The Mini-Spheno-Supraorbital Craniotomy for Treatment of Ruptured Anterior Circulation Aneurysms.

Objective:Yasargil introduced the pterional approach mainly for clipping of anterior circulation (AC) aneurysms. We implemented the mini-spheno-supraorbital (MSS) craniotomy, changing the shape and reducing the size of the classical pterional craniotomy. The literature on clipping ruptured AC aneurysms through reduced-in-size craniotomies is sparse. This study aims to describe the technique and present our experience in clipping ruptured AC aneurysms through the MSS approach. Materials and methods: The MSS craniotomy was used in 114 cases of clipping ruptured AC aneurysms. A single burr hole was placed at the "keyhole" and an ellipsoid bone flap in the spheno-supraorbital region was raised. The tabula interna was thinned circumferentially, the roof of the orbit was flattened. Among aneurysm clipping, the lamina terminalis and the subarachnoid basal cisterns were opened. The imaging modality, the severity of the subarachnoid hemorrhage (SAH) according to Hunt & Hess (H&H), the size of the bone flap, the surgery duration and the aneurysm obliteration rate seen at the postoperative DSA were examined. Results:Out of all patients in the study, 71% had exclusively CT-angiogram as initial imaging and suffered low-grade (H&H I°) SAH (71%). The mean size of the bone flap was 1.6 x 4.5 cm (1.3 x 4.3 - 2 x 8.5 cm). The approach allowed adequate 360°-dissection, sufficient proximal and distal control, brain relaxation though laminoterminotomy and opening of the basal cisterns. The mean duration from skin incision to clip application was 130 minutes (64-236 mins). Total obliteration rate was 97.3%. Conclusion:The MSS craniotomy is feasible in terms of safety and speed for clipping of ruptured AC aneurysms especially in lower-grade SAH.

Purely cystic meningioma: Case report and systematic review of the literature.

Meningiomas are the most common benign intracranial tumors. They are generally asymptomatic, and discovered incidentally during cerebral imaging. The vast majority of meningiomas are solid, highly cellular and well-vascularized neoplasms. However, in several cases, they can be partially or, even rarely, almost completely cystic making their differential diagnosis and management challenging. In this paper, we present the rare case of a 59-year-old female patient, presenting with persistent headaches, who was diagnosed with a left parieto-occipital purely cystic lesion. The patient underwent a complete resection of this cystic lesion because of increasing headaches and volumetric progression. Interestingly, the histological assessment confirmed a cystic WHO grade I meningioma. The evolution was favorable and there was no recurrence after 3 years of follow-up. We also perform a systematic review of the literature concerning purely cystic meningiomas and we discuss the particular histological features of cystic meningiomas as well as the possible pathogenesis. This challenging clinical entity can easily be misdiagnosed as hemangioblastoma or glial/metastatic tumor with cystic component.

The evaluation of the usefulness of CO2 laser in microsurgical resection of brain tumors.

Background: Since its introduction to surgery, the CO2 laser has been used in the treatment of various neurosurgical pathologies as it combines cutting, vaporizing, and coagulating properties in one tool and has a safe penetration depth. In this case series of 29 patients, we present the evaluation of the usefulness of the closed system type - sealed tube surgical CO2 laser in the surgical removal of brain tumors. Methods: The Sharplan 40C model SurgiTouch, sealed tube type CO2 laser, was used in the resection of 29 brain tumors; 13 meningiomas, six metastases, nine gliomas, and one acoustic neuroma. The same senior surgeon (BT) assessed and classified the benefit provided by the CO2 laser in the resection of the neoplasms to considerable (Group 1), moderate (Group 2), and poor (Group 3). Results: Group 1 included 14 patients with 13 meningiomas and one acoustic neuroma, Group 2 included six patients, all of whom had metastases, and Group 3 included nine patients of which six had glioblastoma and three astrocytoma. No complications or technical problems occurred due to the use of the CO2 laser. Conclusion: The CO2 laser is a valuable complementary tool in brain tumor surgery displaying high efficacy and practicality in the resection of neoplasms which are fibrous and have hard consistency. It has high acquisition and maintenance cost and cannot replace the bipolar diathermy. The newest generation of flexible CO2 laser fiber provides more ergonomy and promises new perspectives of its neurosurgical use in the modern era.

