Zespolenie nerwu twarzowego przeszczepem kablowym w odcinku sutkowym. Opis przypadku

We describe a case of a 52-year-old woman in whom surgery for two tumours located in the cerebellar hemisphere and in the posterior petrous bone was complicated by interruption of the facial nerve (CN VII). During the same procedure, anastomosis of CN VII, using a cable graft harvested from the great auricular nerve, was performed. Seven months later the first signs of reinnervation of the facial muscles were noticed. Two and a half years after surgery, CN VII function was assessed as grade II/III according to the House-Brackmann scale. The authors emphasize the significance of immediate repair of CN VII in modern skull base surgery but also the importance of a patient's self-training to obtain the best functional outcome of the facial reanimation. Reconstruction using the great auricular nerve has two significant advantages: first, the patient avoids further procedures for nerve repair, and second, the harvested nerve is located in direct proximity to the operation area.W pracy opisano przypadek 52-letniej kobiety, u której operacja jednoczesnego usunięcia dwóch guzów zlokalizowanych w móżdżku i piramidzie kości skroniowej była powikłana przerwaniem ciągłości nerwu twarzowego. W czasie tego samego zabiegu wykonano zespolenie nerwu VII za pomocą przeszczepu kablowego pobranego z nerwu usznego wielkiego. Po 7 miesiącach pojawiły się pierwsze cechy reinerwacji mięśni twarzy. W późniejszym przebiegu, wraz ze stosowaną samodzielną rehabilitacją twarzy przy lustrze, obserwowano dalszą powolną poprawę. Po ponad 2,5 roku od operacji czynność nerwu VII oceniana jest na II/III stopień w skali House'a-Brackmanna. Autorzy podkreślają w pracy rolę śródoperacyjnych zespoleń nerwu VII we współczesnej chirurgii podstawy czaszki oraz konieczność samodzielnej pracy pacjenta dla osiągnięcia dobrego efektu reanimacji twarzy. Uzyskany dobry wynik regeneracji nerwu VII zachęca do częstszego wykorzystania przypomnianej tu techniki. Rekonstrukcja tym sposobem ma dwie istotne zalety: po pierwsze pacjent unika dodatkowych procedur chirurgicznych w celu naprawy nerwu VII, po drugie nerw pobierany do zespolenia znajduje się w bezpośrednim sąsiedztwie pola operacyjnego

Uszkodzenie nerwu twarzowego u chorych po operacjach guzów kąta mostowo–móżdżkowego. Zapobieganie i kompleksowe postępowanie terapeutyczne

Facial nerve (CN VII) palsy or even its transient paresis causes physical disability but is also a psychosocial problem. Immediately after vestibular schwannoma removal, different degrees of CN VII paresis occur in 20–70% of patients. Facial nerve paresis is observed in 10–40% after surgery of cerebellopontine angle meningiomas. Postoperative facial nerve weakness significantly reduces or completely withdraws with time in the majority of cases. However, even if prognosis for CN VII regeneration is good, proper management is needed because of the potential for serious ophthalmic complications. In this paper, the authors raise the issue of perioperative prophylaxis and comprehensive treatment of postoperative paresis of CN VII. Prophylaxis and treatment of ophthalmic complications are discussed. Current trends in the treatment of intraoperative loss of facial nerve continuity, management of facial paresis with good prognosis and dealing with facial palsy with no spontaneous recovery are also described in the paper.Porażenie, a nawet przejściowy niedowład nerwu twarzowego, powoduje fizyczną niepełnosprawność, ale stanowi również problem psychosocjalny. Bezpośrednio po operacji osłoniaka nerwu przedsionkowego u 20–70% chorych pojawia się różnego stopnia niedowład nerwu VII. W przypadku oponiaków okolicy kąta mostowo-móżdżkowego niedowład nerwu VII obserwuje się po operacji w 10–40% przypadków. U większości chorych pooperacyjny niedowład nerwu VII z czasem znacząco się zmniejsza lub całkowicie wycofuje. Niemniej nawet w przypadku dobrego rokowania co do regeneracji nerwu VII konieczne jest właściwe leczenie ze względu na możliwość wystąpienia poważnych powikłań ocznych. W niniejszej pracy autorzy poruszają zagadnienia okołooperacyjnej profilaktyki uszkodzenia nerwu VII oraz kompleksowego postępowania w przypadku wystąpienia niedowładu tego nerwu po operacji. Omówiono profilaktykę i leczenie powikłań ocznych porażenia nerwu VII. W pracy opisano także aktualne trendy postępowania w przypadku przerwania nerwu VII w czasie usuwania guza, strategie leczenia niedowładu rokującego samoistną regenerację oraz gdy czynność nerwu nie powraca

