One stage removal of periaqueductal glioma in adult via infratentorial supracerebellar and transaqueductal approaches.

Most cases of periaqueductal tumours were found in children and adolescents, so treatment modalities in adults are not evaluated yet. A case of 40 years old woman with tectal and periaqueductal protoplasmatic astrocytoma grade II with history of headache and episodes of syncope is described. MRI showed triventricular hydrocephalus. After a shunt procedure she was doing well for about 15 months. Then she became somnolent, disoriented, and Parinaud syndrome appeared. The solid tumour was resected microsurgically in one stage. A part of it was removed via the supracerebellar infratentorial approach and tectal plate incision. The remainder of the tumour was removed through the fourth ventricle and the aqueduct which was filled by tumour mass. Postoperatively bilateral ptosis, vertical gaze palsy, slight horizontal gaze limitation and pupilloplegia were the main neurological sequelae. They all almost completely resolved within a year. The patient is doing well two and half years after the surgery. MRI showed patency of the aqueduct and no residual tumour. The authors suggest, that direct surgical attempt at total tumour removal should be considered in cases of periaqueductal and tectal gliomas. They also believe it is the first described case, in whom this type of tumour was totally removed by a combined transtectal and transaqueductal route.

[Preoperative administration of a slow releasing somatostatin analog (SR-lanreotide, BIM 23014) in patients with acromegaly in the course of GH-releasing adenoma]. / Przedoperacyjne zastosowanie analogu somatostatyny o przedluzonym dzialaniu (SR-Lanreotide, BIM 23014) u pacjentów z akromegalia w przebiegu makrogruczolaka przysadki.

To evaluate the therapeutic efficacy of slow releasing analogue of somatostatin (SR-Lanreotide) in the pretreatment for GH-releasing adenomas, especially macroadenomas. During the last four years (between January 1996 and December 1999) the authors carried out 382 transsphenoidal operations for to various lesions. There were 169 acromegalic patients in this group. 82 of them received, as pretreatment, the slow releasing analogue of somatostatin (SR-Lanreotide, BIM 23014) in a dose of 30 mg every 14 days for 3 months (6 injections). There were 55 women and 27 men (range 25-68, mean age 44.8 years, SD +/- 10 years) operated on by one experienced neurosurgeon. The concentrations of serum GH--70.5 micrograms/l (range 5.3-500 micrograms/l, SD +/- 83.9 micrograms/l) and IGF-I--1302 micrograms/l (range 610-2030 micrograms/l, SD +/- 360.7 micrograms/l) were high. Out of these 82 patients 79 had macroadenomas with suprasellar and parasellar extension. The volume of the tumours was calculated according to the formula of Di Chiro-Nelson. The mean volume of the tumour was 4146.9 mm3 (range 213.5-38595.3 mm3, SD +/- 5675.9 mm3). The response to the pretreatment suppression of the serum GH, IGF-I level and shrinkage of the tumours--were evaluated before surgery. Second MR examination was performed in 38 pretreated patients. During the Lanreotide treatment mean serum GH level decreased from 70.5 to 15.6 micrograms/l (p < 0.0001), mean serum IGF-I concentration decreased from 1302 to 787 micrograms/l and mean volume of the tumour decreased from 5662 to 2326 mm3 (p < 0.0001). During surgery, tumours were observed to be softer, had liquid consistency and were easier removed. 57 patient (69.5%) who underwent surgery had GH below 5 micrograms/l and were cured. Transsphenoidal microsurgical resection of pituitary adenomas is the primary treatment for acromegaly. Lanreotide pretreatment significantly decreased mean serum GH and IGF-I level, shrinks the tumour and make it much softer and easier to be removed.

[Intravascular embolization of intracranial aneurysms]. / Embolizacja wewnatrznaczyniowa tetniaków wewnatrzczaszkowych.

