Seven Cerebral Aneurysms : A Challenging Case from the Andean Slopes Managed with 1-Stage Surgery

BACKGROUND: Treatment of multiple intracranial aneurysms is particularly demanding and even more so in a developing country where access to specialized centers may be prevented by different factors. METHODS: Single-stage surgical treatment of 7 cerebral aneurysms was performed in a 58-year-old woman from the northern Peruvian Andes. RESULTS: All 7 aneurysms were successfully and safely clipped through 2 lateral supraorbital craniotomies. The double clip technique was used in 3 aneurysms to prevent any residual aneurysmai neck. CONCLUSIONS: Good teamwork and correct application of microsurgical principles may allow effective treatment in complex neurosurgical cases even in resourcechallenged environments.Peer reviewe

Brainstem Cavernous Malformations Management : Microsurgery vs. Radiosurgery, a Meta-Analysis

Given the rareness of available data, we performed a systematic review and meta-analysis on therapeutic strategy microsurgical resection and stereotactic radiosurgery (SRS) for brainstem cavernous malformations (BSCMs) and assessed mortality, permanent neurological deficits (PNDs), rebleeding rate, and patients who require reintervention to elucidate the benefits of each treatment modality. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) were used for protocol development and manuscript preparation. After applying all inclusion and exclusion criteria, six remaining articles were included in the final manuscript pool. In total, this meta-analysis included 396 patients, among them 168 patients underwent microsurgical treatment and 228 underwent SRS. Findings of the present meta-analysis suggest that regarding the total group of patients, in terms of mortality, late rebleeding rate, and PNDs, there was no superiority of the one method over the other. Applying the leave-one-out method to our study suggests that with low robust of the results for the bleeding rate and patients who require reintervention outcome factor, there was no statistical difference among the surgical and SRS treatment. Microsurgical treatment of BSCMs immediately eliminates the risk of rehemorrhage; however, it requires complete excision of the lesion and it is associated with a similar rate of PNDs compared with SRS management. Apparently, SRS of BSCMs causes a marked reduction in the risk of rebleeding 2 years after treatment, but when compared with the surgical treatment, there was not any remarkable difference.Peer reviewe

The Value of Programmable Shunt Valves for the Management of Subdural Collections in Patients with Hydrocephalus

Background. The aim of the present study was to assess the value of electromagnetic programmable shunt valves for the treatment of subdural collections. Methods. Adult patients with hydrocephalus of various causes that were treated with programmable shunt valves during the last ten years were retrospectively studied. In 127 patients, 139 electromagnetic programmable shunt valves were implanted. Results. A nontraumatic subdural fluid collection was detected in 12 patients. The treatment of these patients consisted of reprogramming of the valve’s opening pressure. In 5 patients small subdural hematomas were detected; 4 of these patients were treated by raising the opening pressure alone and one patient required surgical drainage and change of the pressure setting. Traumatic chronic subdural hematomas were detected in 6 patients. These patients were treated by surgical drainage and readjustment of the valve’s opening pressure. Conclusion. The ability to treat a shunt-related complication, such as a subdural fluid collection, by reprogramming the valve’s opening pressure to a higher setting is an advantage over nonprogrammable valves, and it enables the opening pressure to be slowly lowered once the fluid collection is reabsorbed. Based on our results, we believe that programmable shunt valves should be preferred

Primary plasmacytoma of the cranial vault: a case report

We report one case of a 78-year-old woman who referred to our hospital because of a progressive right hemiparesis. On clinical examination a painless large soft mass in the left parietal region was observed. CT and MRI revealed an extra-axial mass in the in the left fronto-temporo-parietal region. The lesion was totally excised despite the bleeding tendency. Histology disclosed the presence of a plasmacytoma. Postoperative, the patient developed an epidural hematoma that required immediate evacuation. On further investigation active tuberculosis was detected. On follow up examination 1 year later no tumor recurrence or evidence of multiple myeloma was detected

Correlation of the intraoperative findings of the neurophysiological monitoring between patient's outcome with cervical disc herniation