Healing of colonic anastomosis in rats under obstructive ileus conditions.

BACKGROUND: The anastomosis leak in colon resections is a crucial post-operative complication with significant morbidity and mortality.  Methods: Forty (40) Wistar rats were allocated in two groups. In SHAM group only anastomosis was performed. In ILEUS group anastomosis was performed following one day of ileus. Animals in both groups were subdivided in two groups according to the day they were sacrificed, 4th or 8th post-operative day. A number of variables between the groups were estimated. RESULTS: Body weight loss was higher following obstructive ileus on both days. Adhesion score in 4th and 8th post-operative day was higher in ILEUS1, ILEUS2 groups compared to SHAM1, SHAM2 groups respectively (p<0.001 for both). Neovascularization decreased following obstructive ileus compared to control on the 4th day (ILEUS1 vs. SHAM1, p=0.038). Bursting pressure was lower in ILEUS2 group than SHAM2 group (p<0.001). The number of fibroblasts decreased following obstructive ileus compared to control on the 4th and 8th day (ILEUS1 vs. SHAM1, p=0.001, ILEUS2 vs SHAM2, p=0.016). Hydroxyproline concentration was decreased in ILEUS2 group compared to SHAM2 group (p<0.001). CONCLUSIONS: The balance of collagenolysis and collagenogenesis plays a decisive role in the healing of anastomoses following bowel obstruction. Under those circumstances, anastomosis' bursting pressure is reduced owning to decreased neovascularization, reduced fibroblast presence and lower hydroxyproline concertation. In our study, local inflammation, neocollagen concentration and collagenase activity were not associated with this adverse effect. However, further research should delineate the mechanisms of healing of colonic anastomoses and identify those factors that can improve our outcomes.

Vertigo: Could this Symptom Indicate the Existence of an Unruptured Intracranial Aneurysm?

Background:Unruptured intracranial aneurysms (UIAs) can be presented with various symptoms, including atypical headaches and cranial nerve deficits. Vertigo is often referred in the literature as a coexisting symptom. Our aim was to investigate the importance of vertigo in the UIA symptomatology and present a possible explanation for its existence. Methods:We conducted a retrospective observational multicenter study concerning patients with surgically treated intracranial aneurysms. During a period of 10 years, 1 085 patients with cerebral aneurysms underwent surgery. There were 812 patients with ruptured intracranial aneurysms (RIA) and 273 with UIA. The medical records for each of the 273 patients were analyzed. Results: After the implementation of exclusion criteria, 89 (32.6%) of UIA patients were selected in the study, from which 71 (79.8%) were females and 18 (20.2%) males. The mean age was 56.9 (± 12.876) years old. Vertigo existed in 72 (80.9%), headache in 41 (46.1%) and visual symptoms in 21 (23.6%) patients. No significant correlation (p >0.05) was demonstrated between gender, age or aneurysm location in correlation with vertigo, headache or visual symptoms, apart from a negative significant correlation between age and vertigo (p=0.031). Conclusion:Vertigo is an alarming symptom that could indicate the existence of an UIA. The pathophysiological mechanism could be explained by the formation of an aneurysmal vortex that projects into the parent artery, leading to disturbances in the laminar flow and formation of an irregular/turbulent flow, which potentially affects the cerebral autoregulation and by consequence, the central processing of movement.

The Use of Real-Time 3D Intraoperative Ultrasound "Angiography" in Localization and Occlusion Control of a Ruptured Mycotic Aneurysm: A Case Report.