UNLABELLED: The paper presents indications for and the technique of the intravascular procedures as well as the results of treating patients with intracranial aneurysms. MATERIAL AND METHOD: Between 1997 and the May 2000, 25 patients (14 women and 11 men) with cerebral aneurysms underwent intravascular embolisation. The aneurysms were embolised with MDS-N BALT with coils. In 5 patients with aneurysm (about 2 cm), the procedure was performed in two or three steps. RESULTS: Aneurysms were embolised successfully in 19 patients. Three patients revealed intra- and postoperative complication manifestations. CONCLUSIONS: Intravascular embolisation of intracranial aneurysms is an affective treatment modality. It carries, though, a certain risk of complication development. Using this method in neurosurgically non-operable cases is a method of choice.

[Syringomyelia associated with intracranial tumors. Case report and literature review]. / Jamistosc rdzenia w przebiegu guzów wewnatrzczaszkowych. Opis przypadku i przeglad pismiennictwa.

A case of 39 years old woman with two intracranial meningiomas and syringomyelia is presented. Large right-sided tentorial meningioma in cerebellopontine angle and middle cranial fossa and small left sided sphenoid wing meningioma co-existed with secondary tonsillar herniation and large syringomyelic cavity in cervical and thoracic spinal cord. The patient had dissociated sensory loss on trunk and upper left extremity, muscle atrophy, left hand paresis, long tracts signs. After having done atlanto-occipital decompression, the intramedullary cavity collapsed and neurological symptoms resolved. Two months later large tentorial meningioma was successfully removed via occipito-suboccipital craniotomy with tentorial transsection. A review of the literature concerning syringomyelia secondary to intracranial tumours was done. To our knowledge this is the first such case described in which syringomyelia syndrome was the prominent symptom of the disease and two staged surgical procedure, first oriented at treatment of syringomyelia itself, was applied.

[Intravascular embolization of intracranial arteriovenous hemangiomas]. / Embolizacja wewnatrznaczyniowa naczyniaków tetniczo-zylnych wewnatrzczaszkowych.

UNLABELLED: The paper presents the technique of the procedures as well as the results of treating patients with operable difficult and non-operable intracranial angiomas. MATERIAL AND METHOD: During 26 months (1997, 1998 and 1999) 13 patients (7 women and 6 men) with intracranial arteriovenous haemangiomas underwent intravascular embolisation. The angiomas were embolised with coils (COOK) and Histoacryl with Lipiodol. RESULTS: Among the angioma patients, 2 were treated successfully during four procedures, 2 were treated during 3 procedures. The treatment was fully successful in 6 patients following the 3-rd and 4-th procedures. 5 patients are still being treated. Complications, during both the treatment and follow-up, were observed in two patients. CONCLUSIONS: The intravascular embolisation of intracranial angiomas is an effective treatment modality. It carries, though, a certain risk of complication development. Using this method in neuro-surgically non-operable cases is a method of choice.

[A case of schizophrenia-like psychosis in a patient with arachnoid cyst]. / Przypadek psychozy schizofrenopodobnej u pacjenta z torbiela pajeczynówkowa.

The aim of this report was the presentation of the extremely rare case of the arachnoid cyst of the brain, with only psychiatric manifestation. According to the literature and own experience the authors conclude, that the treatment of these patients would be interdisciplinary, both neurosurgical and psychiatric.

[Evolution of the growth of multiple intracranial tumors in a case of type 2 neurofibromatosis]. / Dynamika wzrostu guzów wewnatrzczaszkowych w nerwiakowlókniakowatosci typu 2 (NF 2).

A sporadic case of neurofibromatosis type 2 in a 23-year old woman is described with clinical and neuroimaging (CT or MRI) 4 years follow-up. Together with bilateral acoustic tumours multiple intracranial tumours and solitary orbital meningioma were present, the latter being confirmed surgically and histopathologically. Ocular findings of congenital cataract but lack of other external stigmata of neurofibromatosis completed the clinical picture of the disease. Diagnostic criteria of NF2, difficulties in establishing the optimal management options are described and the importance of evaluating of family members is underlined. Neuroimaging pictures showed tumour expansion over 4 years leading to severe disability with total blindness, deafness, paresis and cerebellar syndrome.

