Strategije u prevenciji komplikacija kirurškog liječenja gliomskih tumora mozga: analiza skupine slučajeva

Introduction: Brain glioma is the most common and lethal primary malignant intracranial tumor. Nonetheless, gross tumor resection remains the most successful treatment modality, which may prolong progression free survival of these patients. However, excessive surgery brings a danger of neurological, regional and systemic complications, which may be diminished/ avoided by better pre- and intra-operative care and by modern neurosurgical techniques. Aim: To analyze the incidence and type of peri- and post-operative complications in surgical brain glioma patients. Computing the results, advice on complication prevention was made. Methods: A single institution series of brain glioma patients operated on during a two-year period was analyzed. The incidence, type and time of complications were observed, as well as the patients’ gender and age, and the extent of tumor resection complications, dichotomized as peri- and post-operative variables, were correlated with investigated parameters to find out their possible association. Results: Transitory neurological deficit was the most common peri-operative complication. Seizures, meningitis, and permanent neurological deficit were commonly recorded among post operative complications. Conclusion: Patients’ gender and age, and the extent of tumor resection were not influential to the development of brain glioma complications. Aggressive surgery requires the avoidance of complications by cautious patient selection, multidisciplinary preoperative planning, and scrupulous neurosurgical technique augmented by up-to-date armamentarium.Uvod: Gliomi mozga najučestaliji su smrtonosni primarni intrakranijski tumori. Unatoč tomu, njihovo radikalno kirurško uklanjanje i nadalje ostaje najuspješnija metoda liječenja kojom se može usporiti napredovanje bolesti i donekle produljiti život ovakvih bolesnika. Međutim, agresivno kirurško liječenje može povećati opasnost nastanka neuroloških, regionalnih i sustavnih komplikacija, koje se može pokušati izbjeći boljom pripremom prije i tijekom operacije, kao i uporabom suvremenih neurokirurških tehnika. Cilj: Analizirati učestalost i vrstu perioperacijskih i poslijeoperacijskih komplikacija u kirurški liječenih bolesnika s gliomom mozga. Na temelju obrade rezultata, uspostaviti preporuke za sprječavanje nastanka komplikacija. Metode: Analizirana je skupina bolesnika operiranih zbog glioma mozga tijekom dvogodišnjeg razdoblja. Promatrana je učestalost i vrsta komplikacija, kao i vrijeme njihova nastanka. Također su zabilježeni podaci o dobi i spolu bolesnika te stupnju tumorske resekcije. Komplikacije su dihotomizirane kao perioperacijske i poslijeoperacijske varijable čija je moguća povezanost uspoređivana s istraživanim pokazateljima. Rezultati: Tranzitorni neurološki deficit bio je najučestalija perioperacijska komplikacija. Epileptički napadaj, meningitis i trajni neurološki ispad zabilježeni su kao najčešća poslijeoperacijska komplikacija. Zaključak: Spol i dob bolesnika, kao i stupanj tumorske resekcije nisu utjecali na nastanak komplikacija kirurškog liječenja glioma mozga, koje je moguće izbjeći pažljivim odabirom bolesnika, multidisciplinarnim predoperacijskim planiranjem i primjenom obzirne neurokirurške tehnike poduprte uporabom najsuvremenije operacijske opreme

Kasni nastanak recidivirajuće aneurizmatske tvorbe nakon mikrokirurškog liječenja aneurizme srednje moždane arterije: prikaz slučaja i pregled literature o mogućnostima liječenja

Recurrence of intracranial aneurysm after initial microsurgical or endovascular treatment is uncommon. Although the exact etiology remains unknown, recurrent aneurysms may be observed in surgical patients with big and multiple aneurysms, arterial hypertension, non-atherosclerotic cerebrovascular arteriopathies, as well as in those with a familial history of the disease. Such recurrence can occur over a wide period ranging from several months to years after the initial aneurysm treatment. Still, the occurrence delayed by more than 20 years is rather unusual. Herein, we present a case of a 70-year-old female patient who developed late intracranial aneurysm relapse 30 years after successful microsurgical clipping of the middle cerebral artery aneurysm. We also provide a brief review of relevant literature, discussing the etiology and pathophysiology of aneurysm reappearance, as well as different treatment options available. In conclusion, one should always consider the possibility of intracranial aneurysm recurrence regardless of the mode and time of primary surgery. In such a case, a multidisciplinary management approach using flow diverting endovascular techniques is advised in selected patients.Kasni nastanak recidivirajuće intrakranijske aneurizmatske tvorbe nakon mikrokirurškog liječenja je neuobičajen. Iako točna etiologija ostaje nepoznata, recidiv aneurizme može nastati u kirurških bolesnika s velikim i višekratnim aneurizmama, arterijskom hipertenzijom, neaterosklerotičkom cerebrovaskularnom arteriopatijom, kao i onih s obiteljskom anamnezom u povijesti bolesti. Recidivirajuća se aneurizma može očitovati tijekom dužeg razdoblja, u rasponu od nekoliko mjeseci do nekoliko godina nakon inicijalnog liječenja. Ipak, kasni nastanak aneurizme u vremenu dužem od 20 godina prilično je rijedak. U ovom radu prikazujemo slučaj 70-godišnje bolesnice s recidivirajućom aneurizmom srednje moždane arterije nastalom 30 godina nakon uspješnog mikrokirurškog liječenja. Također donosimo kratak pregled relevantne literature koja govori o etiologiji i patofiziologiji nastanka recidivirajuće aneurizme, kao i o različitim raspoloživim mogućnostima liječenja. Zaključujemo kako uvijek treba voditi računa o mogućnosti nastanka recidivirajuće intrakranijske aneurizme neovisno o načinu liječenja i vremenu proteklom od prvobitnog kirurškog zahvata. U ovakvom se slučaju preporuča multidisciplinarni pristup primjenom metode endovaskularnog preusmjerenog protoka kao najprimjerenije suvremene tehnike u odabranih bolesnika

