Oponiak zatoki strzałkowej górnej z towarzyszącymi obustronnymi przewlekłymi krwiakami podtwardówkowymi – opis przypadku i studium patofizjologiczne

Bilateral chronic subdural haemorrhage accompanying meningioma is a very rare clinical condition. We present a case of a 69-year-old female patient with large meningioma completely obliterating the posterior third part of the superior sagittal sinus with accompanying bilateral chronic subdural haematomas. Three anatomical zones of venous collateral circulation were revealed by the preoperative digital subtraction angiography. The tumour and haematomas were removed completely with no major complications. The most likely pathomechanism of the development of bilateral chronic subdural haematomas was venous hypertension caused by an occlusion of major cerebral venous trunks. As a result of a minor thrombotic incident or insignificant head injury, the distended veins of collateral circulation that were volumetrically burdened could have been damaged. Patients with large tumours occluding the superior sagittal sinus, who did not qualify for or refused surgery, should be carefully monitored clinically and neuroradiologically because of possibly increased risk of an intracranial haemorrhage.Przewlekłe krwawienie podtwardówkowe towarzyszące oponiakowi wewnątrzczaszkowemu jest stwierdzane niezwykle rzadko. W pracy zaprezentowano przypadek 69-letniej pacjentki, bez istotnej przeszłości chorobowej, u której stwierdzono olbrzymi oponiak sklepistości czaszki całkowicie zarastający światło tylnej jednej trzeciej zatoki strzałkowej górnej współistniejący z obustronnymi mnogimi przewlekłymi krwiakami podtwardówkowymi. Przedoperacyjna cyfrowa angiografia subtrakcyjna wykazała obecność trzech stref krążenia obocznego kompensującego niedrożność zatoki strzałkowej górnej. Guz oraz przewlekłe krwiaki podtwardówkowe usunięto doszczętnie, przebieg pooperacyjny był pomyślny. Jedną z opisywanych przyczyn powstawania przewlekłych krwiaków podtwardówkowych w przypadkach powolnego zamknięcia dużych żył mózgowych jest pękanie przeciążonych objętościowo naczyń krążenia obocznego. Opisywany przypadek to prawdopodobnie pierwszy dobrze udokumentowany przykład potwierdzający słuszność tej tezy. Pacjenci z guzami zamykającymi światło zatoki strzałkowej górnej, którzy nie są poddawani leczeniu operacyjnemu, powinni być monitorowani klinicznie i radiologicznie ze względu na zwiększone ryzyko krwawienia wewnątrzczaszkowego

Three-dimensional Collagen Scaffolds in Cultures of Olfactory Ensheathing Cells Used for Severed Spinal Cord Regeneration

BACKGROUND/AIM: The regeneration of a completely damaged spinal cord is still a challenge in modern medicine. A promising treatment method is autologous transplantation of olfactory ensheathing cells (OECs). This study aimed primarily to test methods of culturing OECs with the use of materials and reagents that are certified for pharmaceutical use in the production of an advanced cell therapy product intended for humans. MATERIALS AND METHODS: The culture of OECs was performed using various modifications of the surface of the culture vessels (with fibronectin and poly-D-lysine). The number of cells was assessed after immunofluorescence staining using anti-fibronectin and anti-p75 NGF receptor antibodies. The study compared, in terms of surgical manipulations, scaffolds with OECs prepared based on 3 types of collagen: Acid Solubilized Telo Collagen and Pepsin Solubilized Atelocollagen, and the popular Corning collagen. RESULTS: We have shown that when suspending OECs in collagen gel, it is much better to use acid-solubilized collagen (ASC) than pepsin-solubilized collagen (PSC) because the 3D collagen scaffold from ASC provides much easier handling of the product during a surgical procedure. We also found that the OEC cultures should be grown on the surface modified with fibronectin. Furthermore, we have also shown that the optimal concentration of fetal bovine serum (FBS) for culturing these cells should be around 10%. CONCLUSION: The culture of OECs based on reagents intended for human use can be successfully carried out, obtaining sufficient OECs content in the heterogeneous cell culture to produce a functional advanced therapy medicinal product

Baroreflex sensitivity and heart rate variability are predictors of mortality in patients with aneurysmal subarachnoid haemorrhage.