Zespolenie nerwu twarzowego z połową nerwu podjęzykowego w leczeniu porażenia nerwu twarzowego

Background and purpose Commonly used classic hypoglossal (CN XII) to facial nerve (CN VII) anastomosis has the disadvantage of tongue hemiatrophy. Thus, various attempts have been made to modify this method to reduce the tongue damage. The aim of this report was to present the results of hemihypoglossal-facial nerve anastomosis (HHFA) technique in relation to facial muscles reanimation and hemitongue atrophy. Material and methods The first 7 consecutive patients who underwent CN VII anastomosis with half of the CNXII, for which the follow-up period exceeded 12 months, were analysed. During the procedure, CN VII was transected as proximally as possible after drilling the mastoid process. CN XII was separated longitudinally into two parts at a short distance to allow suture of the stumps without any tension. One half of CN XII was transected and sutured to the distal stump of CN VII. Recovery from facial palsy was quantified with the House-Brackmann grading system (HB). Tongue function was assessed according to the scale proposed by Martins. Results Features of initial reinnervation of facial muscles were visible after 6 months in all 7 patients. All patients achieved satisfactory outcome of CN VII regeneration (HB grade III) until the last control examination (12-27 months after surgery, mean 16). No or minimal tongue atrophy without deviation (grades I-II according to the Martins scale) was found in 4 patients. Mild hemiatrophy with tongue deviation < 30 degrees (grade III) was visible in 3 patients. Conclusions In our experience, HHFA is effective treatment of facial palsy and gives a chance to reduce damage of the tongue.Wstęp i cel pracy W leczeniu porażenia nerwu twarzowego często stosuje się zespolenie z nerwem podjęzykowym. Wadą tej metody jest połowiczy zanik języka, dlatego od wielu lat podejmuje się próby jej modyfikacji, aby zmniejszyć uszkodzenia języka. Celem pracy jest ocena wyników zespolenia nerwu twarzowego z połową nerwu podjęzykowego w kontekście reanimacji mięśni twarzy oraz następowego uszkodzenia języka. Materiał i metody Analizowano wyniki leczenia 7 pierwszych, kolejnych chorych, u których wykonano zespolenie nerwu twarzowego z połową nerwu podjęzykowego, u których czas obserwacji przekraczał 12 miesięcy. W czasie zabiegu wypreparowywano pień nerwu twarzowego z wyrostka sutko-watego oraz jego zewnątrzczaszkowy odcinek aż do jego podziału. Wypreparowywano nerw podjęzykowy, rozdzielano go podłużnie na dwie części na krótkim odcinku, aby uzyskać zespolenie bez żadnego napięcia. Jedną połowę nerwu pod-językowego zeszywano z kikutem dystalnym nerwu twarzowego. Wyniki reinerwacji mięśni twarzy oceniano wg skali House'a-Brackmanna (HB), natomiast nasilenie zbaczania i jednostronnego zaniku języka oceniano za pomocą skali zaproponowanej przez Martinsa. Wyniki Po upływie 6 miesięcy u wszystkich 7 chorych stwierdzono początkowe cechy reinerwacji mięśni twarzy. Do czasu ostatniej kontroli (12–27 miesięcy po zabiegu, średnio 16 miesięcy) u wszystkich chorych uzyskano satysfakcjonujący wynik regeneracji nerwu twarzowego (III stopień HB). Brak lub minimalny jednostronny zanik mięśni bez zbaczania języka (stopnie I–II wg Martinsa) stwierdzono u 4 pacjentów, a średniego stopnia zanik połowiczy ze zbaczaniem języka < 30 stopni (III stopień) u 3 pacjentów. Wnioski Zespolenie nerwu twarzowego z połową nerwu pod-językowego umożliwia w naszym doświadczeniu satysfakcjonującą reanimację mięśni twarzy i daje szanse na zmniejszenie uszkodzenia funkcji języka

Popromienne guzy opon mózgowo-rdzeniowych. Opis ośmiu przypadków i przegląd piśmiennictwa

