The diagnostic challenge of lack of choline level elevation on 1H-MR spectroscopy in grade II-III gliomas.

The accurate diagnosis of brain tumour is very important in modern neuro-oncology medicine. Magnetic resonance spectroscopy (MRS) is supposed to be a promising tool for detecting cancerous lesions. However, the interpretation of MRS data is complicated by the fact that not all cancerous lesions exhibit elevated choline (Cho) levels. The main goal of our study was to investigate the lack of Cho lesion /Cho ref elevation in the population of grade II-III gliomas. 89 cases of gliomas grade II and III were used for the retrospective analysis - glioma (astrocytoma or oligodendroglioma) grade II (74 out of 89 cases [83%]) and III (15 out of 89 cases [17%]) underwent conventional MRI extended by MRS before treatment. Histopathological diagnosis was obtained either by biopsy or surgical resection. Gliomas were classified to the group of no-choline elevation when the ratio of choline measured within the tumour (Cho lesion ) to choline from NABT (Cho ref ) were equal to or lower than 1. Significant differences were observed between ratios of Cho lesion /Cr lesion calculated for no-choline elevation and glial tumour groups as well as in the NAA lesion /Cr lesion ratio between the no-choline elevation group and glial tumour group. With consistent data concerning choline level elevation and slightly lower NAA value, the Cho lesion /NAA lesion ratio is significantly higher in the WHO II glial tumour group compared to the no-choline elevation cases ( p < 0.000). In the current study the results demonstrated possibility of lack of choline elevation in patients with grade II-III gliomas, so it is important to remember that the lack of elevated choline levels does not exclude neoplastic lesion.

The use of MR perfusion parameters in differentiation between glioblastoma recurrence and radiation necrosis.

INTRODUCTION: This study focuses on the challenge of distinguishing between tumour recurrence and radiation necrosis in glioma treatment using magnetic resonance imaging (MRI). Currently, accurate differentiation is possible only through surgical biopsy, which is invasive and may cause additional damage. The study explores non-invasive methods using dynamic susceptibility contrast (DSC) MR perfusion with parameters like relative peak height (rPH) and relative percentage of signal-intensity recovery (rPSR). MATERIAL AND METHODS: Among retrospectively evaluated patients (multicentre study) with an initial diagnosis of the primary and secondary brain tumour, 47 met the inclusion criteria and were divided into two groups, the recurrent glioblastoma (GBM) WHO IV group and the radiation necrosis group, based on MRI of the brain. All patients enrolled into the recurrent GBM group had a second surgical intervention. RESULTS: Mean, minimum and maximum rPH values were significantly higher in the recurrent GBM group than in the radiation necrosis group ( p < 0.001), while rPSR values were lower in the recurrent GBM group than in the radiation necrosis group ( p = 0.011 and p = 0.012). DISCUSSION: This study investigates the use of MR perfusion curve characteristics to differentiate between radiation necrosis and glioblastoma recurrence in post-treatment brain tumours. MR perfusion shows promising potential for distinguishing between the two conditions, but it also has certain limitations. Despite challenges in finding a sufficient cohort size, the study demonstrates significant differences in MR perfusion parameters between radiation necrosis and GBM recurrence. CONCLUSIONS: The results demonstrate the potential usefulness of these DSC perfusion parameters in discriminating between glioblastoma recurrence and radiation necrosis.

Surgical treatment of brainstem cavernomas using diffusion tensor imaging and diffusion tensor tractography.