Cervical disc disease constitutes the second common reason for spine surgery in adults. Surgical treatment usually offers greater pain relief and functional recovery than non-surgical treatment. However, the neurological complications during anterior cervical microdiscectomy and fusion (ACDF) are not negligible. On the other hand, after decompression using ACDF, an improvement is expected, but it is impossible to know for how long this compression exists, when it began and the degree of the clinical improvement. Therefore, the purpose of this prospective study was to evaluate the usefulness of transcranial motor evoked potentials (TcMEP) and free running electromyography (EMG) for preservation of the descending motor pathways and the correlation between intraoperative TcMEP amplitude enhancement and pain reduction, during ACDF in patients with cervical disc disease and radiculopathy. We evaluated 38 patients (13 males, 25 females) that underwent anterior cervical microdiscectomy and fusion (ACDF). TcMEPs and EMG were monitored intraoperatively. All patients had regular follow-up examinations at 3, 6, 12 and 24 months postoperatively and were evaluated using the visual analog scale (VAS) and the ODOM scale (118,117). During the operation, monitoring allowed potential intraoperative damage to the neural structures to be identified rapidly and avoided through corrective action. None of our patients sustained a transient or permanent motor deficit. We found that when there was an increase of TcMEP amplitude over 41% the patients had an excellent postoperative outcome (ODOM scale: I) and when this increase was less 11% or the amplitude remain unchanged, the patient’s outcome was fair (ODOM scale: III). Furthermore, in all patients these findings correlate with the postoperative improvement in VAS score. This pilot study verifies the importance of TcMEP during ACDF surgery to prevent irreversible pyramidal tract damage; the correlation between TcMEP amplitude changes and pain reduction according to VAS scale in patients operated on for cervical disc disease and so proposes an additional prognostic role for the estimation of patient’s improvement.Η πρόσθια αυχενική μικροδισκεκτομή και τοποθέτηση κλωβών (ΠΑΜΚ), έχει αποδειχτεί ως μια επιτυχής χειρουργική μέθοδος για την αντιμετώπιση της αυχενικής δισκοκήλης (ΑΔ) (2) Απ’ την άλλη, το ποσοστό εμφάνισης των μετεγχειρητικών βλαβών στην Α 5 αυχενική ρίζα, που αναφέρεται στην διεθνή βιβλιογραφία μετά από αποσυμπιεστικές επεμβάσεις στην αυχενική μοίρα. είναι αρκετά υψηλό, φτάνοντας το 12% για την πρόσθια και το 30% για τις οπίσθιες προσπελάσεις (3) Για τον λόγο αυτό, πρόσφατα η νευροπαρακολούθηση έχει προταθεί και εφαρμοστεί στην χειρουργική πρακτική, ως μια ασφαλής μέθοδος για την αποφυγή βλαβών διεγχειρητικά, στις νευρονικές δομές εκτός από την χρησιμότητα αυτή. Στην παρούσα μελέτη αναζητείται η προγνωστική αξία τωνδιακρανιακών κινητικών προκλητών δυναμικών (ΔΚΠΔ), η TcMEP ως προς την μετεγχειρητική έκβαση, μετά από μια επιτυχή χειρουργική επέμβαση για κήλη μεσοσπονδυλίου δίσκου στην αυχενική μοίρα (ΚΜΔ ΑΜΣΣ). Η αποσυμπίεση του NM ήταν ίδια σε όλα τα περιστατικά και ήταν πλήρης δεν ήταν όμως πάντα προβλέψιμο το μετεγχειρητικό αποτέλεσμα. Η πρόβλεψη αυτής της έκβασης προσδίδει προγνωστική αξία στα ΠΔ. Διεγχειρητικά πάντα παρατηρούνταν αύξηση του εύρους των ΠΔ με την αποσυμπίεση. Ο βαθμός αύξησης των ΠΔ πάνω από μια ορισμένη τιμή, ήταν ανάλογος του βαθμού της κλινικής βελτίωσης των ασθενών. Σκοπός αυτής της έρευνας είναι να ορίσει επίσης, αυτήν ακριβώς την τιμή (κατώφλι) πάνω από την οποία παρατηρούνταν οι συσχετίσεις μεταξύ ηλεκτροφυσιολογικών ευρημάτων και κλινικής εικόνας. Σ’ αυτήν την εργασία, μελετάται η χρησιμότητα του συνδυασμού των TcMEP και συνεχούς ΗΜΓ καταγραφής, σε ασθενείς με ΑΔ, οι οποίοι υποβλήθηκαν σε ΠΑΜΚ, ο συνδυασμός των TcMEP και συνεχούς ΗΜΓ καταγραφής, παίζοντας τον ρόλο του προειδοποιητικού σινιάλου. Στην περίπτωση άμεσου τραυματισμού των νευρονικών δομών, συνέβαλε αποφασιστικά στην άριστη μετεγχειρητική βελτίωση των ασθενών ακόμη περισσότερο. Διαπιστώσαμε ότι μια αύξηση της τάξεως του 41% της αρχικής τιμής του πλάτους των TcMEP, σχετίζεται μια άριστη μετεγχειρητική βελτίωση (1) σύμφωνα με την κλίμακα του ODOM έτσι τα TcMEPS πιθανόν κατέχουν και έναν επιπλέον προγνωστικό ρόλο βιβλιογραφικά. Mέχρι σήμερα δεν αναφέρεται ότι η βελτίωση των δυναμικών συνεπάγεται άμεσης κλινικής βελτίωσης του ασθενή. H παρούσα μελέτη επιβεβαιώνει: α) την σημασία των TcMEP κατά την διάρκεια των επεμβάσεων ΠΑΜΚ για ΚΜΔ ΑΜΣΣ για την αποφυγή διεγχειρητικών βλαβών στην πυραμιδική οδό, ενημερώνοντας έγκαιρα τον χειρουργό για τους χειρισμούς του. β) την συσχέτιση ανάμεσα στις αλλαγές του πλάτους των TcMEP και της μείωσης του ριζιτικού πόνου στις ίδιες επεμβάσεις. Βάση της κλίμακας VAS συνεπώς τα TcMEP έχουν επιπλέον προγνωστικό ρολό για την εκτίμηση της μετεγχειρητικής βελτίωσης των ασθενών ωστόσο. απαιτούνται περισσότερες μελέτες με μεγαλύτερες σειρές ασθενών, ώστε να επιβεβαιωθούν τα αποτελέσματά μας