[A case of cysticercosis of the IV cerebral ventricle]. / Przypadek wagrzycy IV komory mózgu.

A case of cysticercosis in fourth ventricle is described. After surgical cyst removal the medical treatment with praziquantel was instituted.

[Conservative treatment of post-traumatic intracerebral hematoma]. / Leczenie zachowawcze pourazowych krwiaków sródmózgowych.

Out of 184 patients with posttraumatic intracerebral haematomas 52 were treated conservatively. For this treatment patients were qualified with good consciousness level, in the range of 13-15 GCS score. Presence of massive neurological deficit was not an indication to treatment. Patients with haematomas in the central zone, with multiple haematomas or with contraindications to operation were treated conservatively. Eight patients died (15%), in 2 of them severe brain trauma with multiple haematomas were the cause of death, in 1 case primary brainstem trauma was present, one patient had deeply situated haematoma of the thalamus and ventricular system, and in 4 cases death was due to non-cerebral causes. The size of the haematoma in CT scan was not decisive for the choice of the treatment. Nearly in all cases compression of the ventricular system was present, but in only some cases the ventricles were shifted. In repeated CT scans resorption of the haematomas was observed. Twenty patients were discharged home in good general condition without serious neurological deficit. Twenty-four patients were treated later on in other hospital departments. Later outpatient control examinations showed that even serious neurological deficits regressed in most cases. The main symptoms were those of the post-trauma syndrome. About 25% of patients had epileptic seizures after the treatment. The author believes that if the patient is conscious and his consciousness is not worsening conservative treatment of intracerebral haematomas may be undertaken with good effects, on condition, however, of the availability of immediate surgical intervention if the condition of the patient is deteriorating.

Medical and surgical treatment of intracerebellar haematomas.

15 cases of intracerebellar haematomas [11 spontaneous, 2 traumatic and 2 unclear] were presented. Hypertension was thought to be a main risk factor in 91% in 11 of the spontaneous cases. 11 cases were treated medically. They were usually conscious, scoring not less than 13 in GCS with subacute or chronic picture of illness and harbouring small haematomas below 3 cm in diameter situated almost always in the hemisphere and with no signs of ventricular dilation. Mortality in medically treated patients was 9% [1 case]. The remainder were discharged in good state, usually with no or only slight neurological deficit. Complete haematoma absorption took about 14 days. There were no signs of delayed hydrocephalus in subsequent CT scans. When the haematoma was large, more than 3 cm in diameter, located usually in the vermis or in the vermis and cerebellar hemisphere, sometimes with ventricular involvement, the clinical presentation was acute and required CT diagnosis and surgical evacuation without delay due to low and deteriorating conscious level. Postoperative mortality was 25%, but delayed mortality was 100%. Vertebral angiography was performed in all cases of spontaneous haemorrhage and was normal in 54%, revealed atheromatous changes in 36% and the signs of cerebellar haematoma in only 10%. Arteriovenous malformations were excluded from this study. The authors believe, that the benign course of intracerebellar haematomas is more frequent than it was considered previously and needs no surgical treatment in many cases.

[Surgical treatment of intracranial arachnoid cysts]. / Uwagi o leczeniu operacyjnym wewnatrzczaszkowych torbieli pajeczynówkowych.

The results of surgical treatment in 21 cases of intracranial arachnoid cysts, mostly in adults, are reviewed. There were 19 supratentorial and 2 infratentorial cysts. In all but one supratentorial cyst cases epileptic seizures were the major clinical presentation. CT scan was helpful in the diagnosis in most cases. In 7 patients CT-cisternography was performed and in 3 cases a connection of cyst cavity to intracranial cerebrospinal fluid space was demonstrated. The cysts were treated surgically in different ways including craniotomy for fenestration of cyst wall, resection of cyst wall and neighbouring cerebral structures or cyst-peritoneal shunting. In some cases successive surgical treatment was necessary since the initial surgery proved to be unsuccessful. The authors believe that the best results were achieved by cyst removal with resection of cerebral structures being the source of epileptic discharges under intraoperative electrocorticographic control. The regression or diminished intensity of seizures can be achieved in this way. The fenestration of cyst alone leads to cyst recurrence. Cyst-peritoneal shunting usually did not lead to significant reduction of cyst size and delayed complications caused this kind of treatment to be uneffective. The significant number of infectious complications in all surgical treated cases of arachnoid cysts suggest the need for avoiding operation in asymptomatic or oligosymptomatic cases.

