Endoskopsko liječenje unutarmaternično otkrivene multilokularne interhemisferične ciste u novorođenčeta: prikaz slučaja

Interhemispheric cysts, often associated with agenesis of corpus callosum, are rare lesions. The optimal treatment is still controversial. Placement of cystoperitoneal shunt and open microsurgery are traditional treatments. Neuroendoscopy in children is due to its minimal invasiveness a new emerging option. There have been a few published cases on neuroendoscopic treatment of interhemispheric cyst in children. The authors document the youngest reported child with multiloculated interhemispheric cyst that was treated with neuroendoscopy. The cyst was detected in a male fetus in 35th week of gestation and in utero magnetic resonance imaging was performed in 37th week of gestation. After delivery, progressive macrocrania with signs of raised intracranial pressure developed. Endoscopic cystoventriculocisternostomy was performed 28 days after the birth. There was a marked symptom relief. One month after the surgery, magnetic resonance showed shrinkage of the cyst and expansion of the brain parenchyma. After a 2-month follow up period, the child showed normal neurologic development and head circumference increased by only 0.5 cm. The created fenestrations enabled the brain to expand. Neuroendoscopic treatment of interhemispheric cysts should be considered the operative technique of choice in newborns. Although the intracranial pressure and the size of the cyst have decreased, long-term follow up is necessary and future studies on more cases are needed.Interhemisferične ciste, često s pridruženom agenezom korpusa kalozuma, rijetko se pojavljuju. Optimalno liječenje je još uvijek sporno. Cistoperitonealna drenaža i otvoreni mikrokirurški zahvat su tradicionalne metode. Neuroendoskopija u djece je obećavajuća metoda zbog svoje minimalne invazivnosti. Dosad je objavljeno svega nekoliko slučajeva neuroendoskopskog liječenja interhemisferične ciste u djece. U ovom članku su autori opisali slučaj najmlađeg djeteta s multilokularnom interhemisferičnom cistom operiranog neuroendoskopskom tehnikom. Cista je bila otkrivena u muškog fetusa u 35. tjednu trudnoće, a u 37. tjednu je učinjena magnetska rezonancija unutar maternice. Nakon poroda se razvio ubrzan rast glave i znaci povišenog intrakranijskog tlaka. Učinjena je endoskopska cistoventrikulocisternostomija 28. dana nakon poroda i nastupilo je značajno poboljšanje. Mjesec dana nakon zahvata kontrolna magnetska rezonancija je pokazala smanjivanje ciste i širenje tkiva mozga. Nakon dvomjesečnog praćenja utvrđen je normalan neurološki razvoj djeteta, a opseg glave je porastao za samo 0,5 cm. Otvori u membrani ciste su omogućili širenje mozga. Neuroendoskopsko liječenje interhemisferične ciste bi trebalo smatrati metodom izbora u novorođenčadi. Međutim, iako su se intrakranijski tlak i volumen ciste smanjili, potrebna su daljnja istraživanja na većem broju bolesnika i uz dugoročno praćenje

Trans-endoskopska operacija kraniofaringeoma i oporavak vida nakon sljepoće u odrasle bolesnice - prikaz slučaja

We report a case of trans-endoscopic transventricular approach to a large cystic craniopharyngioma. Surgery was performed three days after visual acuity on both eyes deteriorated to blindness. Magnetic resonance imaging before surgery revealed a large lesion in the suprasellar region that severely compressed the optic chiasm and displaced the third ventricle upward. The lesion was operated through the trans-endoscopic transventricular approach, with the aim of urgent decompression of the optic apparatus. At first, wide ventriculo-cysto-cisternostomy was performed, and then tumor tissue was removed. Postoperatively, visual acuity significantly improved on one eye. Our case shows that this minimally invasive technique is safe and effective and can be an alternative treatment for large cystic craniopharyngiomas. The reported case also shows that loss of vision can still be recovered even after the 72-hour period in adults.U radu je prikazana trans-endoskopska operacija velikog cističnog kraniofaringeoma transventrikulskim pristupom. Bolesnica je operirana tri dana nakon što je potpuno oslijepila. Magnetska rezonanca prije operacije je pokazala veliku cističnu leziju u supraselarnoj regiji s izrazitom kompresijom optičke kijazme i treće moždane komore. Učinjena je trans-endoskopska operacija transventrikulskim pristupom s ciljem hitne dekompresije optičkog aparata. Najprije je šupljina ciste povezana sa subarahnoidnim prostorom i trećom moždanom komorom, a nakon toga je odstranjen solidni dio tumora. Nakon zahvata se vid na jednom oku značajno popravio. Ovaj slučaj pokazuje da trans-endoskopska, minimalno invazivna transventrikulska operacija može biti sigurna i učinkovita metoda u liječenju velikih cističnih kraniofaringeoma. Također pokazuje da je oporavak vida u nekim slučajevima moguć i nakon 72 sata potpune sljepoće u odraslog bolesnika

Minimalno invazivno liječenje idiopatske siringomijelije uporabom ventilacijskih T-cjevčica za bubnjić: prikaz slučaja i operativne tehnike