OBJECT: We aimed to investigate the link between the autonomic nervous system (ANS) impairment, assessed using baroreflex sensitivity (BRS) and heart rate variability (HRV) indices, and mortality after aneurysmal subarachnoid haemorrhage (aSAH). METHODS: A total of 57 patients (56 ± 18 years) diagnosed with aSAH were retrospectively enrolled in the study, where 25% of patients died in the hospital. BRS was calculated using a modified cross-correlation method. Time- and frequency-domain HRV indices were calculated from a time-series of systolic peak intervals of arterial blood pressure signals. Additionally, cerebral autoregulation (CA) was assessed using the mean velocity index (Mxa), where Mxa > 0 indicates impaired CA. RESULTS: Both BRS and HRV indices were lower in non-survivors than in survivors. The patients with disturbed BRS and HRV had more extensive haemorrhage in the H-H scale (p = .040) and were more likely to die (p = .013) when compared to patients with the intact ANS. The logistic regression model for mortality included: the APACHE II score (p = .002; OR 0.794) and the normalised high frequency power of the HRV (p < <.001; OR 0.636). A positive relationship was found between the Mxa and BRS (R = 0.48, p = .003), which suggests that increasing BRS is moderately strongly associated with worsening CA. CONCLUSION: Our results indicated that lower values of HRV indices and BRS correlate with mortality and that there is a link between cerebral dysautoregulation and the analysed estimates of the ANS in aSAH patients

Various neuromodulation methods including Deep Brain Stimulation of the medial forebrain bundle combined with psychopharmacotherapy of treatment-resistant depression—Case report

BackgroundTreatment-resistant depression remains one of the main concerns of modern psychiatry. Novel methods such as Transcranial Magnetic Stimulation (including deep and theta burst protocols, iTBS) and Deep Brain Stimulation (DBS) can be considered as alternative treatment options.Case presentationTwenty-nine-year-old Caucasian female, single, higher-educated was treated with major depressive disorder initially with standard pharmaco- and psychotherapy. Due to diagnosed treatment resistance additional therapeutic approaches were introduced sequentially: Electroconvulsive therapy (efficient only 4 months) and Transcranial Magnetic Stimulation (intermittent Theta Burst Stimulation, iTBS improved just insomnia). Finally the patient was enrolled to the Deep Brain Stimulation (DBS) study with the medial forebrain bundle target. After 20 months of active DBS a reduction of over 80% of depressive symptom severity was observed (Montgomery-Asberg and Hamilton Depression Rating Scales), together with an 87% reduction of anxiety symptoms intensity (Hamilton Anxiety Rating Scale) and a 90% increase in social and occupational functioning. Subjective assessment of the patient performed with questionnaires and visual analog scales showed less pronounced improvement in terms of depressive and anxiety symptoms, and high reduction of anhedonia. Some mild, transient side effects of neurostimulation were eliminated with an adjustment in stimulation parameters.ConclusionsThe presented clinical case confirms the possibility of achieving remission after the use of MFB DBS in treatment-resistant depression, but postponed for many months. Nevertheless, personalization of every combined therapy with DBS is necessary with exploration of individual factors as past traumas and personality traits. More reports on long-term observations in DBS treatment in TRD trials (especially focused on MFB target) are needed

Stereotaktyczne biopsje guzów wewnątrzczaszkowych z zastosowaniem rezonansu śródoperacyjnego

