Chiari malformation Type I (CM-I) is a hindbrain disorder associated with elongation of the cerebellar tonsils, which descend below the foramen magnum into the spinal canal. It occurs in children and ...adults. Clinical symptoms mainly develop from alterations in CSF flow at the foramen magnum and the common subsequent development of syringomyelia.
The authors reviewed English-language reports of pediatric, adult, and combined (adult and pediatric) surgical series of patients with CM-I published from 1965 through August 31, 2013, to investigate the following: 1) geographical distribution of reports; 2) demographics of patients; 3) follow-up lengths; 4) study durations; 5) spectrum and frequency of surgical techniques; 6) outcomes for neurological status, syrinx, and headache; 7) frequency and scope of complications; 8) mortality rates; and 9) differences between pediatric and adult populations. Research and inclusion criteria were defined, and all series that contained at least 4 cases and all publications with sufficient data for analysis were included.
The authors identified 145 operative series of patients with CM-I, primarily from the United States and Europe, and divided patient ages into 1 of 3 categories: adult (>18 years of age; 27% of the cases), pediatric (≤18 years of age; 30%), or unknown (43%). Most series (76%) were published in the previous 21 years. The median number of patients in the series was 31. The mean duration of the studies was 10 years, and the mean follow-up time was 43 months. The peak ages of presentation in the pediatric studies were 8 years, followed by 9 years, and in the adult series, 41 years, followed by 46 years. The incidence of syringomyelia was 65%. Most of the studies (99%) reported the use of posterior fossa/foramen magnum decompression. In 92%, the dura was opened, and in 65% of these cases, the arachnoid was opened and dissected; tonsillar resection was performed in 27% of these patients. Postoperatively, syringomyelia improved or resolved in 78% of the patients. Most series (80%) reported postoperative neurological outcomes as follows: 75% improved, 17% showed no change, and 9% experienced worsening. Postoperative headaches improved or resolved in 81% of the patients, with a statistical difference in favor of the pediatric series. Postoperative complications were reported for 41% of the series, most commonly with CSF leak, pseudomeningocele, aseptic meningitis, wound infection, meningitis, and neurological deficit, with a mean complication rate of 4.5%. Complications were reported for 37% of pediatric, 20% of adult, and 43% of combined series. Mortality was reported for 11% of the series. No difference in mortality rates was seen between the pediatric and adult series.
Before undergoing surgical treatment for CM-I, symptomatic patients and their families should be given clear information about the success of treatment and potential complications. Furthermore, surgeons may benefit from comparing published data with their own. In the future, operative CM-I reports should provide all details of each case for the purpose of comparison.
Posterior cranial fossa (PCF) hemangioblastomas are benign, highly vascularized, and well-differentiated tumors with well-described histopathologic features. Although relatively rare, this tumor is ...the most prevalent primary tumor of the cerebellum in adults.
Because the demographics of patients with such a tumor (as well as the clinical, morphologic, pathologic, surgical features, and outcomes) are not fully understood, we systematized characteristic patient and tumor features.
We undertook a systematic review of the English-language literature in PubMed for PCF hemangioblastomas in adults published in the past 31 years. We analyzed geographic distribution and year of publication of articles; demographic data of patients; presenting symptoms and clinical signs; tumor location and morphology; histopathologic features, extent of tumor resection, perioperative blood loss, and postoperative complications; length of hospital stay; and outcomes.
We reviewed 207 articles describing 1759 infratentorial hemangioblastomas in a cohort of 1515 adult patients. We found female predominance in patients with Von Hippel-Lindau disease (VHLD) compared with male predominance in the general patient group. Symptoms of intracranial hypertension were more common in the VHLD group compared with the general group of patients. The cerebellar location was more common in the VHLD group and solid (parenchymatous) tumor was the most common type. Most patients underwent total resection but rate of resection did not differ between the general and VHLD groups. Most patients had a favorable outcome.
The literature of adult PCF hemangioblastomas is limited and general surgical experience with such tumors is scarce because of their rarity. Rates of postoperative complications and mortality remain higher than expected. However, prognosis and surgical outcomes are generally favorable. Nevertheless, surgery of adult PCF hemangioblastomas is a demanding and challenging task.