BACKGROUND: Infectious (mycotic) aneurysms are rare with high mortality and are most commonly found at the distal branches of the middle cerebral artery (MCA). Because aneurysms of the distal MCA are located deep in the Sylvian fissure and are small in size, intraoperative identification and safe clip occlusion of these aneurysms are challenging. Thus, the use of intraoperative imaging and navigation can be beneficial. We describe the use of intraoperative real-time 3D ultrasound "angiography" (3D-iUS) in localizing and occlusion control of a ruptured MCA M3 segment mycotic aneurysm. To our knowledge, its application in the surgery of a ruptured mycotic distal MCA aneurysm is not yet reported. CLINICAL PRESENTATION: A 54-year-old woman with a history of septic thrombophlebitis treated with long-term antibiotic therapy presented with sudden onset of headaches, dysphasia, and seizures. Computed tomography (CT) revealed subarachnoid hemorrhage in the distal portion of the left Sylvian fissure. Digital subtraction angiography (DSA) showed an aneurysm at the peripheral branch of the M3 segment of the MCA with characteristics of an infectious aneurysm. A microsurgical treatment was decided. 3D-iUS scan showed an aneurysm within the Sylvian fissure at a depth of 5 cm. The aneurysm was clipped and a repeated 3D-iUS scan showed total occlusion of the aneurysm and patency of the parent artery. The intraoperative findings were confirmed with a postoperative DSA. CONCLUSION: Our case report shows that real-time 3D-iUS, despite its limitations, is an important tool to locate and ascertain the successful clip occlusion of an aneurysm, especially when intraoperative angiography (IA) and indocyanine green (ICG) videoangiography are not available due to low-income settings.

Clipping of a basilar tip aneurysm using hypothermia and circulatory arrest: a case report.

Treatment of complex and giant aneurysms remains challenging despite modern endovascular and microsurgical techniques. We report the first case of microsurgical clipping of a complex basilar tip aneurysm under circulatory arrest and hypothermia performed in Greece. A 52-year-old patient presented with a Hunt and Hess Grade 4 subarachnoid hemorrhage. The digital subtraction angiography revealed a complex basilar tip aneurysm. Due to aneurysm complexity, we decided for microsurgical clipping under hypothermia and circulatory arrest. We performed a right pterional craniotomy with orbitozygomatic osteotomy. The patient was then put on heart-lung-machine. Following hypothermia and circulatory arrest, the aneurysm was clipped with its complete occlusion. The patient was discharged with no neurological deficits. Clipping of complex aneurysms under hypothermia and cardiac arrest performed by experienced team is a safe alternative when endovascular therapy or bypass technique is not feasible.

Severe kyphoscoliosis in a 17-year-old patient with T11-T12 hemivertebra: X-ray imaging of the abnormal anatomy of the thoracolumbar spine.

Young patient exhibiting lumbar pain accompanied by severe kyphoscoliosis-hemivertebra of the thoracolumbar spine; a rare etiology with difficult surgical treatment.

Treatment of adjacent segment disease with percutaneous transforaminal endoscopic discectomy: Early experience and results.

PURPOSE: Adjacent segment disease (ASD) constitutes a long-term complication of instrumented spinal fusion. Aim of this study is to analyze the utilization of percutaneous transforaminal endoscopic discectomy (PTED) for the treatment of symptomatic ASD, emphasizing basically in the postoperative course. METHODS: A prospective study with 35 patients was designed. Patients enrolled in our study were distributed in two different groups. Group A constituted of 15 patients featuring ASD as a complication of a previously conducted lumbar spinal fusion. Group B was composed of 20 patients, presenting simple lumbar disc herniation (LDH). All patients were subjected to successful PTED for LDH. Patients were evaluated at regular intervals in 6-week and 3-, 6-, and 12-month postoperatively. Visual analog scale was utilized for leg (VAS-LP) and low back pain (VAS-BP) evaluation. Health-related quality of life was assessed with short-form 36 health survey questionnaire (SF-36). RESULTS: VAS-BP scores were statistically significantly differentiated between the two groups in all intervals of follow-up. In contrast, VAS-LP scores demonstrated statistically significant differentiation in none of follow-up intervals, indicating similar results between the two groups. Maximal improvement was in both cases for all patients observed in 6-week postoperatively, with subsequent stabilization. SF-36 preoperative evaluation denoted a statistically significant differentiation in bodily pain and role emotional parameters, which was continually until the end of follow-up observed. The other SF-36 parameters featured similar values between the two groups preoperatively as well as during the follow-up intervals. CONCLUSION: PTED is capable of successfully dealing with LDH and furthermore with complications of fusion as ASD.