Syringomyelia is characterized by a fluid-filled cavity within the spinal cord. Expansion of the syrinx often results in the clinical course of progressive neurologic deficit. Surgery for syringomyelia generally aims to treat the underlying cause, if it is known. However, little is known about idiopathic syringomyelia, which requires specific management. In our paper, an alternative, minimally invasive treatment option for large symptomatic idiopathic cervicothoracic syrinx is described and discussed. We present a case of a 44-year-old male without a history of spinal cord trauma, infection, or other pathologic processes, who presented for thoracic pain. Due to progressive pain and left leg paresis, magnetic resonance imaging (MRI) was performed and revealed extensive septated syringomyelia from T5 to T7 and hydromyelia cranially. We applied minimally invasive technique for shunting the idiopathic syrinx into the subarachnoid space using two Richards modified myringotomy T-tubes. Postoperative MRI revealed significant decrease in the syrinx size and clinical six-month follow-up showed improvement of clinical symptoms. This minimally invasive treatment of syringomyelia was found to be an effective method for idiopathic septated syrinx, without evident underlying cause. However, long-term follow-up and more patients are necessary for definitive evaluation of this technique.Siringomijeliju predstavlja stvaranje šupljina ispunjenih tekućinom unutar kralježnične moždine. Širenje šupljine često dovodi do pojave neuroloških poremećaja koji se postupno pogoršavaju. Operativno liječenje je usmjereno na otklanjanje uzroka siringomijelije, ako je taj uzrok poznat. Međutim, malo se zna o idiopatskoj siringomijeliji koja zahtijeva poseban tretman. U našem članku opisujemo alternativnu, minimalno invazivnu metodu liječenja velike simptomatske idiopatske vratno-prsne siringomijelije. Prikazujemo slučaj 44-godišnjeg bolesnika bez prethodno poznate ozljede, upale ili drugih bolesti kralježnične moždine, koji se žalio na bolove u prsnoj kralježnici. Zbog pogoršanja bolova i slabosti lijeve noge učinjena je magnetska rezonanca koja je pokazala veliku pregrađenu siringomijeliju u razini od 5. do 7. prsnog kralješka i kranijalno posljedičnu hidromijeliju. Primijenili smo minimalno invazivnu tehniku drenaže sirinksa u subarahnoidni prostor uporabom dviju ventilacijskih cjevčica za bubnjić (Richardsove modificirane T-cjevčice). Snimke nakon operacije su pokazale značajno smanjenje sirinksa, a kontrolni pregled nakon šest mjeseci poboljšanje neuroloških simptoma. Ova minimalno invazivna operacija siringomijelije se pokazala učinkovitom metodom u liječenju idiopatskog, membranom pregrađenog sirinksa nepoznate etiologije. Međutim, za konačnu procjenu ove metode potrebno je duže praćenje i veći broj slučajeva

Microvascular decompression is effective method for treatment of trigeminal neuralgia in elderly patients

Background: The study aimed to determine the possible differences in the effectiveness of microvascular decompression for the treatment of trigeminal neuralgia between patients aged 65 or younger and patients older than 65 years, and to clarify the efficacy and safety of the MVD in elderly patients.Methods: In 40 patients MVD was used for treatment of typical TN. The pain relief immediately and 2 years after MVD for TN in 22 patients aged more than 65 years and in 18 patients younger than 65 years was evaluated and compared between the groups. Other parameters were also compared, such as duration of pain before surgery, operative fitness status, type of vessel (artery or vein) compressing the nerve, length of hospital stay, and complications after the surgery.Results: There was no significant difference in immediate pain relief and pain relief 2 years after MVD between the older and younger patients (P = 0.381, P = 0.185). 2 years after MVD, more pain free patients were found in cases of arterial compression in both groups (P &lt; 0.001). The patients in the younger group showed better operative fitness status (P = 0.027). Length of hospital stay was shorter in younger patients (P &lt; 0.001). There were no fatal outcomes, cranial nerve deficits, or any other permanent neurological deficits in either of the groups.Conclusions: Microvascular decompression is a safe and effective treatment for typical trigeminal neuralgia in elderly patients. This surgical technique is more successful in cases of trigeminal nerve compression by an artery. Physical fitness and not patient age should be a limiting factor for microvascular decompression as the treatment of choice for trigeminal neuralgia.</p