[Effect of stimulation of the spinal cord on phasic and tonic reflexes in patients with central motor neuron damage]. / Wplyw stymulacji rdzenia kregowego na odruchy fazowe i toniczne u pacjentów z uszkodzeniem centralnego neuronu ruchowego.

Spinal cord stimulation (SCS) is a method enabling the control of increased muscle tonus to be achieved in various spinal cord injuries. Polyelectromyographic (PEMG) methods were used for neurophysiological assessment of the degree of cord damage and persistent spinal reflexes as well as supramedullary influences. The analysed material comprised 40 PEMG records in 19 patients with spastic paraparesis or paraplegia after cord injury, cord tumour or multiple sclerosis. In 15 cases tentative epidural cord stimulation was done and 11 patients received implantation of a system for long-term stimulation. In most cases the epidural electrodes were implanted below the damaged segment, usually in the thoracic part of the cord. Before and after SCS beginning PEMG was done with a 16-channel Mingograph Siemens Elema with simultaneous recording of the responses from the symmetric muscles: quadriceps, semitendinous, adductor femoris, anterior tibialis and triceps surae. The effect of SCS was analysed on exteroceptive and proprioceptive reactions during testing of knee and ankle reflexes, and on the response of the muscles to vibration. In most patients a reduction was observed of the intensity of tendon reflexes, particularly the spread of the reflex to the contralateral extremity was no longer seen. The vibration reflex had a tonic character persisting in 48% of the studied muscles, even in patients with clinically complete transsection of the cord. The change of the character of monosynaptic reflexes and the presence of the vibration reflex suggest that SCS modifies the proprioceptive segmental spinal reactions.

[Conservative treatment of intracranial hematomas and the dynamics of their resorption]. / Leczenie zachowawcze krwiaków sródmózgowych i dynamika ich wchlaniania.

In 10 out of 63 patients with intracerebral haematomas treated conservatively the authors measured approximately the volume of haematomas by means of serial CT examinations during observation of their resorption. These were large and medium-size haematomas, from 20 to 70 ml in volume. The mean rate of resorption was from 0.7 to 1.0 ml daily. Gradual regression of mass effects was noted. All patients were on admission in a relatively good condition, conscious or only somnolent, with focal neurological signs. In some cases signs of increased intracranial pressure were present. Improvement of the general condition and neurological status was relatively rapid, even pronounced paresis and aphasia regressed in most cases. Two patients (3%) died of non-cerebral causes. It is believed that most intracerebral haematomas may be treated conservatively. The presence of mass effects, increased intracranial pressure or even a major neurological syndrome are not regarded as indications to operation if the state of consciousness is good and is not deteriorating. Even large and deeply situated haematomas may be resorbed without leaving a gross neurological deficit. A careful observation of the state of the patient, control CT investigations and the possibility of carrying out emergency operation in case of deterioration of the level of consciousness are indispensable for safe conservative treatment of these patients.

Immunological method for prediction of progress in neurological deficit in patients with intracranial aneurysm rupture.

Skin tests of nonspecific antigens (immunoskin test Sevac) were performed on patients suffering from intracranial aneurysms, scheduled for surgical clipping. It was found that high antibody titre correlated well with the severity and progress of neurological deficit developing after surgery. This deficit was absent in patients who exhibited low antibody titre in response to the skin test before surgery. These results indicate that the immunological processes may play a role in the development of neurological deficit after neurosurgical procedures. Thus the skin test employed may have prognostic value in predicting neurological deficit following intracranial aneurysm surgery.