INTRODUCTION: The aims of this study were to assess the prognosis of patients after a single haemorrhage from the cavernoma, and also in the case of rehaemorrhage, and to determine the indications for surgical treatment of brainstem cavernomas. MATERIAL AND METHODS: The study included a group of 35 patients with brainstem cavernomas, 23 women and 12 men aged 27 to 57 years (mean age 38.4). Up to 2005, MRI perfusion-weighted imaging/diffusion-weighted imaging had been carried out in 13 surgically treated patients. From 2005 onwards, the other 22 patients also underwent MRI diffusion tensor imaging and diffusion tensor tractography (DTI/DTT). DTI/DTT assessed the course of long fibre tracts. The course of the corticospinal tract, medial lemniscus and transverse pontine tracts was entered into the neuronavigation system. The surgical approach and the safe entry zone were determined based on the DTI/DTT. RESULTS: Our study showed that rehaemorrhage from a cavernoma depends on its size and volume. However, it is not related to its location. Based on the modified Rankin scale, the results of treatment of our patients after the first haemorrhage were better compared to the assessment after another haemorrhage. Complete resection was performed in 32 cases (91%) and partial resection in the remaining three (9%). Two patients underwent another surgery after several years due to partial resection. One patient presented with another haemorrhage after three years. New deficits developed postoperatively. Already existing deficits were exacerbated, but gradually resolved. Symptoms of cerebellar dysfunction and cranial nerve injury (including respiratory disorders) were the most difficult to resolve. CONCLUSIONS: Patients with brainstem cavernomas should undergo surgical treatment after their first haemorrhage, especially in the case of a large cavernoma. DTI/DTT should be used to determine the trajectory to the cavernoma, particularly to the deep cavernoma, and to determine the safe entry zone. Total resection of the cavernoma should be performed even where this means that reoperation is required.

Influence of infiltration anaesthesia on perioperative outcomes following lumbar discectomy under surgical pleth index-guided general anaesthesia: A preliminary report from a randomised controlled prospective trial.

PURPOSE: Severe postoperative pain (SPP) may occur after lumbar discectomy. To prevent SPP and reduce rescue opioid consumption, infiltration anaesthesia (IA) has been combined with general anaesthesia (GA). This study verified how GA combined with IA facilitated intra- and postoperative demand for opioids and affected the incidence of SPP in patients subjected to open lumbar discectomy. MATERIALS/METHODS: Ninety-nine patients undergoing lumbar discectomy under GA with Surgical Pleth Index (SPI)-guided fentanyl (FNT) administration were randomly assigned to receive IA combined with either 0.2% bupivacaine (BPV) or 0.2% ropivacaine (RPV) with FNT 50 µg and compared with controls (BF, RF, and C groups, respectively). RESULTS: Ninety-four patients were included in the final analysis. Adjusted according to SPI, total intraoperative FNT dosages did not differ between the study groups (p = 0.23). The proportion of patients who reported SPP was the highest in group C (41.9%) than in the RF (12.9%) and BF groups (31.3%) (p < 0.05). Mild pain was experienced by 67.7%, 53.1% and 32.3% of patients from the RF, BF and C groups, respectively (p < 0.01). Morphine requirement was the highest in the control group (7.1 ± 5.9 mg), followed by the RF (2.7 ± 5.3 mg) and BF groups (4 ± 4.9 mg) (p < 0.05). CONCLUSIONS: IA using RPV/FNT mixture significantly reduced SPP and postoperative demand for morphine in patients subjected to lumbar discectomy under GA.

Surgical treatment and prognosis of adult patients with brainstem gliomas.

The paper presents 47 adult patients who were surgically treated due to brainstem gliomas. Thirteen patients presented with contrast-enhancing Grades III and IV gliomas, according to the WHO classification, 13 patients with contrast-enhancing tumours originating from the glial cells (Grade I; WHO classification), 9 patients with diffuse gliomas, 5 patients with tectal brainstem gliomas and 7 patients with exophytic brainstem gliomas. During the surgical procedure, neuronavigation and the diffusion tensor tractography (DTI) of the corticospinal tract were used with the examination of motor evoked potentials (MEPs) and somatosensory evoked potentials (SSEPs) with direct stimulation of the fundus of the fourth brain ventricle in order to define the localization of the nuclei of nerves VII, IX, X and XII. Cerebellar dysfunction, damage to cranial nerves and dysphagia were the most frequent postoperative sequelae which were also the most difficult to resolve. The Karnofsky score established preoperatively and the extent of tumour resection were the factors affecting the prognosis. The mean time of progression-free survival (14 months) and the mean survival time after surgery (20 months) were the shortest for malignant brainstem gliomas. In the group with tectal brainstem gliomas, no cases of progression were found and none of the patients died during the follow-up. Some patients were professionally active. Partial resection of diffuse brainstem gliomas did not prolong the mean survival above 5 years. However, some patients survived over 5 years in good condition.