Background and purpose We present our early experience in intraoperative magnetic resonance (iMRI)-guided stereotactic frameless biopsies with special regard to its safety, efficacy and diagnostic value. Material and methods The records of patients who underwent frameless stereotactic iMRI-guided biopsies between June 2009 and April 2011 were analysed prospectively. All the operations were performed under local anaesthesia, with the use of a passive side-cutting biopsy needle. The needle was introduced into the pathological lesion with the help of optic neuronavigation system guidance. The iMRI scans served as reference images. We analysed the patients’ demographic and epidemiological data, the preparation and surgery times, diagnostic values of collected specimens, lengths of the hospital stay (LOS) and the complication rate. Results Fifteen iMRI-guided stereotactic biopsies were performed in the analysed period. The mean patient age was 52 ± 18 yrs, the median WHO score was 2 (range: 1–3), there were 9 (60%) males in the study group. The average preparation time was 53 ± 24 minutes and the operation time 69 ± 25 minutes. No major complications were noted. The median total length of hospital stay was 5 days. The histopathological diagnoses were as follows: glioblastoma multiforme – 6 cases, low-grade gliomas – 4 cases, lymphomas – 3 cases, and other pathologies – 2 cases. In all the cases biopsy material allowed specified histopathological diagnoses to be obtained. Conclusions Frameless stereotactic iMRI-guided brain tumour biopsy is a safe and diagnostically effective procedure. The use of iMRI might increase the diagnostic value and safety of stereotactic biopsy and positively influence its economic balance.Wstęp i cel pracy W pracy przedstawiono doświadczenia własne z zastosowania niskopolowego śródoperacyjnego rezonansu magnetycznego (iMRI) w biopsjach stereotaktycznych guzów mózgu. Celem pracy było przedstawienie techniki operacji oraz analiza bezpieczeństwa i skuteczności diagnostycznej procedury. Materiał i metody Analizie poddano dane pacjentów, u których w okresie od czerwca 2009 r. do kwietnia 2011 r. wykona no bezramowe stereotaktyczne biopsje patologii wewnątrzczaszkowych. Operacje wykonywano drogą otworu trepanacyjnego z wykorzystaniem pasywnej igły biopsyjnej z bocznym oknem tnącym. Igłę wprowadzano w obręb zmiany patologicznej według wskazań systemu neuronawigacji optycznej, opartych na skanach iMRI. Prospektywnej ocenie poddano dane demograficzne i epidemiologiczne, czas przygotowań i czas operacji, wartość diagnostyczną pobranego materiału, częstość powikłań oraz długość hospitalizacji. Wyniki W analizowanym okresie wykonano 15 biopsji stereotaktycznych z wykorzystaniem iMRI. Średni wiek pacjentów wynosił 52 ± 18 lat, mediana WHO – 2, mężczyźni stanowili 60% operowanych. Średni czas przygotowań do operacji wynosił 53 ± 24 min, średni czas operacji 69 ± 25 min. W ocenianej grupie pacjentów nie stwierdzono powikłań neurologicznych, krwotocznych i infekcyjnych. Średni czas hospitalizacji wynosił 5 dób. W badaniach histopatologicznych stwierdzono: 6 glejaków nisko zróżnicowanych, 4 glejaki wysoko zróżnicowane, 3 chłoniaki oraz 2 inne patologie. Wnioski Stereotaktyczne biopsje guzów mózgu z wykorzystaniem iMRI mogą być tak samo bezpieczne jak wykonywane w sposób klasyczny. Zastosowanie iMRI może zwiększyć ich skuteczność diagnostyczną oraz wpływać pozytywnie na bilans ekonomiczny procedury

Prospektywna ocena przydatności niskopolowego śródoperacyjnego rezonansu magnetycznego w operacjach) neurochirurgicznych

Background and purpose The application of intraoperative magnetic resonance imaging (iMRI) is related to a series of challenges of both a technical and an organizational nature. We present our experience in the application of low-field iMRI in everyday neurosurgical practice. Material and methods A group of 58 patients operated on using low-field iMRI was subject to prospective controlled observation. The significance of differences in the range of preparation time, duration and direct operation results between the iMRI group and controls was analysed. The influence of epidemiological and demographic factors and technical aspects related to iMRI application on direct outcome of the surgery was assessed. Results Twenty-eight tumour resections using craniotomy, 17 transsphenoidal resections of pituitary adenomas and 13 stereotactic procedures were conducted in the group of 24 men and 34 women operated on using iMRI. The control group was not significantly different in terms of epidemiological and demographic factors. The preparation and operation times were significantly longer in the iMRI group (p &lt; 0.001 and p = 0.002, respectively). Longer duration of the surgery was not related to an increased frequency of complications. A higher percentage of postoperative improvement in neurological status (31% vs. 14%, p = 0.045), lower complication percentage (10% vs. 28%, p = 0.03) and a similar time of hospitalization (13 ± 7 vs. 12 ± 4 days, p = 0.33) were noted in the iMRI group. Conclusions The application of low-field iMRI prolongs the duration of neurosurgical procedures but does not negatively influence their safety. It is associated with above-average functional results and a lower percentage of total complications.Wstęp i cel pracy W pracy przedstawiono pierwsze doświadczenia w wykorzystaniu śródoperacyjnego niskopolowego rezonansu magnetycznego (iMRI) w codziennej praktyce neurochirurgicznej, z uwzględnieniem wyników prospektywnej obserwacji wpływu jego zastosowania na bezpośrednie wyniki operacji. Materiał i metody Prospektywnej kontrolowanej obserwacji poddano grupę 58 pacjentów operowanych z wykorzystaniem iMRI. Grupę kontrolną stanowili pacjenci operowani z wykorzystaniem neuronawigacji optycznej bez zastosowania iMRI. Zbadano istotność różnic w zakresie czasu przygotowań, czasu trwania i bezpośrednich wyników operacji pomiędzy grupą badaną i grupą kontrolną. Oceniano wpływ czynników epidemiologicznych, demograficznych oraz aspektów technicznych związanych z zastosowaniem iMRI na bezpośredni wynik operacji. Wyniki W grupie 24 mężczyzn i 34 kobiet operowanych z wykorzystaniem iMRI wykonano 28 resekcji guzów mózgu drogą kraniotomii, 17 przezklinowych resekcji gruczolaków przysadki i 13 procedur stereotaktycznych. Czas przygotowań i czas operacji były istotnie dłuższe w grupie iMRI (odpowiedniop &lt; 0,001 i p = 0,002). Wydłużenie czasu trwania procedury nie było związane ze wzrostem częstości powikłań. W grupie operowanej z wykorzystaniem iMRI stwierdzono większy odsetek osób z pooperacyjną poprawą stanu neurologicznego (31% vs 14%, p = 0,045), mniejszy odsetek powikłań (10% vs 28%, p = 0,03) oraz zbliżony czas hospitalizacji (13 ± 7 vs 12 ± 4 dni, p = 0,33). Wnioski Zastosowanie niskopolowego iMRI, choć wydłuża czas procedur neurochirurgicznych, nie wpływa negatywnie na ich bezpieczeństwo. Pozwala przy tym uzyskać lepsze od przeciętnych wyniki funkcjonalne oraz mniejszy globalny odsetek powikłań

