiparetic and with a persistent right 3rd nerve paresis at 6 weeks after the traumatic event, but was able to speak and to ambulate with assistance. Given the large bony defect that remained, a frontal and facial bony reconstruction was made by an interdisciplinary team using titanium plates and screws. Considering the excellent results in this case we advocate that young patients who suffered severe TBI even if they present in a very bad neurological shape should be given access to the best treatment

Brain metastases of neuroendocrine tumor with unknown primary location: Case report

Neuroendocrine tumors are tumors derived from the cells of the neuroendocrine system. The majority of metastases of neuroendocrine tumors occur in liver, lungs and bone. The brain is an uncommon site of metastasize for this type of tumor. The authors of this paper present a case of brain metastases of neuroendocrine tumor with undetermined primary location. The patient, a 35 years-old man, was admitted in our clinic with headache, nausea, vomiting and a mild right facial paresis. Head CT scan and cerebral MRI identified two lesions: one larger lesion with mixed solid and cystic components located in the left basal ganglia and thalamus and a second cystic lesion located deep in the right parietal lobe. All complementary investigations (including thoracic CT scan and whole-body MRI) failed to reveal the primary tumor location. Due to the high vital-risks associated with the open surgical procedure, the patient and his family chose the less invasive procedure of stereotactic biopsy. Postoperatively the patient had no additional neurologic deficits, presenting only the initial mild right central facial paresis. The result of immunohistochemistry examination was cerebral metastases of neuroendocrine tumor. The patient was directed to the Institute of Oncology Fundeni for further investigations and therapeutically management. In conclusion, even if these are rare tumors which rarely metastasize in the brain, the neurosurgeons should take in consideration this pathology when they examine a patient with multiple cerebral lesions with unknown location of primary tumor

Vagus nerve stimulation for the treatment of refractory epilepsy

Vagus nerve stimulation (VNS) represents one of the main surgical options for the treatment of the refractory epilepsy in pediatric and adult patients. There are several mechanism involved in vagal nerve stimulation which could influence the pathophysiology of seizures like neuromodulation of the thalamic and subthalamic nuclei involved in seizure initiation and the modulation of the neurotransmitters pattern norepinefrin, GABA, and serotonin. The VNS system is composed of the implanted components (the generator, the lead with the electrodes attached) and the programming system components (programming wand and handheld computer). The authors present their experience with 81 patients diagnosed with refractory epilepsy, investigated, selected and implanted with vagal neurostimulators between December 2012 and January 2015 in Neurosurgery Clinic, "Bagdasar-Arseni" Emergency Hospital. The surgical technique and the potential pitfalls are described in detail. There were 20 children (24,7%) and 61 (75,3%) adults in this series. There was no death in this series and no intraoperative incidence. One patient presented dysphagia postoperatively which completely remitted after two months of follow-up. The outcome in term of seizure frequency and severity was better for patients under 30 years compared with patients older than 30 years. VNS represents now a safe, quick and efficient surgical procedure with a minimum period of hospitalization and a short recovery period. The good results on long term improve the quality of life of the patients and facilitate the social and professional reinsertion

Giant asymptomatic intracranial hydatid cyst in a 3 years old child: Case report

ObjectiveAlthough hydatid cysts are known commonly to affect the liver and lung, it can also affect the brain (1-2% of cases). Brain involvement is more commonly seen in children (50-75% of intracranial hydatid cysts), and usually has intraparenchymal localization. In this paper we present a case of a 3 years old child diagnosed incidentally with a giant intracranial hydatid cyst.Case presentationThe patient was admitted in the hospital with a mild craniocerebral trauma, with an epicranial haematoma. The clinical and neurological examinations were normal. The CT scan of the brain revealed a giant solitary cystic lesion, located in the left fronto-parietal lobe, with features suggestive of hydatid cyst. The removal of the cyst, without rupture, was performed using the Dowling technique modified by Arana-Iniguez. Postoperatively the neurological exam was normal and the patient was asymptomatic at 7 months follow-up.ConclusionThe hydatid cyst usually enlarges slowly, but this is variable, the growth being higher in children, in whom it can reach giant dimensions without or with minimal symptoms. It is a benign lesion, and the removal of the cyst without rupture is very important

Preoperative mapping of the eloquent cortical areas using navigated transcranial magnetic stimulation combined with intraoperative neuronavigation for intracerebral lesions