Surgical treatment of adult patients with thalamic tumors with the aid of tractography, fMRI, transcranial electrical stimulation and direct electrical stimulation of the subcortical white matter.

The aim of investigation was to assess treatment outcomes in adult patients with thalamic tumors, operated on with the aid of tractography (DTI) and monitoring of motor evoked potentials (MEPs) generated due to transcranial electrical stimulation (TES) and direct electrical stimulation (DES) of the subcortical white matter. 38 subsequent patients with thalamic tumors were operated on using tractography (DTI)-integrated neuronavigation, transcranial electrical stimulation (TES) and direct electrical stimulation (DES). The volumetric method was used to calculate pre- and postoperative tumor volume. Total tumor resection (100%) was performed in 18 (47%) patients, subtotal in 9 (24%) (mean extent of resection -89.4%) and partial in 11 (29%) patients (mean extent of resection -77.18%). The mean extent of resection for all surgical patients was 86.5%. Two (5.2%) patients died postoperatively. Preoperative hemiparesis was present in 18 (47%) patients. Postoperative hemiparesis was observed in 11 (29%) patients of whom only in 5 (13%) new paresis was noted due to surgical intervention. In patients with hemiparesis significantly more frequently larger tumor volume was detected preoperatively. Low mean normal fractional anisotropy (nFA) values in the internal capsule were observed statistically significantly more frequently in patients with preoperative hemiparesis as compared to the internal capsule of the unaffected hemisphere. Transcranial electrical stimulation helps to predict postoperative paresis of extremities. Direct electrical stimulation is an effective tool for intraoperative localization of the internal capsule thus helping to avoid postoperative deficit. In patients with tumor grade I and II the median time to tumor progression was 36 months. In the case of patients with grades III and IV it was 14 months. The median survival time in patients with grades I and II it was 60 months. In patients with grades III and IV it was 18 months. Basing on our results, patients with glioma grade I/II according to WHO classification are the best candidates for surgical treatment of thalamic tumors. In this group of the patients more often resection is radical, median time to progression and survival time are longer than in patients with gliomas grade III and IV. Within a 7-year follow-up none of the patients with GI/GII grade glioma died.

Anaplastic transformation of low-grade gliomas (WHO II) on magnetic resonance imaging.

INTRODUCTION: Malignant transformation among gliomas WHO II ranges between 35% and 89%. However, according to some reports, all gliomas WHO II undergo such transformation over time. The aim of the study was to analyse MRI parameters indicating anaplastic transformation of gliomas WHO II. MATERIAL AND METHODS: Forty-six consecutive patients were enrolled in the study (20 females and 26 males; range of age 36 ± 9 years) with supratentorial glioma WHO II. Multiparametric MR examination included morphological imaging, perfusion-weighted imaging, diffusion-weighted imaging and proton magnetic resonance spectroscopy. Group division depended on the course of disease (ST - stable group, AT - anaplastic transformation group). RESULTS: Subtotal tumour resection was achieved in the whole AT group, whereas in the ST group, total tumour resection was achieved in 10/29 (34%) patients. The size of the residual tumour after surgery was statistically significantly higher in the AT group compared to the ST group (AT: 51.5 cm³ ± 37.7 vs. ST: 29.0 cm³ ± 37.9; p = 0.011). Contrast enhancement in the AT group occurred in 5/11 (45%) of tumours and in none of the patients' areas of contrast enhancement were resected during surgery/biopsy. However, the initial MR showed contrast enhancement in 10/29 (34%) of patients in the ST group. The areas of contrast enhancement were totally resected in all patients. Compared to the ST group tumours that underwent anaplastic transformation had statistically significantly higher values of mean nrCBV and max nrCBV on the initial MR, the follow-up and final MR examinations. However, statistically significant differences between the groups in ADC values were observed on the follow-up and final MR whereas mean Cho/Cr and mean Cho/NAA were observed as late as on the final MR examination. CONCLUSIONS: Multiparametric MR examination allows the detection of LGGs with high probability of rapid anaplastic transformation and the detection of transformation prior to the occurrence of contrast enhancement. The value of nrCBV is the most useful in the diagnosis of anaplastic transformation. The resection of contrast enhancement area of the tumour significantly increases time to anaplastic transformation of LGGs.

