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

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

Particular aspects of cerebral metastases secondary to malignant melanoma in comparison with other brain metastases

Authors present a retrospective study of 427 patients with brain metastases admitted and treated in third and fourth neurosurgical departments of Emergency Clinical Hospital “Bagdasar-Arseni” Bucharest, from January, 2005 until December, 2014. 62.1% of all patients were men and 37.9% were women, with a medium age of 56.8 years, ranging between 17 and 85 years. 311 patients (72.8%) had a single metastasis, 79 patients (18.5%) developed 2 or 3 metastases and 37 patients (8.7%) had more than 3 metastases. The biggest four metastases in multiple cases were noted in database regarding location, either reported to left / right hemisphere, either related to site (frontal parietal etc.), and dimensions. In the case of malignant melanoma (22 men and 24 women) the status of the primary tumor was noted: the malignant melanoma was operated in 32 cases (69.6%) and in 7 patients (15.2%) the primary tumor was not operated. In another 7 cases the status of the primary tumor was not noted. The most frequent location for malignant melanoma was the legs in women and anterior thorax in men. In conclusion, cerebral metastases from malignant melanoma have most frequent intratumoral hemorrhages, comparative with other primary sources. Common primary sites founded in this study is legs in women and anterior thorax in men. Treatment of cerebral metastases is complex, multimodal, implying neurosurgeons, oncologists and radiotherapists

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

Partial thrombosed parasagittal AVM, complete resection: Case report

Arteriovenous malformations (AVMs) are congenital lesions formed by a network of dysplastic vessels. CASE REPORT: We report a case of a 63 years old man, admitted with seizures and headache. Imaging findings, angio-CT, angio-MR and angiography revealed a partially thombosed right parasagittal frontal AVM, with fully thrombosed associated flow-related aneurysm on the main arterial feeder. The patient underwent surgery and we performed total resection of the AVM. The particularity of this case is the rare possibility of outcome with regression of the vascular malformation. CONCLUSIONS: Brain AVMs are evolutive lesions. Regression, through progressive thrombosis of the nidus is a rare possible outcome in brain AVMs. In thrombosed AVMs angiography is not reliable, and angio-CT and/or angio-MR are mandatory, in order to correctly evaluate nidus size and associated lesions. Symptomatic AVMs require surgery. Partial thombosed AVMs can be safely resected

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

Management of intramedullary astrocytomas

Primitive IMT represent 8-10% of all primary tumors of the spinal cord. Only 2-4% of all CNS tumors in adults are IMT. Adult astrocytomas are 25-35% of total IMT (1). We prospectively analyzed clinical, imaging and pathological data from all consecutive patients operated for intramedullary tumors in our department (Neurosurgery I Clinic, Ward II) between January 2003 and August 2009 (80 months). All surgical interventions were performed by the same surgical team. We emphasized the technical difficulties raised by ablation of IMT depending on the type of the tumor and postoperative neurological outcome

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

Traumatic lumbar Spondylolisthesis: Case Report

Only few cases of traumatic spondylolisthesis (from the cranial to lumbosacral joint) have been reported to date. Recovery of neurological function is dependent on the time of decompression and stabilization. We highlight the paramount importance that the time past between injury and surgical decompression have on neurological recovery and implant durability. Authors present the case of a 26 years old patient who suffered a motor crash 10 days ago before admission in our institution for cauda equina syndrome (L5 level). He also presented abdominal trauma with left kidney contusion, spleen contusion, thoracic contusion and left fibular fracture. X-ray and MRI examinations of the lumbosacral spine revealed grade 3 of spondylolistesis (60% anterior dislocation L5 - S1, intervertebral disc and posterior ligaments laceration, severe compression of the dural sac and dural laceration with CSF leakage through the posterior muscular mass). Surgery performed 14 days after the injury consisted in a posterior approach with L5 laminectomy, dural decompression and duroplasty with fascia lata, segmental reduction and stabilization with transpedicular screws, L5-S1 discectomy and anterior intervertebral grafting with two tricortical iliac crest grafts. Posterior lumbar interbody fusion was carried out using titanium screws (Solas system). Decompression, reduction with L5, S1 pedicular screw fixation, L5 – S1 disc excision and anterior intervertebral grafting with two tricortical iliac crest grafts is an appropriate surgical technique wich offer a good stabilization and fine functional recovering

Supratentorial neuroectodermal tumor in a 4 years old child presented with intratumoral hemorrhage: Case presentation and review of the literature

Brain tumors represent the most frequent solid malignancy in children and the first cause of cancer-related deaths in pediatric population. Supratentorial neuroectodermal tumor (PNET) represents one of the most aggressive brain tumors at this age. Incidence of S-PNET is 2-3% of all brain tumors in children, but reaches up to 20% of brain tumors in 0 - 3 years old children. Although in the last years the outcome has improved, the prognosis remains dismal. We choose to present the case of a 4 years old child who was at presentation in a comatose state (GCS 4 points) with anisocoria (right pupil was mydriatic). The performed head CT-scan showed a right fronto-parietal tumor with intratumoral hemorrhage, maximal dimensions of 52/75/70 mm and a midline shift of 15 mm. The surgery was performed in emergency and we made a gross total resection. Immediate postoperative CT-scan confirmed the total resection. The histopathological diagnosis was S-PNET, this result being confirmed by immunochemistry. After neuromotor rehabilitation, at the 4 month follow-up visit the GOS was MD. The patient was also referred to the oncologist and was made chemotherapy and radiotherapy of the entire craniospinal axis. The tumor showed no signs of recurrence during 12 months of follow-up