Serum biomarkers and cerebral autoregulation as early warnings of delayed cerebral ischemia risk in patients after aneurysmal subarachnoid haemorrhage.

BACKGROUND Identifying patients at risk of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid haemorrhage (aSAH) remains challenging. This study aimed to evaluate the concentration of serum biomarkers along with cerebral autoregulation impairment on DCI. METHODS 55 patients suffering from aSAH were enrolled in the study. Serum S100protein B (S100B) was tested both on the day of admission and over three consecutive days following the occurrence of aSAH. Cerebral autoregulation was assessed using a tissue oxygenation index (TOxa) based on near-infrared spectroscopy. RESULTS Changes in serum S100B levels interacted with DCI status (presence vs. absence): F = 3.84, p = 0.016. Patients with DCI had higher S100B concentration level on day 3 than those without DCI (3.54 ± 0.50 ng/ml vs. 0.58 ± 0.43 ng/ml, p = 0.001). S100B concentration on day 3 following aSAH predicted DCI (AUC = 0.77, p = 0.006). Raised level of serum S100B on day 3 was related with higher TOxa, thus with impaired cerebral autoregulation (r = 0.52,p = 0.031). Multivariate logistic regression analysis showed thatimpaired cerebral autoregulation andelevatedS100B concentration on day 3 increasethe likelihood of DCI. CONCLUSIONS Tracking changes in the serum biomarkers concentration along with monitoring of cerebral autoregulation, may play a role in early detection of patients at risk of DCI after aSAH. These results need to be validated in larger prospective cohorts

The Long-Term Effect of Treatment Using the Transcranial Magnetic Stimulation rTMS in Patients after Incomplete Cervical or Thoracic Spinal Cord Injury

Repetitive transcranial magnetic stimulation (rTMS) may support motor function recovery in patients with incomplete spinal cord injury (iSCI). Its effectiveness mainly depends on the applied algorithm. This clinical and neurophysiological study aimed to assess the effectiveness of high-frequency rTMS in iSCI patients at the C2–Th12 levels. rTMS sessions (lasting 3–5 per month, from 2 to 11 months, 5 months on average) were applied to 26 iSCI subjects. The motor cortex was bilaterally stimulated with a frequency at 20–25 Hz and a stimulus strength that was 70–80% of the resting motor threshold (15.4–45.5% maximal output) during one therapeutic session. Surface electromyography (sEMG) recordings at rest and during maximal contractions and motor evoked potential (MEP) recordings were performed from the abductor pollicis brevis (APB) and the tibialis anterior (TA) muscles. The same neurophysiological studies were also performed in patients treated with kinesiotherapy only (K group, n = 25) and compared with patients treated with both kinesiotherapy and rTMS (K + rTMS). A decrease in sEMG amplitudes recorded at rest from the APB muscles (p = 0.001) and an increase in sEMG amplitudes during the maximal contraction of the APB (p = 0.001) and TA (p = 0.009) muscles were found in the K + rTMS group. A comparison of data from MEP studies recorded from both APB and TA muscles showed significant changes in the mean amplitudes but not in latencies, suggesting a slight improvement in the transmission of spinal efferent pathways from the motor cortex to the lower spinal centers. The application of rTMS at 20–25 Hz reduced spasticity in the upper extremity muscles, improved the recruitment of motor units in the upper and lower extremity muscles, and slightly improved the transmission of efferent neural impulses within the spinal pathways in patients with C2–Th12 iSCI. Neurophysiological recordings produced significantly better parameters in the K + rTMS group of patients after therapy. These results may support the hypothesis about the importance of rTMS therapy and possible involvement of the residual efferent pathways including propriospinal neurons in the recovery of the motor control of iSCI patients