MR-guided focused ultrasound: a new generation treatment of Parkinson's disease, essential tremor and neuropathic pain.

The application of high intense focused ultrasound (HIFU) is currently the subject of many experimental and clinical trials. The combination of HIFU with MRI guidance known as MR-guided focused ultrasound (MRgFUS) appears to be particularly promising to ablate tissues located deep in the brain. The method can be the beginning of interventional neurology and an important alternative to neurosurgery. Studies conducted to date show the effectiveness of the method both in chronic diseases and in emergency cases. The safety and effectiveness of this method have been observed in parkinsonian and essential tremor as well as in neuropathic pain. The procedure does not require anaesthesia. Ionizing radiation is not used and there is no risk of cumulative dose. Such advantages may result in low complication rates and medical justification for further development of MRgFUS.

The use of functional magnetic resonance imaging in reducing a risk of postoperative neurological deficits in the patients with brain tumour.

BACKGROUND AND PURPOSE: The purpose of the study was to compare the results of operative treatment of tumours located in the sensory-motor cortex guided with functional magnetic resonance imaging (fMRI) combined with the neuro-na-vigation system to the results of classical operative treatment. MATERIAL AND METHODS: The studied group comprised 28 pa-tients with a tumour located in the sensory-motor cortex area who underwent surgery guided with fMRI and the neuro-na-vigation system. A control group comprised 30 patients with the same clinical diagnosis, operated on without functional neuronavigation. RESULTS: The use of functional neuronavigation allowed for an 18% reduction in the intensity of neurological deficits after surgical treatment in patients from the studied group, compared to the subjects from the control group (p = 0.0001). In the patients with diagnosed high-grade glioma, improvement in the neurological condition in the studied group was 16% (p = 0.03). The initial neurological condition and the results of surgical treatment in patients with a tumour located less than 5 mm from the sensory-motor cortex, determined in fMRI examination, are worse than in patients with a tumour located more than 5 mm. CONCLUSIONS: In patients with a diagnosed brain tumour in the sensory-motor cortex who have neurological deficits, fMRI provides valuable imaging data on active areas. Tumour location of more than 5 mm from the fMRI active area of the sensory-motor cortex is connected with a considerably lower risk of postoperative neurological deficits. Removing a tumour in the sensory-motor cortex region, guided with fMRI and the neuronavigation system, considerably lowers the risk of postoperative development or exacerbation of neurological deficits.

Reoperations of patients with low-grade gliomas in eloquent or near eloquent brain areas.

BACKGROUND AND PURPOSE: Reoperations of patients with recurrent low-grade gliomas (LGG) are not always recommended due to a higher risk of neurological deficits when compared to initial surgery. The purpose of the present study was to evaluate surgical outcomes of patients operated on for recurrent LGG. MATERIAL AND METHODS: Sixteen patients who had surgery for recurrent LGG out of 68 LGG patients who underwent surgery at the Department of Neurosurgery in Sosnowiec, Poland between 2005 and 2011 were enrolled in the study. RESULTS: A large tumour volume prior to the initial surgery was the most significant parameter influencing LGG progression (96.6 cm³ vs. 47.9 cm3, p = 0.01). Increased incidence of epileptic seizures and decreased mental ability according to Karnofsky score were the most common symptoms associated with tumour recurrence. In the group of patients with malignant transformation, the relative cerebral blood volume (rCBV) was considerably increased (1.21 vs. 2.41, p < 0.01). No statistically significant difference was found in terms of the extent of resection between initial surgery and reoperation. Similarly, no significant difference was found in the number of patients with a permanent neurological deficit after initial surgery and reoperation. CONCLUSIONS: Reoperations of the patients with recurrent LGG are not burdened with a higher risk of neurological sequelae when compared to initial surgery. The extent of resection during the surgery for LGG recurrence is comparable to initial surgery. The increase of rCBV seems to be a significant biomarker that indicates malignant transformation.

