Emergency decompressive craniectomy after removal of convexity meningiomas

BACKGROUND: Convexity meningiomas are benign brain tumors that are amenable to complete surgical resection and are associated with a low complication rate. The aim of this study was to identify factors that result in acute postoperative neurological worsening after the removal of convexity meningiomas. METHODS: Clinical evaluation and neuroradiological analysis of patients who underwent removal of a supratentorial convexity meningioma were reviewed. Patients were selected when their postoperative course was complicated by acute neurological deterioration requiring decompressive craniectomy. RESULTS: Six patients (mean age: 43.3 years) underwent surgical removal of a supratentorial convexity meningioma. Brain shift (mean: 9.9 mm) was evident on preoperative imaging due to lesions of varying size and perilesional edema. At various times postoperatively, patient consciousness worsened (up to decerebrate posture) with contralateral paresis and pupillary anisocoria. Computed tomography revealed no postoperative hematoma, however, did indicate increased brain edema and ventricular shift (mean: 12 mm). Emergency decompressive craniectomy and brief ventilator assistance were performed in all patients. Ischemia of the ipsilateral posterior cerebral artery occurred in 3 patients and hydrocephalus occurred in 2 patients. Outcome was good in 2, fair in 2, 1 patient had severe disability, and 1 patient died after 8 months. CONCLUSIONS: Brain shift on preoperative imaging is a substantial risk factor for postoperative neurological worsening in young adult patients after the removal of convexity meningiomas. Emergency decompressive craniectomy must be considered because it is effective in most cases. Other than consciousness impairment, there is no reliable clinical landmark to guide the decision to perform decompressive craniectomy; however, brain ischemia may have already occurred

Alfa Internexin Expression in a Series of 137 Gliomas and its Correlation with Oligodentroglial Morphology IDH1, P53 SYN and EGFR Expression

Background: Distinguishing glial subtypes based on nuclear and cellular morphology alone is subjective,with significant interobserver variability, even among highly experienced neuropathologists. Genetic subtyping of a given histological phenotype and robust biomarkers has improved the diagnostic and prognostic assessment. Recently, IDH1 (more rarely IDH2) mutations have been found in nearly 40% of gliomas and strongly predict lower grade in histology and better outcomes. Aim: To evaluate if the expression of alpha-internexin (INA) can be used a reliable diagnostic, prognostic and cost-effective marker, a proneural gene-coding neurofilament interacting protein significantly correlated with oligodendroglial phenotype, 1p/19q codeletion as well as higher chemosensitivity and better prognosis to our study population. Material: We studied INA expression in 137gliomasand correlated it with pure oligodendroglial histology, IDH1, p53, EGFR and SYN expression by immunohistochemistry.Results: INA was expressed in 72.2% of grade II oligodendrogliomas (n = 22), 62.5% of grade III oligodendrogliomas (n = 16), 57.2% of grade II oligoastrocytomas (n = 7), 66.7% of grade III oligoastrocytomas (n = 6), 66.7% of glioblastomas with oligodendroglial component (n = 12), 0% of grade I astrocytomas (n = 13), 0% of grade II astrocytomas (n = 4), 0% of grade III astrocytomas (n = 12) and 2.5% of glioblastomas and gliosarcomas (n = 40).INA was expressed by 27(71.1%) of pure oligodendrogliomas(n=38) versus 17(17.2%) of no pureoligodentrogliomas(n=99), Chi-square was p < 10-4; Cramer’s V was 0.517; p <10-4, which show a very strong relationship.INA was expressed by 32(45.1%) of gliomas with IDH1 mutation (n=71) versus 12(18.2%) of gliomas without IDH1 mutation (n=66), Chi-square was p < 0.001; Cramer’s V was 0.288; p < 0.001, which show a very strong relationship. INA was expressed by 26(27.4%) of gliomas with P53 mutation (n=95) versus 18(42.9%) of gliomas without P53 mutation (n=42), Chi-square wasp=0.05 which show they were negatively correlated. INA was expressed by 30(50.0%) of gliomas with SYN expression (n=60) versus 14(18.2%) of gliomas without SYN expression (n=77), Chi-square was p < 10-4; Cramer’s V was 0.338; p < 10-4, which show a very strong relationship. INA was expressed by 12(27.3%) of gliomas with EGFR expression (n = 44) versus 32(34.%) of gliomas without EGFR expression (n=44), Chi-square was p=0.05 which show they were negatively correlated. Conclusion: INA expression is a fast, cheap and reliable diagnostic and prognostic marker, which helps identify patients of different prognostic groups in diffuse gliomas and should be used routinely in the pathologic diagnosis of glial tumours.Keywords: Glial tumours, Alpha-internecine, IDH1, P53, Synaptophysin, EGFR protein

