Neurosurgery Training in Greece.

OBJECTIVE: The structure and specifics of neurosurgery residency training vary substantially across programs and countries, potentially leading to differences in clinical reasoning, surgical skills, and professionalism. The Greek neurosurgical training system is unique in numerous respects. This manuscript delineates the current state of neurosurgical residency training in Greece and outlines future directions. METHODS: A narrative review was conducted to describe the Greek neurosurgical residency training structure. The perspectives of the authors regarding challenges in training and future directions were synthesized. RESULTS: This manuscript describes the neurosurgery residency curriculum and board certification process, existing training programs, and key challenges in neurosurgery residency training in Greece. The authors propose future directions to reform neurosurgical training in Greece. CONCLUSIONS: Neurosurgery residency training in Greece has been largely unchanged for many years. This review leads to suggested modification of the existing training process may improve the quality of training and equip neurosurgeons to respond to the rapidly changing landscape of the field.

Localization of Vestibular Cortex Using Electrical Cortical Stimulation: A Systematic Literature Review.

The vestibular system plays a fundamental role in body orientation, posture control, and spatial and body motion perception, as well as in gaze and eye movements. We aimed to review the current knowledge regarding the location of the cortical and subcortical areas, implicated in the processing of vestibular stimuli. The search was performed in PubMed and Scopus. We focused on studies reporting on vestibular manifestations after electrical cortical stimulation. A total of 16 studies were finally included. Two main types of vestibular responses were elicited, including vertigo and perception of body movement. The latter could be either rotatory or translational. Electrical stimulation of the temporal structures elicited mainly vertigo, while stimulation of the parietal lobe was associated with perceptions of body movement. Stimulation of the occipital lobe produced vertigo with visual manifestations. There was evidence that the vestibular responses became more robust with increasing current intensity. Low-frequency stimulation proved to be more effective than high-frequency in eliciting vestibular responses. Numerous non-vestibular responses were recorded after stimulation of the vestibular cortex, including somatosensory, viscero-sensory, and emotional manifestations. Newer imaging modalities such as functional MRI (fMRI), Positron Emission Tomography (PET), SPECT, and near infra-red spectroscopy (NIRS) can provide useful information regarding localization of the vestibular cortex.

Giant aneurysm arising from a cortical middle cerebral artery branch presenting as an extra-axial tumour: a case report.

The size and anatomical complexity make giant intracranial aneurysms challenging surgical lesions. There is limited literature available for those arising from distal branches. The cases that have been reported in the literature have all presented with symptoms from a rupture leading to an intracranial haemorrhage. In this case report, the authors present a case of a giant aneurysm arising from a cortical branch of the middle cerebral artery presenting as an extra-axial tumour. A 76-year-old gentleman presented with a 2-day history of subjective left arm numbness. Imaging revealed a large conical right-sided parietal lesion. Intraoperatively, it was found that the lesion was being supplied by a single vascular pedicle. Histology was consistent with an aneurysm. In this case, that patient did not have any evidence of a rupture unlike all reported cases of cortical giant aneurysms. This case highlights the myriad location and presentation of giant intracranial aneurysms.

The Role of Extra-Operative Cortical Stimulation and Mapping in the Surgical Management of Intracranial Gliomas.

BACKGROUND: Aggressive resection without compromising the patient's neurological status remains a significant challenge in treating intracranial gliomas. Our current study aims to evaluate the efficacy and safety of extra-operative stimulation and mapping via implanted subdural electrodes with or without depth (EOCSM), offering an alternative approach when awake mapping is contraindicated. METHODS: Fifty-one patients undergoing EOCSM for glioma resection in our institution formed the sample study of our current retrospective study. We assessed the effectiveness and safety of our approach by measuring the extent of resection and recording the periprocedural complications, respectively. RESULTS: The mean age of our participants was 58 years (±9.4 years). The lesion was usually located on the left side (80.4%) and affected the frontal lobe (51.0%). EOCSM was successful in 94.1% of patients. The stimulation and electrode implantation procedures lasted for a median of 2.0 h and 75 h, respectively. Stimulation-induced seizures and CSF leakage occurred in 13.7% and 5.9% of our cases. The mean extent of resection was 91.6%, whereas transient dysphasia occurred in 21.6% and transient hemiparesis in 5.9% of our patients, respectively. CONCLUSIONS: Extraoperative stimulation and mapping constitute a valid alternative mapping option in glioma patients who cannot undergo an awake craniotomy.

Intermediate surgical outcome in patients suffering poor-grade aneurysmal subarachnoid hemorrhage. A single center experience.