Meningiomas of the anterior portion of the craniovertebral junction: immediate and late outcome following surgical removal using a partial transcondylar approach.

BACKGROUND AND PURPOSE: The partial transcondylar approach (PTA) is an alternative to the suboccipital approach in the surgical treatment of meningiomas of the anterior portion of the craniovertebral junction (APCVJ). The purpose of this study is to present our results of treatment of these meningiomas using PTA. MATERIAL AND METHODS: Fourteen patients (11 women, 3 men) with meningioma of the APCVJ were included in the study. Neurological status of the patients was assessed before and after surgery as well as at the conclusion of the treatment. The approximate volume of the operated tumour, its relation to large blood vessels, cranial nerves and brainstem, along with its consistency and vascularisation were assessed. RESULTS: The symptom duration ranged from 1 to 36 months (median: 11 months). In 79% of patients, motor deficits of the extremities were predominant symptoms. Less frequent symptoms included headache, cervical pain and sensory deficits of cervical nerves C2 to C5. Approximate volume of the tumours ranged from 2.5 mL to 22.1 mL (mean: 11.7 mL). Gross total or subtotal resection was achieved in 86% of patients. The postoperative performance status improved in 57%, did not change in 36% and deteriorated in 7% of the patients. CONCLUSIONS: The PTA is a useful technique for removal of meningiomas expanding intradurally of the APCVJ without significant compression of the medulla. The results of treatment were good in most patients.

[Partial transcondylar approach - analysis of the surgical technique in cadaver simulation]. / Dostep przezklykciowy czesciowy - analiza techniki operacyjnej na podstawie symulacji na zwlokach.

The aim of the study was to present consecutive stages of the partial transcondylar approach. Six simulations of the partial transcondylar approach were performed on non-fixed human cadavers without any known pathologies in the head and neck. The consecutive stages of the procedure were documented with photographs and diagrams. The starting point for the partial transcondylar approach is a posterior repositioning of the suboccipital segment of the vertebral artery. The approach is achieved by partial removal of the occipital condyle and lateral mass of the atlas as well as by suboccipital craniectomy. Elevation of the cerebellar hemisphere presents an important supplement of the approach. The partial transcondylar approach is a reproducible technique, which provides surgical penetration of the anterior part of the cranio-cervical junction and related regions. This approach is particularly useful in the treatment of intradural tumours localized ventrally to the medulla.

The assessment of prognostic factors in surgical treatment of low-grade gliomas: a prospective study.