Background and purpose Despite their rarity, post-radiation meningeal tumours seem to be a growing problem due to the increasing application of radiation therapy. The aim of the study was to ascertain the specific features of these tumours. Material and methods Among 433 intracranial meningeal tumours treated from 2000 to 2008, eight cases (2%) have been presumed to be associated with high-dose therapeutic radiation for previous neoplasm of the head (7) or neck (1). On average, tumours were diagnosed 24 years after irradiation. All patients had a solitary meningeal tumour, but two of them also developed other neoplasms in the irradiated area. Results All tumours were microsurgically removed. The postoperative course was uncomplicated in two cases only. In the remaining 6 (75%), complications included liquorrhoea (2), brain oedema (1), venous thrombosis (1), bleeding into the tumour bed (1) and focal deficit due to manipulation (3). Most tumours (5) were WHO grade I meningiomas. These benign meningiomas exhibited some peculiar histological features, including focal increase of cellularity, focal enhancement of proliferation index, pleomorphism of nuclei, occasional mitotic figures and, in one case, evidence of brain invasion. One meningioma was assigned to WHO grade II, one to WHO grade III and one appeared to be meningeal fibrosarcoma. The event-free survival and overall survival rate at 4.4 years of follow-up were 63% and 75%, respectively. Conclusions Radiation-induced tumours of the meninges show certain characteristic histopathological features, which may promote invasiveness of the tumour and higher risk of malignancy.Wstęp i cel pracy Popromienne guzy opon mózgowo-rdzeniowych – mimo że stwierdzane rzadko – wydają się narastającym problemem ze względu na szerokie zastosowanie radioterapii. Celem pracy jest charakterystyka kliniczna i histopatologiczna tych guzów. Materiał i metody Spośród 433 śródczaszkowych guzów oponowych operowanych w latach 2000–2008, w 8 przypadkach (2%) stwierdzono związek pomiędzy powstaniem guza a przebytą radioterapią z powodu nowotworów głowy (7) i szyi (1). Guzy popromienne były rozpoznawane średnio po 24 latach od napromieniania. U wszystkich pacjentów wystąpiły pojedyncze guzy opon, ale u 2 dodatkowo pojawiły się inne nowotwory w obszarze napromienianym. Wyniki Wszystkie guzy były leczone mikrochirurgicznie. Przebieg pooperacyjny bez powikłań obserwowano tylko u 2 pacjentów. U pozostałych 6 (75%) komplikacje pooperacyjne obejmowały: płynotok (2), obrzęk mózgu (1), zakrzepicę żylną mózgu (1), krwawienie do loży pooperacyjnej (1) oraz ogniskowe deficyty neurologiczne wskutek manipulacji (3). W większości przypadków (5) stwierdzono oponiaki o niskim stopniu złośliwości histologicznej (I stopień wg WHO), które jednak wykazywały szczególne cechy histopatologiczne: ogniskowy wzrost zagęszczenia komórkowego i podwyższony indeks proliferacyjny, pleomorfizm jąder komórkowych, pojedyncze figury podziałów mitotycznych oraz, w jednym przypadku, cechy naciekania mózgu. W jednym przypadku rozpoznano oponiaka II stopnia wg WHO, w jednym III stopnia wg WHO i w jednym włókniakomięsaka opon. Przeżycie wolne od zdarzeń i przeżycie całkowite w okresie obserwacji trwającym 4,4 roku wyniosły odpowiednio 63% i 75%. Wnioski Popromienne guzy opon mózgowo-rdzeniowych wykazują znamienne cechy histopatologiczne, które mogą sprzyjać większej inwazyjności i złośliwości tych guzów

Results of surgical treatment of anterior clinoidal meningiomas – our experiences