BACKGROUND: It is known that patients suffering poor-grade aneurysmal subarachnoid hemorrhage (aSAH) have a dismal prognosis. The importance of early intervention is well established in the pertinent literature. Our aim was to assess the functional outcome and overall survival of these patients undergoing surgical clipping. MATERIAL AND METHODS: In the current retrospective study we included all consecutive poor-grade patients after spontaneous SAH who presented at our institution over an eight-year period. All participants suffering SAH underwent brain CT angiography (CTA) to identify the source of hemorrhage. We assessed the severity of hemorrhage according to the Fisher grade classification scale. All patients were surgically treated. The functional outcome was evaluated six months after the onset with the Glasgow Outcome Scale. Finally, we performed logistic and Cox regression analyses to identify potential prognostic risk factors. RESULTS: Our study included twenty-three patients with a mean age of 53 years. Five (22%) patients presented with Hunt and Hess grade IV, and eighteen (78%) with grade V. The mean follow-up was 15.8 months, while the overall mortality rate was 48%. The six-month functional outcome was favorable in 6 (26%) patients. The vast majority of our patients died between the 15th and the 60th post-ictal days. We did not identify any statistically significant prognostic factors related to the patient's outcome and/or survival. CONCLUSIONS: Poor-grade aSAH patients may have a favorable outcome with proper surgical management. Large-scale studies are necessary for accurately outlining the prognosis of this entity, and identifying parameters that could be predictive of outcome.

Surgical and functional outcome of olfactory groove meningiomas: Lessons from the past experience and strategy development.

OBJECT: Olfactory groove meningiomas (OGMs) constitute a unique subset of intracranial meningiomas, since they usually remain clinically silent for a long period of time, and they may be of large size upon their diagnosis. Their surgical management remains quite challenging. The surgical and the neuropsychological outcome of patients with OGM are presented in our current study, in order to establish a basis for developing efficacious surgical strategies for the management of this clinico-pathological entity. METHODS: A retrospective study covering a 17-year period examined a total of 78 patients (31 males and 47 females) diagnosed with OGM, and surgically managed in the two participating institutions (Greece and Romania). The patients' charts as well as their imaging studies (head CT, brain MRI/1HMRS, brain MRA/MRV, cerebral DSA), and their operative reports were carefully reviewed. All participants underwent pre- and post-operative neurocognitive evaluation with the Mini Mental Status Examination (MMSE), and the Frontal Assessment Battery (FAB). Microsurgical resection was performed by employing a bilateral subfrontal, a unilateral subfrontal, or a pterional approach. The Simpson scale was utilized for assessing the extent of resection. The histological type of the resected meningioma was identified. The follow up period ranged from 2 to 15 years (mean: 5.6). RESULTS: Non-specific headache was the most common presenting symptom, followed by personality changes in our series. Grade 1 Simpson resection was accomplished in 19.2%, grade 2 in 46.2%, grade 3 in 17.9%, and grade 4 in 16.7%. The most common postoperative complication was anosmia (89.7%), followed by CSF leakage (21.8%). The observed 5-year recurrence rate was 11.8%. Analysis of our data demonstrated that patients with larger tumors presented with poorer neurocognitive status, and had also lower, compared with patients with smaller meningioma, postoperative neurocognitive outcome. Meningioma's histological type had no correlation with complication occurrence or tumor recurrence. Surgical resection significantly improved the preoperative MMSE scores of our patients, while the observed postoperative improvement of the FAB scores was not statistically significant. The bilateral subfrontal approach demonstrated higher complication rate than the other two approaches, in our series. Interestingly, bifrontal approach was associated with higher tumor recurrence rate. Tumor size, patient's age, and ethmoid bone infiltration seem to be predisposing factors for complication occurrence and tumor recurrence. CONCLUSION: Individualized surgical strategy is necessary for mitigating the postoperative complication rate, and the possibility of recurrence in the management of OGMs. The exact role of less invasive, endoscopic approaches in the management of these patients remains to be defined.

Unusual case of subarachnoid haemorrhage in patient with Fabry's disease: case report and literature review.

Fabry's disease is a rare, X linked recessive disease affecting 1 in 40 000 persons. The symptoms result from a lack of or a non-functioning enzyme α galactosidase, which leads to globotriaosylceramide accumulation in the walls of blood vessels. Mortality is generally from cardiac or renal complications and death from subarachnoid haemorrhage is distinctly rare. The authors report a man with Fabry's disease who died after subarachnoid haemorrhage from a progressively enlarging fusiform basilar aneurysm.