OBJECTIVE: A prospective volumetric analysis of extent of resection (EOR) was carried out to assess surgical outcomes in adults diagnosed with hemispheric low grade gliomas (LGGs). MATERIALS AND METHODS: 68 consecutive patients diagnosed with LGGs were enrolled in the study. Pre- and post-operative tumor volumes and EOR were measured based on FLAIR MRI. Dynamic susceptibility contrast perfusion magnetic resonance imaging (DSC MRI) was used for the assessment of relative cerebral blood volume (rCBV). Three outcome measures were assessed: overall survival (OS), progression-free survival (PFS), and malignant degeneration-free survival (MFS). RESULTS: In 6 (9%) patients permanent neurologic deficits were observed. No statistically significant dependence between the EOR and the occurrence of permanent deficits was found. The eloquent or close to the eloquent location was statistically connected with lower EOR (p=0.023). The preoperative volume of tumors treated with gross total resection was significantly smaller than the volume of tumors in subtotal or partial resection groups (p=0.020, p<0.001, respectively). OS was predicted by age at diagnosis (p=0.032), and rCBV (p=0.002). Progression and malignant transformation occurred in 22 (32%) and 11 (16%) out of 68 patients. PFS was predicted by preoperative tumor volume (p=0.005), postoperative tumor volume (p=0.008), the EOR (p=0.001), and by the rCBV (p=0.033). MFS was predicted by preoperative tumor volume (p=0.034), the EOR (pp=0.020), and by rCBV (p=0.022). Postoperative tumor volume was associated with a trend of improved MFS (p=0.072). The univariate analysis shows the statistical trend for the relationship between histological subtype and PFS and MFS (p=0.079, p=0.078, respectively). Multivariate analysis selected preoperative tumor volume and rCBV as independently associated with PFS (p=0.009, p=0.019, respectively) and MFS (p=0.023, p=0.035, respectively). EOR was associated with a trend of improved PFS, and MFS (p=0.069, p=0.094, respectively). CONCLUSIONS: Tumor resection of LGG with the use of intraoperative monitoring and neuronavigation is associated with a low risk of new permanent deficits, but EOR significantly decreases with the size of the tumor and/or its location in/close to the eloquent areas. Smaller preoperative tumor volume and greater EOR are significantly associated with longer OS, PFS and MFS. Preoperative rCBV is one of the important prognostic factors significantly connected with survival. Prognosis in LGGs is still under discussion. Other factors such as age, histopathological subtype and KPS should not be underestimated.

Mucocoele and mucopyocoele of the frontal sinus penetrating to the cranial cavity and the orbit.

BACKGROUND AND PURPOSE: Mucocoele of the paranasal sinuses falls within the scope of interest for neurosurgery when erosion of the sinus wall and the osseous structures of the skull base develops and the lesion extends towards the cranial cavity, the orbit, the cavernous sinus or the sella turcica. The pa-per aims to present the method of treatment of extensive mucocoele which is used in our clinic. MATERIAL AND METHODS: We treated 7 patients (2 women and 5 men; age range: 27-68 years). Mucopyocoele was diagnosed in two cases, and mucocoele in the other five. In 5 cases, extension of the mucocoele to the cranial cavity and the orbit or to the ethmoid sinus and the orbit was observed. In the remaining 2 cases, mucopyocoele extended to the ethmoid sinus, the sphenoid and maxillary sinuses, cranial cavity and the orbit. The purpose of surgery was to remove the mucocoele or the mucopyocoele and to prevent recurrence. RESULTS: The postoperative course in all 7 patients was uneventful. All symptoms gradually receded. No relapse was observed in any patient during a follow-up period that varied from 10 months to 8 years; nor did incidents of inflammation of collateral sinuses occur. CONCLUSIONS: The treatment of mucocoele or mucopyocoele of the frontal sinus penetrating to the cranial cavity and the orbit consists of the following stages: cranialization of the frontal sinus, complete resection of the mucosa, tight closing of the frontal-nasal duct, and separating the air space of the opened collateral nasal sinuses from the cranial cavity with a large pedicled periosteal flap.

Surgical treatment of insular tumours with tractography, functional magnetic resonance imaging, transcranial electrical stimulation and direct subcortical stimulation support.