Hibridni mikrokirurški i endovaskularni pristup u liječenju višestrukih moždanih aneurizmi: ilustrativni prikaz slučajeva i usporedba s podacima iz literature

Contemporary cerebral aneurysm treatment has advanced due to the expansion of microsurgical and endovascular techniques having different advantages and restraints. However, some aneurysms cannot be effectively treated by a single method alone due to their specific anatomy, location, complexity, and/or multiplicity. Subsequently, multiple aneurysms sometimes necessitate a hybrid strategy integrating both methods. The study aims were to discuss indications, possibilities, and challenges of a hybrid strategy in the decision making and treatment of multiple intracranial aneurysms. A single-institution illustrative case series of multiple intracranial aneurysm patients treated by a hybrid approach was analyzed and management outcome discussed and correlated with literature data. Following the treatment, both patients from our case series recovered well, having complete and stable aneurysmal occlusion with no relapse and no postoperative procedure-related complications or long-lasting neurological symptoms. In conclusion, a hybrid approach is advised as a treatment option for multiple cerebral aneurysms when a single modality is insufficient to bring satisfactory results. It may be a suitable and safe addition to an assortment of treatments pledging clinical improvement and enabling positive management outcome in patients with ruptured and non-ruptured multiple cerebral aneurysms.Suvremeno je liječenje cerebralnih aneurizmi uvelike napredovalo zahvaljujući ekspanziji mikrokirurških i endovaskularnih postupaka koji se odlikuju različitim podobnostima, ali i ograničenjima. Međutim, pojedine je aneurizme ponekad nemoguće uspješno liječiti samo jednom od metoda s obzirom na njihovu specifičnu anatomiju, lokalizaciju, složenost i/ili višestrukost. Upravo su višestruke aneurizme gdjekad podobne za hibridni pristup koji objedinjuje obje navedene metode. Namjera je ovoga rada raspraviti indikacije, mogućnosti i izazove hibridne strategije pri donošenju odluke o obliku liječenja višestrukih intrakranijskih aneurizmi. U radu prikazujemo analizu bolesnika s navedenim aneurizmama u kojih je primijenjen hibridni pristup i raspravljamo o rezultatima i ishodu liječenja uspoređujući ih s podacima iz literature. Oboje se je naših bolesnika uspješno oporavilo nakon provedenog liječenja, kad je nastupila potpuna i stabilna okluzija aneurizme bez znakova ponovne pojave aneurizme i bez komplikacija povezanih s provedenim postupkom, kao i bez trajnog neurološkog deficita. Zaključujemo kako je hibridni pristup preporučena opcija liječenja višestrukih moždanih aneurizmi u slučajevima kada je pojedinačna metoda liječenja nedostatna za osiguravanje zadovoljavajućih rezultata. Ovakav je pristup podoban i siguran kao alternativa rasponu drugih oblika liječenja usmjerenih ka kliničkom poboljšanju i pozitivnom ishodu u bolesnika s rupturiranim i nerupturiranim višestrukim moždanim aneurizmama

Giant Choroid Plexus Cyst as an Accidental Finding in an Older Man

Choroid plexus cysts (CPC) are usually found at the end of the second trimester of pregnancy. Sometimes they can be accidentally and found on prenatal ultrasound examinations. Vast majority of CPC resolve spontaneously by 28th weeks gestation. In the older aged group the choroid plexus cysts are extremely rare pathomorphologic medical entity. Since they are almost always asymptomatic, they are therefore accidentally found on brain magnetic resonance (MR) or computed tomography (CT) scans. They are usually located in the lateral ventricles and measure around 2 cm in diameter. We present a case of a 75-year old male with a giant choroid plexus cyst whose leading symptom was excruciating headache refractory to previous conservative therapy. He underwent surgery when osteoplastic craniotomy was performed with cyst fenestration and ablation. His recovery was uneventful with total regression of headaches. Reviewing the recent literature we did not find such a case considering the patients age and the size of the choroid plexus cyst