Spinal ependymomas: Prognostic factors and treatment results

Objective: We retrospectively analyzed patients with spinal ependymomas who were treated in our institute. We correlated outcome and recurrence with clinical and pathological features. Materials and Methods: Between January 2000 and January 2010, we treated 14 patients with spinal ependymoma (10 males, 4 females; mean age: 48.3±18 years, range: 18-79 years). All patients were operated and received standard postoperative care. The outcome was estimated based on Frankel scale. Results: The most common presenting symptom was pain. All tumors were operated through a posterior approach and gross total resection was performed in 13/14 cases. Histopathological examination revealed the presence of one anaplastic ependymoma, nine grade II ependymomas, and four myxopapillary ependymomas. The mean Ki-67 index was 1.5%. All the patients were followed up postoperatively for an average of 5.1 years. One patient was reoperated because of recurrent disease and another received radiotherapy due to dissemination of disease. No association was found between extent of resection, tumor location, Ki-67 index, and recurrence of disease. There was a trend toward a higher risk of recurrence in myxopapillary ependymomas. Eight patients improved postoperatively. Interestingly, during the follow-up period, four patients developed a secondary neoplasia. Conclusion: Early intervention and gross total resection of spinal ependymomas are associated with a favorable outcome. Further studies are needed to clarify the incidence of the development of a second cancer in these patients

Levosimendan in the Treatment of Patients with Severe Septic Cardiomyopathy

(1) Background: The optimal treatment of septic cardiomyopathy (SCM) remains questionable. The aim of the study was to compare the treatment of SCM based on levosimendan versus the best available therapy. (2) Methods: We conducted an observational study including patients with severe septic cardiomyopathy and circulatory failure. (3) Results: Fourteen patients (61%) received levosimendan, and nine received other treatments. The patients in the levosimendan group were more severely ill [APACHE II: 23.5 (14, 37) vs. 14 (13, 28), respectively, p = 0.012], and there was a trend for more decompensated LV function depicted by the LVEF [15% (10, 20) vs. 25% (5, 30), respectively, p = 0.061]. However, they presented a significantly higher increase in LVEF after seven days [15% (10, 20) to 50% (30, 68) (p p = 0.309), and a significantly higher decrease in lactate levels during the first 24 h [4.5 (2.5, 14.4) to 2.85 (1.2, 15), p = 0.036 vs. 2.9 (2, 18.9) to 2.8 (1, 15), p = 0.536]. Seven-day survival (64.3% vs. 33.3%, p = 0.424) and ICU survival (50% vs. 22.2%, p = 0.172) were higher in the first group, although differences did not reach statistical significance. The degree of left ventricular impairment and the magnitude of EF improvement by the seventh-day post-SCM onset were associated with mortality in regression analysis. (4) Conclusions: Our study presents main hemodynamic data supporting the possible efficacy of levosimendan treatment in patients with severe SCM