BACKGROUND AND PURPOSE: Surgical treatment of insular tumours carries significant risks of limb paresis or speech disturbances due to their localization. The development of intraoperative neuromonitoring techniques that involve evoked motor potentials induced via both direct and transcranial cortical electrical stimulation as well as direct subcortical white matter stimulation, intraoperative application of preoperative tractography and functional magnetic resonance imaging (fMRI) in conjunction with neuronavigation resulted in significant reduction of postoperative disabilities that enabled widening of indications for surgical treatment. The aim of this study was to present the authors' own experience with surgical treatment of insular gliomas. MATERIAL AND METHODS: Our cohort comprises 30 patients with insular gliomas treated at the Department of Neurosurgery in Sosnowiec. Clinical symptoms included sensorimotor partial seizures in 86.6%; generalized seizures in 23.3%; persistent headaches in 16.6% and hemiparesis in 6.6%. All the patients were operated on with intraoperative neuromonitoring that included transcranial cortical stimulation, direct subcortical white matter stimulation as well as tractography and fMRI concurrently with neuronavigation. The analysis in-cluded postoperative neurological evaluation along with the assessment of the radicalism of resection evaluated based on postoperative MRI. RESULTS: Postoperatively, four patients had permanent hemiparesis (13.3%); importantly, two out of those patients had preoperative deficits (6.6%). Persistent speech disturbances were present in four patients (13.3%). Partial sensorimotor seizures were noted in two patients (6.6%). Seizures in the other patients receded. Intraoperative transcranial electrical stimulation as well as direct subcortical white matter stimulation along with tractography (DTI) and fMRI facilitated gross total resection of insular gliomas in 53.5%, subtotal in 13.3% and partial resection in 33.1%. CONCLUSIONS: Implementation of TES, direct subcortical white master stimulation, DTI and fMRI into the management protocol of the surgical treatment of insular tumours resulted in total and subtotal resections in 66% of cases with permanent motor disability in 6.6% of patients. Poor prognosis for independent living after surgery mainly affects patients with WHO grade III or IV.

Early and long-term results of the treatment of jugular paragangliomas using different ranges of surgical approach.

BACKGROUND AND PURPOSE: The applied approach to the jugular foramen is a combination of the juxtacondylar approach with the subtemporal fossa approach type A. The purpose of this study is to present our results of treatment of jugular paragangliomas using the aforementioned approach. MATERIAL AND METHODS: Twenty-one patients (15 women, 6 men) with jugular paragangliomas were included in the study. The neurological status of the patients was assessed before and after surgery as well as at the conclusion of treatment. The approximate volume of the tumour, its relation to large blood vessels, cranial nerves and brainstem, as well as consistency and vascularity were also assessed. RESULTS: The duration of symptoms ranged from 3 to 74 months. In 86% of patients hearing loss was the predominant symptom. The less frequent symptoms included pulsatile tinnitus in the head, dysphagia and dizziness. Approximate volume of the tumours ranged from 2 to 109 cm3. A gross total resection was achieved in 71.5% of patients. The postoperative performance status improved in 38% of patients, did not change in 38% and deteriorated in 24% of patients. CONCLUSIONS: A proper selection of the range of the approach to jugular foramen paragangliomas based on their topography and volume reduces perioperative injury without negative consequences for the radicality of the resection.

A case of carotid body paraganglioma and haemangioblastoma of the spinal cord in a patient with the N131K missense mutation in the VHL gene.

The article describes paraganglioma case in woman with von Hippel-Lindau disease. She was found to be a carrier of a rare germline mutation in the VHL gene (393C>A; N131K). The patient developed large, untypical for von Hippel-Lindau disease, carotid body paraganglioma at the common carotid artery bifurcation. The carotid body paraganglioma coexisted with the haemangioblastoma situated intramedullary in region C5/C6. The haemangioblastoma reached the right-sided dorsal part of the spinal cord in section C5/C6. It produced radicular symptoms within C5/C6, followed by the later paresis of the right limbs. The haemangioblastoma was resected completely. Twelve months after the operation, the spinal symptoms receded and the carotid body paraganglioma still was asymptomatic. The current case of carotid body paraganglioma in patient with the 393C>A (N131K) missense mutation in the VHL gene, supports association of this specific mutation and VHL disease type 2, and suggests its correlation with susceptibility to paragangliomas.

Fibre integrity and diffusivity of the pyramidal tract and motor cortex within and adjacent to brain tumour in patients with or without neurological deficits.