Perkutana laser dekompresija – naša iskustva s upotrebom diodnog lasera

Introduction: PLDD (Percutaneous laser disk decompression) is a safe, non-destructive and successful surgical treatment for lumbar disk herniation. The purpose of this study was the evaluation of advantages in the procedure of percutaneous laser disk decompression in the treatment of lumbar disk herniation in comparison to open surgical methods on lumbar disk herniation like microdisectomy. Patients: From June 2008 till July 2009 in the Clinical hospital “Sister of Mercy” Zagreb 91 patients have been treated with percutaneous laser disk decompression and 125 patients have been treated with microdisectomy. Methods: The percutaneous laser disk decompression is done with the usage of a diode laser (LASE maR 1000), intensity of 1000 j, power 12 W and wave length 980 nm. Open surgical methods for lumbar disk herniation are performed with the surgical technique microdisectomy. The input criterion for the research was the adulthood of the examinee and advanced herniation of the intervertebral disk in the lumbar spine, which needed surgical treatment. The analysed parameters were: success of the surgical treatment; relapsing lumbar disk herniations; postsurgical complications; postsurgical stay in the hospital; time needed to return to every-day activities. The data achieved with the analyses of input and output parameters have been compared with the help of the MacNab criteria. There have not been found any statistically significant results in the comparison of data for age, sex and the stage of intervertebral disk herniation in both groups. This is a retrospective research and lasted 12 months. Results: Patients treated with the percutaneous laser disk decompression had in 89,6 % (n=81) very good or excellent results and were satisfied with the success of the treatment. In the group of patients treated with microdisectomy the number of patients, which had very good or excellent results, is minor and numbers 81,2% (n=101). Postsurgical complications appeared in 2,5% (n=2) in the group of patiens operated with percutaneous laser disk decompression. One patient had another percutaneous laser disk decompression and another patient had a MET-Rx interlaminectomy. In the group of patients treated with microdisectomy, the number of patients, where complications appeared, is higher and numbers 6,5% (n=8). As the research moved on the frequency of percutaneous lumbar disk decompression increased, so that this surgical method has been the most present in the last months of the research, while the presence of the microdisectomy was gradually decreasing. Conclusion: The results of the conducted research have afirmated the comparative advantages of contemporary surgical methods in treating lumbar disk herniation in reference to classical treating methods.PLDD (Perkutana laser disk dekompresija) siguran je, nedestruktivan i uspješan kirurški zahvat kod lumbalne diskus hernije. Cilj ove studije je bio evaluacija prednosti procedure perkutane laser disk dekompresije u tretmanu lumbalne diskus hernije naspram otvorenih operacijskih metoda slabinske diskus hernije tipa mikrodiskektomije. Od lipnja 2008.god do srpnja 2009 god. u Kliničkoj bolnici Sestara milosrdnica, 91 bolesnik je tretiran uz pomoć perkutane laser disk dekompresije i 125 bolesnika tretiranih uz pomoć mikrodiskektomije. Perkutana laser disk dekompresije sec.Choy je rađena uz uporabu diodnog lasera (LASE maR 1000) jačine 1000 j, snage 12 W i valne duljine 980 nm. Kriterij uključivanja u istraživanje bio je odrasla životna dob ispitanika i uznapredovala hernijacija intervertebralne ploče slabinske kralježnice, koja je zahtijevala kirurško liječenje. Analizirani izlazni parametri bili su: uspješnost operacijskoga liječenja; recidivirajuće slabinskie diskus hernije; poslijeoperacijske komplikacije; dužina poslijeoperacijskoga boravka u bolnici; vrijeme potrebito za povratak svakodnevnim aktivnostima. Podatke dobivene analizom ulaznih i izlaznih parametara smo uspoređivali uz pomoć Macnab kriterija. Usporedbom podataka za dob, spol, razinu hernijacije intervertebralne ploče u obje skupine bolesnika nisu nađeni statistički značajni rezultati. Ovo je retrospektivno istraživanje u trajanju od 12 mjeseci. Bolesnici kojim je urađena perkutana laser disk dekompresija su u 89,6% imali dobre ili odlične rezultate i bili su zadovoljni uspjehom liječenja. U skupini bolesnika tretiranih uz pomoć mikrodiskektomije broj bolesnika koji su imali dobre ili odlične rezultate nakon operacijskog zahvata i bili zadovoljni uspjehom istog je manji i iznosi 81,2%. Poslijeoperacijske komplikacije su se pojavile kod 2,5% boelsnika operiranih perkutanom laser disk dekompresijom. Od toga je jedan bolesnik ponovno operiran perkutanom laser disk dekompresijom a drugi uz pomoć METRx interlaminektomije. Broj bolesnika sa komplikacijama kod kojih je rađena mikrodiskektomija je znatno veći i iznosi 6,5%. Kako je istraživanje odmicalo učestalost se perkutane lumbalne dekompresije diska povećavala, tako da je ova operacijska metoda bile najzastupljenija u zadnjim mjesecima istraživanja, dok se učestalost mikrodiskektomije postupno smanjivala. Rezultati provedenoga istraživanja afirmirali su komparativne prednosti suvremenih operacijskih metoda liječenja slabinske diskus hernije u odnosu na klasične metode liječenja