Penetrating traumatic brain injury accompanied by perforating ocular injury caused by low-velocity foreign bodies is a life-threatening condition, a surgical emergency and a major challenge in ...surgical practice, representing a severe subtype of non-missile traumatic brain injury, which is a relatively rare pathology among civilians. Optimal management of such an injury remains controversial, requiring full understanding of its pathophysiology and a multidisciplinary expert approach. Herein, we report a case of penetrating brain and associated perforating eye injury and discuss relevant literature providing further insight into this demanding complex multi-organ injury. We present a case of 39-year-old male patient with transorbital penetrating brain and perforating ocular injury undergoing emergency surgery to remove a retained sharp metallic object from the left parietal lobe. Following appropriate and urgent diagnostics, a decompressive left-sided fronto-temporo-parietal craniectomy was immediately performed. A retained sharp metallic object (a slice of a round saw) was successfully removed, while primary left globe repair and palpebral and fornix reconstruction were performed afterwards by an ophthalmologist. A prophylactic administration of broad-spectrum antibiotics was applied to prevent infectious complications. Early postoperative recovery was uneventful. The patient was discharged on day 45 post-injury having moderate right-sided motor weakness, ipsilateral facial nerve central palsy, and light motoric dysphasia. The vision to his left eye was completely and permanently lost. In conclusion, management of non-missile transorbital penetrating brain injury can be satisfactory when proper clinical and radiologic evaluation, and amply, less radical surgical approach is performed early. A multidisciplinary routine is a prerequisite in achieving a favorable management outcome.
Microsurgical clipping and endovascular coiling are both effective management modalities for intracranial aneurysms, whereas recent procedures are mainly directed towards endovascular treatment ...because of its minimally invasive nature. However, such a treatment has been associated with a bigger risk of recurrent aneurysmal growth and re-bleeding urging a selection of optimal strategies to overcome these hazards. It seems that the most appropriate method of choice is microsurgical clipping, which is much more technically challenging due to recurrent aneurysm demanding configuration created by the initial coiling. Herein, we present an illustrative institutional case series of recurrent intracranial aneurysms following endovascular treatment, and discuss the controversies and benefits of their subsequent microsurgical management, based on our experience and on literature review. Considering the results reported in this paper, it seems that careful selective microsurgical neck clipping with/without aneurysmal sac resection and coil extraction remains the preferred management option for recurrent intracranial aneurysms, resulting in high obliteration rates, long-term occlusion stability, and low morbidity/mortality. In conclusion, to bring a satisfactory outcome, the multidisciplinary management of recurrent intracranial aneurysms after endovascular treatment should be adjusted to aneurysm morphology/size/location, and individualized according to patient needs.
Intracranial germ cell tumors are rare brain tumors that are distinguished based on their histology and selected tumor markers. Non-germinomatous germ cell tumors are a diverse group of such tumors ...having the poorest prognosis. Most commonly, they are located in the suprasellar and pineal regions. Since the exact treatment protocol has not yet been established, there is currently no standardized modality of management. We present a case of intracranial multifocal non-germinomatous germ cell tumor in an 18-year-old male, along with relevant literature review. We describe initial diagnostic and treatment procedures in a young adult presented with diplopia and ataxic gait. Neuroradiological findings and elevated alpha fetoprotein and beta chain of the human chorionic gonadotropin tumor markers indicated the possible mixed germ cell tumor. Chemotherapy regimen was adjusted accordingly, biopsy was not performed. The patient's clinical condition improved significantly and his alpha fetoprotein values decreased remarkably after initiation of chemotherapy. In conclusion, initial evaluation with neuroimaging, tumor markers, and cytology from cerebrospinal fluid is important as guidance to further treatment and prognosis. In selected cases, biopsy may not be indicated to start adjuvant chemotherapy. We emphasize the importance of specific treatment modality selection based mainly on tumor markers, regardless of the precise histologic classification.
Parental socioeconomic status is a multidimensional concept of special importance for the growth, development, health outcomes and education of children. Its definition generally refers to the amount ...of parents' income, their employment status and level of education. Hence, lack of economic resources and poverty of parents affect all aspects of the child's life, health outcomes and education, as well as his/her social inclusion. Accordingly, the consequences of a reduced parental socioeconomic status leave long-term effects on their children. Therefore, in order to create interventional programs for children of parents with low income and lower socioeconomic status, as well as with lower level of education, it is important to address the direct aspects of poverty. This review contributes to the evidence indicating that the parental socioeconomic status is highly influential in determining the child's physical and mental health and future outcomes including his/her academic achievements and education, as well as the parameters of his/her physical abilities, cognitive function and fundamental neurobiology affecting brain development.