BACKGROUND: Assessment of the relationship between preoperative neurological deficits and diffusion tensor imaging (DTI) parameters in patients with brain tumour within/adjacent to pyramidal tract and motor cortex. Evaluation of the difference in fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values in patients with low and high grade gliomas. MATERIAL AND METHODS: 20 patients with supratentorial brain tumours were divided into two groups: I with preoperative neurological deficits and II without preoperative neurological deficits. 8/20 tumours were classified as low grade gliomas, 10/20 as high grade gliomas and 2/10 as metastases. All MR examinations were performed on a 3T scanner. FA and ADC values were calculated for a precentral gyrus (PCG), a posterior limb of the internal capsule (PLIC) and a pyramidal tract (PT) ipsilateral and contralateral to the tumour side. These values were compared between patients with and without preoperative neurological deficits, with low and high grade gliomas. RESULTS: A statistical analysis revealed significant differences between patients with and without preoperative neurological deficits in PCGs and PTs ipsilateral to the tumour side. Separate analysis conducted in the group with preoperative neurological deficits showed significant statistical differences only in terms of FA values comparing ipsilateral and contralateral tumour side. No statistically significant difference was observed comparing FA and ADC values ipsilateral and contralateral to the tumour side in the group without preoperative neurological deficits and between patients with low and high grade gliomas. CONCLUSIONS: There is a relation between FA and ADC values and preoperative deficits in patients with brain tumour adjacent/within the main white matter tracts. Tumour relation to the white matter tracts is more important than the glioma WHO grade.

[Fronto-temporo-orbito-zygomatic approach - analysis of the surgical technique on cadaver simulations]. / Dostep czolowo-skroniowo-oczodolowo-jarzmowy - analiza techniki operacyjnej na podstawie symulacji na zwlokach.

This paper presents consecutive stages of the fronto-temporo-orbito-zygomatic approach (FTOZA). Two simulations of FTOZA were performed on non-fixed human cadavers without any known pathologies in the head and neck. The consecutive stages of the procedure were documented with photographs and schematic diagrams. The starting point for FTOZA is a pterional craniotomy and osteotomy including the orbital rim, body of the zygomatic bone and zygomatic arch. In justified cases it is also possible to temporarily remove the upper and lateral walls of the orbit. Wide drawing apart of the Sylvian fissure is an important supplement of the approach. The fronto-temporo-orbito-zygomatic approach is a reproducible technique, which provides surgical penetration of the middle cranial fossa and related regions. This approach is particularly useful in the treatment of tumours of the above-mentioned anatomical areas as well as vascular malformation of the posterior part of the arterial circle of the brain.

Medial sphenoid ridge meningiomas: early and long-term results of surgical removal using the fronto-temporo-orbito-zygomatic approach.

BACKGROUND AND PURPOSE: The fronto-temporo-orbito-zygomatic approach (FTOZA) is an alternative to the pte-rional approach in surgical resection of meningiomas of the medial part of the lesser wing of the sphenoid bone. The purpose of this study is to present our results of treatment of these meningiomas using the FTOZA. MATERIAL AND METHODS: Thirty patients (19 women, 11 men) with a central skull base tumour were included in the study. The neurological status of the patients was assessed before and after surgery as well as at the conclusion of treatment. The approximate volume of the operated tumour, its relation to large blood vessels, cranial nerves and brainstem, as well as consistency and vascularisation were assessed. RESULTS: The symptom duration ranged from 1 to 36 months (median: 6 months). Impaired visual acuity was the predominant symptom in 27.5% of patients. Less frequent symptoms included paresis/paralysis of the third cranial nerve, headache, psychoorganic syndrome and epilepsy. Approximate volume of the tumours ranged from 5 to 212 mL (median: 63 mL). Total or subtotal resection was achieved in 77% of patients. The postoperative performance status improved in 16.5%, did not change in 52.8% and deteriorated in 26.4% of patients. One (3.3%) patient died after the surgery. CONCLUSION: The FTOZA is a useful technique for removal of tumours expanding superiorly to the middle cranial fossa base without significant compression of the brain. Ability to remove tumours through the described approach decreases as the degree of infiltration of the clivus increases.