Somatosensory Evoked Potentials in Children with Brain Ventricular Dilatation

Aim: To determine possible nerve conduction changes in the somatosensory pathway in children with brain ventricular dilatation and to estimate the relation between the ventricular size and somatosensory evoked potentials (SEP). Methods: Twelve children with ventricular dilatation (frontal and occipital horn ratios >0.44) and 19 children without ventricular dilatation (control group), aged between 2 and 15 years, were included in the study. Somatosensory evoked responses to median nerve stimulation were recorded in both groups. Evoked potentials were recorded by silver/silver-chloride cup electrodes from Erb’s point in the supraclavicular fossa (wave N9), the cervical spine at the C7 vertebral prominence (wave N13), and the scalp above the contralateral sensory cortex at the point C3’ or C4’, 1 cm behind the C3 or C4 site in the standard 10-20 system (wave N19). Computed tomography scanning was performed to estimate ventricular dilatation. Results: The conduction time of the central somatosensory pathway (N19-N13 interwave latency) was significantly longer in the children with ventricular dilatation than in the control group (P = 0.046). A statistically significant but weak correlation was found between the frontal and occipital horn ratio values and the N19-N13 interwave latencies in the subjects with enlarged ventricles (r = 0.579, P = 0.045) Conclusion: Ventricular dilatation is associated with prolonged conduction of the central part of the somatosensory pathway in children. Early detection and treatment of hydrocephalus could be useful in preventing long-term consequences of high intraventricular pressure

Intracranial Pressure and Biochemical Indicators of Brain Damage: Follow-up Study

Aim: To investigate the relation between metabolic parameters of the brain tissue, as direct indicators of real metabolic conditions within the brain, and intracranial pressure, as the consequence of pathophysiological changes. Methods: Twelve patients with closed head injuries were followed up for 24 hours after injury. A Codman parenchymal intracranial pressure and a Neurotrend electrode were inserted within 3 hours after injury to monitor parenchymal intracranial pressure, brain tissue partial oxygen pressure (PbrO2), brain tissue partial carbon dioxide pressure (PbrCO2), pH, and brain tissue temperature. Data detected at 8-hourly intervals were compared with repeated measures analysis of variance. Results: At the initial observation, the mean value of intracranial pressure was 22.2 ± 3.2 mm Hg. Although it increased at the second and decreased at the third measurement, the differences between the measurements were not significant (P = 0.320). The value of PbrCO2 was increased from the beginning (63.3 ± 6.0 mm Hg), whereas PbrO2 was within the normal range at the first measurement (38.9 ± 6.9 mm Hg), but significantly decreased after 8 hours (P = 0.004), remaining low at later time points. Conclusion: After brain injury, changes in PbrCO2 are visible earlier than those in PbrO2. Improvement in intracranial pressure values did not necessary mean improvement in the brain tissue oxygenation. In addition to intracranial pressure, PbrO2, PbrCO2 and pH should also be monitored, as they directly reflect the real metabolic conditions within brain tissue and may be used in predictions about the outcome and possible therapeutic approaches

Insertion of the subduro-peritoneal drainage in a patient with recurrent bilateral subdural hygroma: a case report

Background: Subdural hygroma is collection of the cerebrospinal-like fluid in the subdural space. It is usually asymptomatic. Sometimes gradual increase is noted which acts tensionally and causes pressure on the brain structures. It this case surgical treatment is necessary which is usually straightforward.Results: In the paper a case of a patient is presented where after craniocerebral injury bilateral symptomatic subdural hygroma developed. He was first treated with insertion of bilateral subdural drainage and then with repeated subdural taps. After both therapeutic measures the hygroma always recurred with worsening of the clinical condition. For permanent resolution of the hygroma an insertion of the subduro-peritoneal drainage was needed. After this operation the patient fully recovered. Two months after the operation he is without problems and the hygroma did not recur.Conclusions: This case report proves that in recurrent subdural hygroma insertion of the subduro-peritoneal drainage is a good treatment option. Unilateral drainage could be beneficial even in bilateral hygroma.</p

Fetal cerebrovascular response to chronic hypoxia - implications for the prevention of brain damage

Fetal hypoxia is one of the leading causes of perinatal morbidity and mortality. One of the most severe sequels of fetal hypoxic insult is the development of perinatal brain lesions resulting in a spectrum of neurological disabilities, from minor cerebral disorders to cerebral palsy. One of the most important fetal adaptive responses to hypoxia is redistribution of blood flow towards the fetal brain, known as the 'brain sparing effect'. The fetal blood flow redistribution in favor of the fetal brain can be detected and quantified by the Doppler cerebral/umbilical ratio (C/U ratio = cerebral resistance index (CRI)/umbilical resistance index (URI)). Our studies on animal models and human fetuses have demonstrated clearly that this phenomenon cannot prevent the development of perinatal brain lesions in the case of severe or prolonged hypoxia. Fetal deterioration in chronic and severe hypoxia is characterized by the disappearance of the physiological cerebral vascular variability (vasoconstriction and vasodilatation), followed by an increase in cerebral vascular resistance. However, our latest study on growth-restricted and hypoxic human fetuses has shown that perinatal brain lesions can develop even before the loss of cerebrovascular variability. The fetal exposure to hypoxia can be quantified by using a new vascular score, the hypoxia index. This parameter, which takes into account the degree as well as duration of fetal hypoxia, can be calculated by summing the daily % C/U ratio reduction from the cut-off value 1 over the period of observation. According to our results, the use of this parameter, which calculates the cumulative, relative oxygen deficit, could allow for the first time the sensitive and reliable prediction and even prevention of adverse neurological outcome in pregnancies complicated by fetal hypoxia