Spontaneous Epidural Hematoma of the Cervical Spine Following Thrombolysis in a Patient with STEMI-Two Medical Specialties Facing a Rare Dilemma.

Spontaneous spinal epidural hematoma (SSEH) is a rare, albeit well-documented complication following thrombolysis treatment in ST elevation myocardial infarction (STEMI). A SSEH usually manifests with cervical pain and neurologic deficits and may require surgical intervention. In this case report, we present the first reported SSEH to occur following thrombolysis with reteplase. In this case, the SSEH manifested with cervical pain shortly after the patient emerged from his rescue percutaneous coronary intervention (PCI). Although magnetic resonance imaging reported spinal cord compression, the lack of neurologic symptoms prompted the treating clinicians to delay surgery. A dangerous dilemma emerged, as the usual antithrombotic regimen that was necessary to avoid stent thrombosis post-PCI, was also likely to exacerbate the bleeding. As a compromise, the patient only received aspirin as a single antiplatelet therapy. Ultimately, the patient responded well to conservative treatment, with the hematoma stabilizing a week later, without residual neurologic deficits. In conclusion, the conservative treatment of SSEH appears to be an acceptable option for carefully selected patients, but the risks of permanent neurologic deficits and stent thrombosis have to be weighted for each patient.

Salter-Harris type II fracture of the distal femur in a newborn: Acute anatomic imaging alterations after labor dystocia.

A rare clinical presence of Salter-Harris type II fracture of the distal femur in a newborn. The crucial role of imaging in depicting urgent anatomical alterations.

An incidental intracranial lesion in a young woman with head trauma: The key role of CT bone reconstruction in the diagnosis of an osteoma of the anterior cranial fossa.

A young female was subjected to brain CT due to head trauma after a car accident. A lesion was found in the area of the right frontal lobe raising concern. After reconstruction of the CT slices, the radiologic features indicated a skull base osteoma, without the need for further intervention.

Comparison of Quality of Life Between Men and Women Who Underwent Transforaminal Percutaneous Endoscopic Discectomy for Lumbar Disc Herniation.

BACKGROUND: Studies describing the efficacy of transforaminal percutaneous endoscopic discectomy (TPED) on shortness of recovery and improvement of postoperative quality of life are limited, especially regarding gender, something that has never been reported before in the literature. The purpose of this study is to evaluate, in accordance with the sex of the patients, possible differences in the health-related quality of life of those who underwent TPED for lumbar disc herniation (LDH). METHODS: A total of 76 patients diagnosed and treated with TPED for LDH with 1-year follow-up were selected and divided into 2 groups of equal number depending on sex. Their quality of life was evaluated by using the 36-Item Short Form Health Survey before the operation, then 6 weeks and 3, 6, and 12 months postoperatively. A statistical analysis was conducted, in order to compare the 8 scaled scores of the 36-Item Short Form Health Survey, each time combining 2 chronological phases for the total number of patients, for each group, and between groups. RESULTS: Fifty-two (68.4%) patients were ≤63 years old, whereas the other 24 (31.4%) were >63 years old (mean ± SD = 56.5 ± 12.1 years). Apart from the physical function domain, the scores were higher in every visit for the 2 groups, but the change between groups was not significant. Women had a significantly higher increase of physical function score in 3 months after TPED and in the interval 6 weeks to 3 months compared with men. However, in the intervals 3 to 6 months and 3 to 12 months, men presented a significantly higher increase compared with women. CONCLUSIONS: Statistically significant improvement of the quality of life for both men and women was observed. Generally, there was no significant difference between the 2 groups. With regard to the physical functioning, it appears to be a significant difference that is counterpoised over time. LEVEL OF EVIDENCE: 2. CLINICAL RELEVANCE: Transforaminal percutaneous endoscopic discectomy for LDH does not present major differences in the improvement of quality of life regarding gender.

A rare case of spinal cord compression due to cervical spine metastases from paraganglioma of the jugular foramen-how should it be treated?