Objective Presentation of our experience in the treatment of anterior clinoidal meningiomas, including evaluation of factors that may affect early and long-term treatment outcomes. Methods Thirty patients were operated with strategy of complete tumor resection using fronto-orbito-zygomatic approach. Outcomes were assessed by Glasgow Outcome Scale at discharge and by Karnofsky Performance Scale at follow-up. Results There were 6 tumors in group I, 20 in group II, and 4 in group III according to Al-Mefty classification. Complete tumor resection (Simpson I or II) was achieved in 19 patients, incomplete resection (Simpson IV) in 11: due to strict tumor adhesion to cerebral arteries in 5 and tumor extension to cavernous sinus in 6 cases. Operative mortality was 6.7%. Visual acuity improved in six among nine patients with impaired vision but in no one among nine patients with blindness. Normal life activity (80–100KPS) could be carried out by 88% patients at follow-up. Recurrence was observed in two (11.8%) patients after radical removal and progression of residual tumor in two (25%) after subtotal resection. Conclusions Complete tumor removal is possible with an acceptable risk of death and severe neurological deficits, except for cases with tumor extension to the cavernous sinus or strict tumor adhesion to cerebral arteries. Visual acuity improvement may be expected in two thirds of patients with impaired vision, but not in cases of blindness. In cases of incomplete tumor removal, use of stereotactic radiosurgery immediately after surgery seems justified

Surgical treatment of sporadic and von Hippel–Lindau syndrome-associated intramedullary hemangioblastomas

Object Intramedullary hemangioblastomas are rare lesions. They can be related to von Hippel–Lindau syndrome or they may be sporadic. This study describes surgical treatment for this infrequent tumor. Methods Twelve consecutive patients received surgery to remove sporadic or von Hippel–Lindau syndrome-associated intramedullary hemangioblastomas. Patients were evaluated at four time points: before treatment, on postoperative day one, on the day of discharge, and at a follow-up examination. Results The patients showed good preoperative neurological status. The cohort had a slight female predominance. All tumors spanned at least one spinal segment. In all cases, total tumor removal was achieved, and a good outcome was obtained. None of the following factors had a significant effect on outcome: age, sex, tumor size, the presence of a syrinx, or the presence of von Hippel–Lindau syndrome. Conclusions The surgical removal of intramedullary hemangioblastomas resulted in satisfactory long-term functional outcomes. The best results were obtained before neurological symptoms occurred. Thus, we suggest that surgery should be considered for managing asymptomatic, surgically accessible, space-occupying lesions in sIH group, and isolated, space-occupying lesions in vHLS-IH group

Surgical treatment of intramedullary ependymomas

Object The aims of this study were to present the results of surgery for intramedullary ependymomas (IEs), analyze complication and recurrence rates, and analyze factors that might influence outcome. Methods The charts of 29 consecutive patients (women – 8, men – 21; mean age – 38 years; range: 18–72) operated for IE were retrospectively analyzed. Mean follow-up was 9 years. Eighteen tumors (62%) were located in the cervical or cervicothoracic spine, and average tumor length was four spinal levels. Twenty patients (69%) presented with neurological deficit. Results Gross total resections (GTRs) comprised 87% of cases, subtotal resections (STRs) 10%, and partial resections 3%. The neurological outcome on postoperative day 1 was as follows: modified McCormick scale (mMS) grade I – 6%, grade II – 21%, grade III – 21%, grade IV – 31%, and grade V – 21%; at follow-up, outcomes were mMS grade I – 42%, grade II – 34%, grade III – 10%, and grade V – 14% of patients. Compared to the preoperative period, 69% of patients deteriorated postoperatively; however, 62% improved or remained without deficit in follow-up, and deterioration persisted in 24%. The functional results were significantly worse when the intraoperative monitoring potentials dropped below 50% (p=0.005) and if the tumor involved >3 spinal levels (p=0.039). Fourteen postoperative complications in 10 patients (34%) included respiratory failure (14%), pneumonia (7%), urinary infection (10%), bed sores (10%), and CSF leak (7%). Two tumors progressed after STR, with progression-free survival times of 5 and 14 years. No recurrence was observed after GTR. Conclusions Total tumor resection is the treatment of choice in cases of IEs: no tumor re-growth occurred after total resection, 86% of patients were independent at follow-up, and the 10-year survival rate was 79%

Epidermoid cysts of the cerebellopontine angle: Clinical features and treatment outcomes