Alfa Internexin Expression in a Series of 137 Gliomas and its Correlation with Oligodentroglial Morphology IDH1, P53 SYN and EGFR Expression

Background: Distinguishing glial subtypes based on nuclear and cellular morphology alone is subjective,with significant interobserver variability, even among highly experienced neuropathologists. Genetic subtyping of a given histological phenotype and robust biomarkers has improved the diagnostic and prognostic assessment. Recently, IDH1 (more rarely IDH2) mutations have been found in nearly 40% of gliomas and strongly predict lower grade in histology and better outcomes. Aim: To evaluate if the expression of alpha-internexin (INA) can be used a reliable diagnostic, prognostic and cost-effective marker, a proneural gene-coding neurofilament interacting protein significantly correlated with oligodendroglial phenotype, 1p/19q codeletion as well as higher chemosensitivity and better prognosis to our study population. Material: We studied INA expression in 137gliomasand correlated it with pure oligodendroglial histology, IDH1, p53, EGFR and SYN expression by immunohistochemistry.Results: INA was expressed in 72.2% of grade II oligodendrogliomas (n = 22), 62.5% of grade III oligodendrogliomas (n = 16), 57.2% of grade II oligoastrocytomas (n = 7), 66.7% of grade III oligoastrocytomas (n = 6), 66.7% of glioblastomas with oligodendroglial component (n = 12), 0% of grade I astrocytomas (n = 13), 0% of grade II astrocytomas (n = 4), 0% of grade III astrocytomas (n = 12) and 2.5% of glioblastomas and gliosarcomas (n = 40).INA was expressed by 27(71.1%) of pure oligodendrogliomas(n=38) versus 17(17.2%) of no pureoligodentrogliomas(n=99), Chi-square was p < 10-4; Cramer’s V was 0.517; p <10-4, which show a very strong relationship.INA was expressed by 32(45.1%) of gliomas with IDH1 mutation (n=71) versus 12(18.2%) of gliomas without IDH1 mutation (n=66), Chi-square was p < 0.001; Cramer’s V was 0.288; p < 0.001, which show a very strong relationship. INA was expressed by 26(27.4%) of gliomas with P53 mutation (n=95) versus 18(42.9%) of gliomas without P53 mutation (n=42), Chi-square wasp=0.05 which show they were negatively correlated. INA was expressed by 30(50.0%) of gliomas with SYN expression (n=60) versus 14(18.2%) of gliomas without SYN expression (n=77), Chi-square was p < 10-4; Cramer’s V was 0.338; p < 10-4, which show a very strong relationship. INA was expressed by 12(27.3%) of gliomas with EGFR expression (n = 44) versus 32(34.%) of gliomas without EGFR expression (n=44), Chi-square was p=0.05 which show they were negatively correlated. Conclusion: INA expression is a fast, cheap and reliable diagnostic and prognostic marker, which helps identify patients of different prognostic groups in diffuse gliomas and should be used routinely in the pathologic diagnosis of glial tumours

Preservation of the temporal muscle during the frontotemporoparietal approach for decompressive craniectomy: Technical note

Background In patients undergoing decompressive craniectomy, resection and detachment of the temporal muscle produces esthetic and functional damage, due to atrophy of the frontal portion of the temporal muscle in the temporal fossa. We have performed en-block temporal muscle detachment in decompressive craniectomy patients to avoid esthetic and functional damage to the temporal muscle. Methods Twenty-one patients underwent decompressive craniectomy using a frontotemporoparietal approach. Through a three-leaf clover flap skin incision, the temporal muscle was detached en-block and overturned antero-inferiorly conjoined with the frontal myocutaneous flap. A decompressive craniectomy and duraplasty were performed. A polyethylene sheet was added to prevent adherence of the temporal muscle to the dura mater. Results The decompressive craniectomy was effective in all patients. When subsequent cranioplasty was performed, the temporal muscle was easily repositioned. No complications resulted from the en-block temporal muscle detachment or the use of the polyethylene sheet. In 18 patients eligible for clinical and radiological follow-up, excellent (n=4) or good (n=14) esthetic results were detected. Chewing ability is considered normal by all patients. Conclusion Although it requires that the patient undergo two surgical procedures, en-block detachment of the temporal muscle during decompressive craniectomy allows good esthetic and functional results