Robot-assisted brain tumor biopsy is becoming one of the most important innovative technologies in neurosurgical practice. The idea behind its engagement is to advance the safety and efficacy of the ...biopsy procedure, which is much in demand when planning the management of endocranial tumor pathology. Herein, we provide our earliest institutional experiences in utilizing this mesmerizing technology. Cranial robotic device was employed for stereotactic robot-assisted brain glioma biopsy in three consecutive patients from our series: an anaplastic isocitrate dehydrogenase (IDH) negative astrocytoma (WHO grade III) located in the right trigone region of the periventricular white matter; a low grade diffuse astrocytoma (WHO grade II) of bilateral thalamic region spreading into the right mesencephalic area; and an IDH-wildtype glioblastoma (WHO grade IV) of the right frontal lobe producing a contralateral midline shifting. Robot-assisted tumor biopsy was successfully performed to get tissue samples for histopathologic and immunohistochemical analysis. The adjacent tissue iatrogenic damage of the eloquent cortical areas was minimal, while the immediate postoperative recovery was satisfactory in all patients. In conclusion, considering the preliminary results of our early experiences, robot-assisted tumor biopsy was proven to be a feasible and accurate procedure when surgery for brain glioma was not an option. It may increase safety and precision, without expanding surgical time, being similarly effective when compared to standard stereotactic and manual biopsy. Using this method to provide accurate sampling for histopathologic and immunohistochemical analysis is a safe and easy way to determine management strategies and outcome of different types of brain glioma. Key words: Neurosurgery; Brain glioma; Robotics; Stereotactic biopsy
Aim To evaluate the influence of preoperative symptoms duration on surgical outcome of one-level lumbar disc herniation surgery. Methods In a prospective randomized study, 67 adult patients with ...one-level lumbar disc herniation were analysed. The patients whose duration of symptoms was <6 months were included in the case group, while those with the duration of symptoms ˃6 months formed the control group. The investigated preoperative variables were: pain intensity in the back and legs (Visual Analogue Scale - VAS), Sciatica Bothersomeness Index (SBI), index of disability (Oswestry Disability Index - ODI). Postoperative variables were: pain intensity in the back and legs (VAS), SBI, ODI, and outcome according to the Odom’s criteria (excellent, good, satisfactory and poor). Significance level was set at p <0.05. Results A statistically significant difference was recorded between the groups, showing a better decrease of radicular pain intensity and sciatica bothersome, as well as patients disability in the case group (p<0.001). According to the Odom’s criteria the outcome was better in the case group, since the difference between the groups was statistically significant too (p<0.05). Conclusion Early lumbar disc herniation surgery performed within the first 6 months from the start of symptoms is beneficial due to decreases of radicular pain intensity, sciatica bothersomeness, and patient’s disability.
The suboccipital ligament Alabaster, Kelsey; Fred Bugg, M; Splavski, Bruno ...
Journal of neurosurgery,
01/2018, Letnik:
128, Številka:
1
Journal Article
Recenzirano
OBJECTIVE A fibrous structure located dorsal to the dura at the posterior craniocervical junction stretches horizontally between the bilateral occipital condyles and the upper borders of the C-1 ...laminae. Partially covered by the occipital bone, this structure is always encountered when the bone is removed from the foramen magnum rim during approaches to the posterior cranial fossa. Although known to surgeons, this structure has not been defined, studied, or named. The most appropriate name for this structure is "the suboccipital ligament," and a detailed rationale for this name is provided. METHODS This 3-year-long study included 10 cadaveric specimens and 39 clinical patients: 31 consecutive surgically treated patients with Chiari Type I malformations (CM-I subgroup) and 8 other patients with posterior fossa pathologies (non-CM-I subgroup). The dimensions were defined, the function of this ligament was hypothesized, size and histological composition were compared between patient subgroups, and its origin and relationship to the surrounding structures were analyzed. Possible statistical differences in the parameters between the 2 groups were also evaluated. RESULTS The suboccipital ligament consists of horizontally oriented hyaline fibers and has a median length of 35 mm, height of 10 mm, and thickness of 0.5 mm. These dimensions are not significantly different between the CM-I and non-CM-I patients. The median age of the patients was 43 years, with CM-I patients being significantly younger (median 35 years) than non-CM-I patients (median 57 years). There was no statistically significant difference in weight, height, and body mass index between patient subgroups. There was no significant correlation between the body mass index or height of the patients and the dimensions of the ligament. No statistically significant differences existed between the subgroups in terms of smoking history, alcohol consumption, and the presence of diabetes mellitus, hypertension, hydrocephalus, or headaches. The ligament tissue in the CM-I patients was disorganized with poorly arranged collagen bands and interspersed adipose tissue. These patients also had more hyalinized fibrosis and showed changes in the direction of fibers, with hyaline nodules ranging from 0 to 2+. The result of the histological evaluation of the suboccipital ligament for hyaline nodules, calcification, and ossification was graded as 2+ if present in 3 or more medium-power magnification fields (MPFs); 1+ if present in 1-2 MPFs; and 0, if present in less than 1 MPF. Histological examination of the ligaments showed structural differences between CM-I and non-CM-I patients, most notably the presence of hyaline nodules and an altered fiber orientation in CM-I patients. CONCLUSIONS The suboccipital ligament extends between the occipital condyle and the superior edge of the C-1 lamina, connecting the contralateral sides, and appears to function as a real ligament. It is ventral to the occipital bone, which covers approximately two-thirds of the height of the ligament and is loosely attached to the dura medially and more firmly laterally. Because of its distinctive anatomy, characteristics, and function, the suboccipital ligament deserves its own uniform designation and name.
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