Introduction: Maximal surgical resection with the preservation of cortical functions is the treatment of choice for brain tumors. Achieving these objectives is especially difficult when the tumor is located in an eloquent area. Navigated transcranial magnetic stimulation (nTMS) is a modern non-invasive, preoperative method for defining motor and speech eloquent areas.Material and methods: Patients with tumors located in motor and speech eloquent areas who presented at our institution between March 2017 and December 2017 were prospectively included. Exclusion criteria were frequent generalized epileptic seizures and cranial implants. For lesions involving motor eloquent areas we performed a nTMS motor mapping and for lesions involving speech eloquent areas we supplemented the motor mapping with speech and language mapping. MR images were exported from the nTMS system in a DICOM format and then loaded in the intraoperative neuronavigation system. Based on these findings, the optimal entry point and trajectory were determined, in order to achieve a maximum surgical resection of the lesion, while avoiding new postoperative neurological deficits.Results: Nineteen patients underwent an nTMS brain mapping procedure between March 2017 and December 2017. In all cases a motor mapping procedure was done, but only in eight cases a speech mapping was also performed. Three patients presented new minor post-operatory deficits that consecutively remitted. The rest of the patients presented no added neurological deficits after surgery. In five cases the preexistent deficit was ameliorated after surgery and in three cases the deficit remitted. In one patient there was no improvement in the neurologic deficit after surgery.Conclusion: nTMS is a reliable tool for the preoperative planning of eloquent area lesions. It must be taken into account that functional areas have a high individual variability. Therefore, knowing preoperatively the extent of the eloquent area helps the neurosurgeon adapt the surgical approach in order to obtain a better functional outcome

Intraoperative neuronavigation integrated high resolution 3D ultrasound for brainshift and tumor resection control

The link between the neurosurgeon’s knowledge and the scientific improvements made a dramatic change in the field expressed both in impressive drop in the mortality and morbidity rates that were operated in the beginning of the XXth century and in operating with high rates of success cases that were considered inoperable in the past. Neuronavigation systems have been used for many years on surgical orientation purposes especially for small, deep seated lesions where the use of neuronavigation is correlated with smaller corticotomies and with the extended use of transulcal approaches. The major problem of neuronavigation, the brainshift once the dura is opened can be solved either by integrated ultrasound or intraoperative MRI which is out of reach for many neurosurgical departments. METHOD: The procedure of neuronavigation and ultrasonic localization of the tumor is described starting with positioning the patient in the visual field of the neuronavigation integrated 3D ultrasonography system to the control of tumor resection by repeating the ultrasonographic scan in the end of the procedure. DISCUSSION: As demonstrated by many clinical trials on gliomas, the more tumor removed, the better long term control of tumor regrowth and the longer survival with a good quality of life. Of course, no matter how aggressive the surgery, no new deficits are acceptable in the modern era neurosurgery. There are many adjuvant methods for the neurosurgeon to achieve this maximal and safe tumor removal, including the 3T MRI combined with tractography and functional MRI, the intraoperative neuronavigation and neurophysiologic monitoring in both anesthetized and awake patients. The ultrasonography integrated in neuronavigaton comes as a welcomed addition to this adjuvants to help the surgeon achieve the set purpose. CONCLUSION: With the use of this real time imaging device, the common problem of brainshift encountered with the neuronavigation systems is covered and any eventual tumor residue can be spotted by ultrasonography and resected

Combined telovelar-minimal transvermian approach for a bleeding pontine cavernoma in a 48-year-old patient: Case report and review of literature

Symptomatic pontine cavernous malformations carry a high risk of recurrent bleeding, which may result in permanent neurological deficit. Such lesions require surgical management that can be challenging to the neurosurgeon due to their anatomical location and their proximity to delicate neural structures. An ideal surgical approach should provide maximal surgical resection with minimal morbidity. We present the case of a 48-year-old woman with a pontine cavernoma with repeated spontaneous intralesional hemorrhages, resected using a telovelar approach extended by a minimal incision of the inferior vermis, with good surgical outcome. The telovelar approach provided a good access to the lateral recesses and the foramen of Luschka, while the lower vermian incision provided a greater vertical working angle inside the ventricle

Intracranian arahnoid cysts in children (ACs)

Intracranial arachnoid cysts (ACs) represent an extremely common condition in pediatric pathology. With the development of CT Scan and especially MRI these cysts could be find more constantly. ACs are congenital lesions with maximum frequency in middle cranial fossa, followed by supraselar aria , ponto-cerebelar angle and cranial posterior fossa. These cysts are often incidentally uncovered during a routine neuroimaging investigations for cranio-cerebral trauma or other diseases. The authors present a series of 317 cases in children with ACs over a period of 10 years. The authors avocate over the MRI evaluation of Acs and refering to therapeutic approach it is recomanded only in compresive forms with focal neurologica sings or seizures. Are rewiewed therapeutical procedures as: microsurgical fenestration with cystwall excision, endoscopic approach, stereotaxic suction, cyst shunting by cysto-peritoneal procedures. A number of cases remain under observation the surgical treatment beeing unnecesary. The surgical treatment must be carfuly chosen, there is non therapeutical priority. It remains that improved neuroendoscopic methods to improve operator prognosis in Acs