Lumbar hemorrhagic synovial cysts: diagnosis, pathogenesis, and treatment. Report of 3 cases

To define the etiologic, clinical, histological, and surgical features of lumbar hemorrhagic synovial cysts (LHSCs). Three personal cases are reported together with a review of the pertinent literature. We identified 3 cases of LHSC treated in our departments and 20 cases culled from the literature. A total of 23 cases of LHSC were selected. All the patients underwent surgical treatment because of untreatable radicular pain and/or neurological deficits. The amount of bleeding, either massive or minor but repeated, influenced the timing of surgery. In our cases, the histological examinations showed an inflammatory reaction within the cyst and the consequent formation of neoangiogenic vessels. Hemorrhagic synovial cyst of the spine is rare and its most common localization is lumbar. Bleeding within the cyst leads to an increase of its volume, accompanied by neurological deficits and/or painful symptoms that are violent and generally intractable

Autologous Skull Bone Flap Sterilization after Decompressive Craniectomy: An Update

OBJECTIVE: Preservation of a bone flap is variably performed after decompressive craniectomy. Here, we report new results with ethylene oxide sterilization and new experiences with autogenous bone flaps autoclaved at a high or low temperature. METHODS: We included 45 patients that underwent a decompressive craniectomy. We determined bone flap preservation with ethylene oxide and with high or low temperature autoclave sterilization. RESULTS: The bone flap was repositioned after a mean of 10 weeks in the ethylene oxide group and after 6 weeks in the other sterilization groups. One patient (2%) sustained a bone flap infection, which required removal and subsequent methylmethacrylate cranioplasty. In one child, the bone flap had partially reabsorbed after 12 months. In all other patients, esthetic results were good after an average follow-up of 42 months. At follow-up, computed tomography or magnetic resonance imaging of the bone flap showed preservation of structural features with apparent fusion and revitalization at the bone flap margins. CONCLUSION: We found that ethylene oxide and high or low temperature autoclave bone sterilization techniques were safe, rapid, and inexpensive for the preservation of autologous bone flaps after decompressive craniectomy

Epidemiological Study of 1368 Cases of Surgical Repair for Traumatic Peripheral Nerve Injury.

Traumatic injury of the peripheral nerves should be treated in specialized centres. This study presents the epidemiological data of 1368 consecutive patients operated for peripheral nerve injuries beside the Service of neurosurgery, Department of Neurosciences, UHC "Mother Theresa", Tirana. In order to obtain the necessary data for this study we revised the clinical records, surgical registers and pre, intra and postoperative photo/video of the cases operated for peripheral nervous system injuries. A data recording program of the surgery cases was built ad hoc, categorizing the cases according to several variables. The data collected from the operated cases were manually inserted to be processed by the program. Results of informatics elaboration of the data were obtained, reviewed and categorized by: age, gender, type of trauma, localization of injury and type of nerve repair. Future studies to be conducted in this field will focus in determining the level of nerve injury, time from the injury to intervention, distance from the site of trauma to the effector organ. The data will build necessary information for data mining, which based on these important factors that influence the result of nerve repair, will be useful for the prediction of the result in new patients harbouring peripheral nerve injury before undergoing surgery

Preservation of the temporal muscle during the frontotemporoparietal approach for decompressive craniectomy: Technical note

Background In patients undergoing decompressive craniectomy, resection and detachment of the temporal muscle produces esthetic and functional damage, due to atrophy of the frontal portion of the temporal muscle in the temporal fossa. We have performed en-block temporal muscle detachment in decompressive craniectomy patients to avoid esthetic and functional damage to the temporal muscle. Methods Twenty-one patients underwent decompressive craniectomy using a frontotemporoparietal approach. Through a three-leaf clover flap skin incision, the temporal muscle was detached en-block and overturned antero-inferiorly conjoined with the frontal myocutaneous flap. A decompressive craniectomy and duraplasty were performed. A polyethylene sheet was added to prevent adherence of the temporal muscle to the dura mater. Results The decompressive craniectomy was effective in all patients. When subsequent cranioplasty was performed, the temporal muscle was easily repositioned. No complications resulted from the en-block temporal muscle detachment or the use of the polyethylene sheet. In 18 patients eligible for clinical and radiological follow-up, excellent (n=4) or good (n=14) esthetic results were detected. Chewing ability is considered normal by all patients. Conclusion Although it requires that the patient undergo two surgical procedures, en-block detachment of the temporal muscle during decompressive craniectomy allows good esthetic and functional results