Objective To report clinical characteristics, treatment outcomes and risk of recurrence in patients with surgically treated cerebellopontine angle epidermoids. Methods In 1994–2013, we operated 17 patients, including 7 with tumor limited to the cerebellopontine angle, 7 with cerebellopontine angle tumor penetrating supratentorially, and 3 with cerebellopontine angle tumor extending along skull base to contralateral cerebellopontine angle. All patients were followed-up for the mean duration of 126 months. Results On admission cranial nerve symptoms predominated. Total tumor removal was achieved in 5 patients, and incomplete removal (with small tumor remnants left on vessels, nerves, or brainstem) in 12 patients. Postoperatively, preoperative deficits worsened in 2 and new postoperative deficits occurred in 10 patients. The extent of tumor expansion had no effect on postoperative morbidity and risk of recurrence. During long-term follow-up, improvement or resolution of preoperative deficits was seen in 11 of 17 patients, and new postoperative deficits in 8 of 10 patients. Symptomatic recurrences after an average of more than 9 years were noted in 5 patients, 3 of whom were reoperated. Recurrences occurred in some younger patients and always in area of primary tumor. No effect of extent of tumor removal on risk of recurrence was found. Conclusions The extent of tumor removal had no effect on the risk of recurrence, and thus it may be acceptable to leave tumor capsule fragments adhering closely to nerves, vessels, or brainstem. During long-term follow-up, resolution or improvement of present preoperatively and new postoperative neurological deficits may be expected in most patients

Surgery for sporadic vestibular schwannoma. Part II. Complications (not related to facial and auditory nerves)

Introduction The aim of this study was to analyze the frequency and consequences of postoperative complications (PC) after surgery for sporadic vestibular schwannoma and to find factors that increase the risk of PC occurrence. Materials and methods The study included 220 consecutive patients (134 women, 86 men; age ranged from 18 to 74) operated on with the retrosigmoid (217) or translabyrinthine (3) approach. Complicated postoperative period was defined as an occurrence of at least one of: cerebrospinal fluid (CSF) leakage, hematoma in the tumor bed, intracerebellar hematoma, cerebellar swelling, brainstem stroke, hydrocephalus (HCP), healing problems, meningitis and cranial nerves (excluding VII–VIII) palsies or cerebellar symptoms. Correlation studies and multivariate regression analysis were performed. Results PC occurred in 55 patients (25%). PC included lower cranial nerve (LCN) palsy (8.2%), cerebellar symptoms (7.3%), CSF leakage (5.9%), HCP (5%), CNVI palsy (3.1%), meningitis (1.8%), cerebellar swelling (1.4%), CNV dysfunction (0.9%), intracerebellar hematoma (0.5%) and lethal brainstem stroke (0.5%). In long term follow-up, LCN deficit was present in 2 patients (0.9%), cerebellar syndrome in 4(1.8%) and facial hypoesthesia in 2(0.9%). One patient (0.5%) developed bilateral blindness, secondary to preoperative optic nerve atrophy. As a result of PC, 10 patients (4.5%) required 11 additional surgical procedures. In statistical analysis, PC were independently related to preoperative cerebellar syndrome (p=0.002) and tumor size (>30mm vs.<30mm, p<0.05). The risk of PC diminished significantly with the increased number of performed procedures from 40% at the beginning to 16.4% in the last 55 cases. Conclusions Tumor size, cerebellar syndrome at presentation and experience of the team were the three most important risk factors for PC occurrence. Permanent deficit secondary to PC remained in only 4% of the patients

Surgical treatment of parasagittal and falcine meningiomas invading the superior sagittal sinus

Objective We present our experience with surgery of parasagittal and falcine meningiomas invading the superior sagittal sinus with special consideration of the surgical complications and the incidence of tumour recurrence. Materials and methods The analysis included 37 patients with parasagittal and falcine meningiomas invading the superior sagittal sinus. In 13 cases, the sinus was ligated and resected with tumour. In 14 cases, the sinus was entered with the goal of tumour resection and the sinus was reconstructed, while in 10 patients the sinus was not entered and the remaining residual tumour was observed for growth. Results Out of 13 patients after radical resection of the tumour and invaded part of sinus, 9 revealed haemodynamic complications: venous infarction (4), significant brain oedema (3) and hypoperfusion syndrome (2). 2 out of 14 patients after resection of the tumour from the lumen of the superior sagittal sinus with subsequent sinus repair developed venous infarction after surgery. Among 27 patients after radical tumour excision the remote follow-up revealed recurrence in 2 patients. There were no significant haemodynamic complications in none of 10 cases, in which the residual tumour was left after surgery in the superior sagittal sinus. In this group, 3 cases were subjected to early post-operative radiotherapy and local recurrence was observed in 4 patients. Conclusions The aggressive surgical treatment of meningiomas infiltrating the superior sagittal sinus is associated with a high surgical risk. The incidence of recurrence of these tumours increases significantly in the case of non-radical excision of the tumour