Paragangliomas are benign neoplasms that arise from the autonomic nervous system and the associated paraganglia. Although benign, they have been shown to possess metastatic potential. Involvement of the spine is rare. Even rarer is considered the involvement of the cervical spine. We report a case of a patient with a history of an extra-adrenal non-functional paraganglioma of the jugular foramen which was initially treated with intra-arterial embolization. After a 3-year disease-free follow-up, the patient was presented with symptoms of spinal cord compression due to spinal metastases in C2 and C3 vertebrae. The patient was then treated with surgical decompression and external beam radiation. Therapeutic management with additional treatment options is now under discussion by a multidisciplinary team. Paraganglioma of the jugular foramen with spinal metastasis is an uncommon presentation where increased physician awareness and long-term follow-up are mandatory for all patients with history of paraganglioma.

Functional extra-adrenal paraganglioma of the retroperitoneum giving thoracolumbar spine metastases after a five-year disease-free follow-up: a rare malignant condition with challenging management.

Paragangliomas are benign neoplasms that arise from the autonomic nervous system and the associated paraganglia. Although benign, they have been shown to possess metastatic potential. Extra-adrenal retroperitoneal paraganglioma with vertebral metastasis is considered very uncommon. Here, we present a case of a functional extra-adrenal paraganglioma of the retroperitoneum giving metastasis to T4 vertebra after five years of follow-up in a 48-year-old man who had been initially treated with complete resection of the primary tumor. The condition of the patient improved significantly after radiosurgery and somatostatin analogs treatment, until lumbar spine lesions appeared six months later. Our case demonstrates that retroperitoneal paraganglioma is a rare condition which should be considered in the differential diagnosis of a retroperitoneal mass combined with vertebral lesions. Additionally, increased physician awareness and long-term follow-up is mandatory for all patients with history of retroperitoneal paraganglioma since metastases may occur after long latent intervals from the initial diagnosis.

Hemivertebra of the cervical spine: an uncommon background for neck pain, cervical scoliosis, and torticollis.

A 15-year-old female patient presented with neck pain accompanied by cervical scoliosis, on the existence of torticollis. Although rare, hemivertebra of the cervical spine is a congenital deformation associated with these three clinical features.

Single anterior cervical discectomy and fusion (ACDF) using self- locking stand-alone polyetheretherketone (PEEK) cage: evaluation of pain and health-related quality of life.

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) constitutes the conventional treatment of cervical disc herniation due to degenerative disc disease (DDD). ACDF with plating presents a variety of complications postoperatively and stand-alone cages are thought to be a promising alternative. The aim of this study was firstly, to analyze prospectively collected data from a sample of patients treated with single ACDF using C-Plus self-locking stand-alone PEEK cage system, without the use of plates or screws, in order to evaluate pain levels of patients, utilizing Neck and Arm Pain scale as an expression of visual analogue scale (VAS). Secondly, we aimed to evaluate health-related quality of life, via the short-form 36 (SF-36) and Neck Disability Index (NDI). METHODS: Thirty-six patients (19 male and 17 female) with mean age 49.6±7 years old who underwent successful single ACDF using self-locking stand-alone PEEK cage for symptomatic cervical DDD were selected for the study. Neck and Arm pain, as well as SF-36 and NDI were estimated preoperatively and 1, 3, 6, and 12 months postoperatively. Patients underwent preoperative and postoperative clinical, neurological and radiological evaluation. RESULTS: The clinical and radiological outcomes were satisfactory after a minimum 1-year follow-up. All results were statistically important (P<0.05), excluding improvement in NDI measured between 6 and 12 months. SF-36, Neck Pain, as well as Arm Pain featured gradual and constant improvement during follow-up, with best scores presenting at 12 months after surgery, while NDI reached its best at 6 months postoperatively. CONCLUSIONS: Generally, all scores showed improvement postoperatively during the different phases of the follow-up. Subsequently, ACDF using C-Plus cervical cage constitutes an effective method for cervical disc herniation treatment, in terms of postoperative improvement on pain levels and health-related quality of life and a safe alternative to the conventional method of treatment for cervical DDD.