A snapshot of European neurosurgery December 2019 vs. March 2020: just before and during the Covid-19 pandemic.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or Covid-19), which began as an epidemic in China and spread globally as a pandemic, has necessitated resource management to meet emergency needs of Covid-19 patients and other emergent cases. We have conducted a survey to analyze caseload and measures to adapt indications for a perception of crisis. METHODS: We constructed a questionnaire to survey a snapshot of neurosurgical activity, resources, and indications during 1 week with usual activity in December 2019 and 1 week during SARS-CoV-2 pandemic in March 2020. The questionnaire was sent to 34 neurosurgical departments in Europe; 25 departments returned responses within 5 days. RESULTS: We found unexpectedly large differences in resources and indications already before the pandemic. Differences were also large in how much practice and resources changed during the pandemic. Neurosurgical beds and neuro-intensive care beds were significantly decreased from December 2019 to March 2020. The utilization of resources decreased via less demand for care of brain injuries and subarachnoid hemorrhage, postponing surgery and changed surgical indications as a method of rationing resources. Twenty departments (80%) reduced activity extensively, and the same proportion stated that they were no longer able to provide care according to legitimate medical needs. CONCLUSION: Neurosurgical centers responded swiftly and effectively to a sudden decrease of neurosurgical capacity due to relocation of resources to pandemic care. The pandemic led to rationing of neurosurgical care in 80% of responding centers. We saw a relation between resources before the pandemic and ability to uphold neurosurgical services. The observation of extensive differences of available beds provided an opportunity to show how resources that had been restricted already under normal conditions translated to rationing of care that may not be acceptable to the public of seemingly affluent European countries.

Diagnostic approach to reveal retroperitoneal injury during lumbar discectomy.

For decades, lumbar discectomy has been one of the most common surgical practices performed by neurosurgeons. Although it has proved to be an effective and safe surgical procedure, life threatening complications may occur in rare cases, including iliac artery and/or vein injuries, superior rectal artery injury, common iliac artery aneurysms, iliac arteriovenous fistula, intestinal injuries, and ureteral injuries. Ureteral damage during the lumbar L4-5 microdiscectomy was reported in a slim 50 year-old male patient. Because of a small amount of bleeding occurred during the surgery as soon as the patient came out of anesthesia, an angio-computed tomography (CT) of the abdomen was performed. It showed no hematoma and no major vascular injury, but air bubbles were seen in the retroperitoneal region, indicating that perforation had occurred. The patient was then monitored carefully for immediate and possible subsequent injuries, in this way; ureteral damage was found and repaired. This is perhaps the first such case report in the literature of the early detection of ureteral damage using an angio CT scan. If there is a suspicion of perforation of the anterior annulus fibrosus and anterior longitudinal ligaments but no indication for an emergency laparotomy, an abdominal angio CT done immediately after the surgery and an abdominal non-contrast CT 4 hours later will give sufficient information concerning the potential occurrence of nearly all the major complications associated with lumbar discectomy.

Do cyst wall thickness and cyst size have any effect on the intra-operative inadvertent rupture of echinococcal hydatid cyst of central nervous system?

Our primary aim was to investigate whether there is any association between thickness of the hydatid cyst's wall and size and whether it has any effect on intact removal of the cyst, independent of the surgeons' technique. Sixteen cases of echinococcal hydatid cyst of the central nervous system, operated on between 1991 and 2007 by various surgeons, were examined. Cyst diameter was directly measured on the specimen or calculated on radiological scans. Histological preparations were made identically by cutting 5-microm-thick longitudinal sections from paraffin blocks of formalin-fixed tissue and stained with HE. Wall thickness was measured using a micrometer by the same pathologist blinded to the measurements of cyst diameter. Cyst diameter and wall thickness correlated negatively (the larger the cyst the thinner the cyst wall); however this was not statistically significant. Neither the cyst size nor the wall thickness proved to be statistically significant as a factor having an effect on intact removal of the cyst. In conclusion, the cyst size and wall thickness do not have any effect on the intact removal of hydatid cyst. It seems that the use of appropriate surgical techniques play the most effective role in outcome of hydatid cyst surgery.

Intracranial cholesteatoma - case report and critical review.

OBJECTIVE: Chronic otitis media is a potentially serious disease because of its complications, most of which are common in conjunction with cholesteatomas. There is variance in the terminology used by neurosurgeons, otorhinolaryngologists and neuropathologists. Synonyms for cholesteatoma found in the literature include epidermoid tumor, epidermoid cysts and epithelial inclusion cyst. Intracranial extension of an acquired cholesteatoma is a rarely documented occurrence. PATIENTS/MATERIAL AND METHODS: A 47-year-old woman who had undergone a right tympanomastoidectomy 20 years previously, presented with a long history of mild headaches that had become progressively more severe over the last 3 years. Clinical and radiological evaluation of the patient raised the suspicion of an intracranial cholesteatoma. RESULTS: A right temporal craniotomy was performed. The mass was completely excised and histopathological study revealed the tumor to be a cholesteatoma. The patient's post-operative recovery was uneventful. CONCLUSIONS: Cholesteatomas possess the capacity for eroding bone and can have an insidious onset, but once established, grows relentlessly and destroys neighboring structures. Since a gradual intracranial involvement does not usually cause acute symptoms of increased intracranial pressure, the correct diagnosis may be difficult. Detailed clinical and radiographic studies in particular are diagnostically helpful. Because of the high incidence of delayed recurrence, life-long follow-up is required. The inconsistency in the histopathological classification of intracranial cholesteatomas should be clarified.

Elastic and inelastic scattering of He atoms from Bi(111).

Elastic and inelastic scattering of helium atoms has been used to study the Bi(111) surface. Sharp diffraction peaks are found with results in excellent agreement with previous structure determinations of the Bi(111) surface. The rather large first order peaks with respect to the zero order peak indicate a stronger surface corrugation than observed in helium scattering from other metallic surfaces. Time-of-flight spectra of scattered He atoms clearly reveal two inelastic scattering maxima, which allow a first report on phonon creation and annihilation events on the Bi(111) surface. An estimate of the group velocity shows that the phonon creation peak is likely to correspond to a Rayleigh mode.

[Making the differential diagnosis between pituitary apoplexy and craniopharyngioma]. / Difficulté du diagnostic différentiel entre l'apoplexie hypophysaire et le craniopharyngiome.

Pituitary apoplexy is characterized by an abrupt neurological deteriorating condition associated with rapid expansion of the pituitary gland, caused by ischemic necrosis and hemorrhage. Craniopharyngioma may be difficult to distinguish from pituitary apoplexy. In this study, we discuss a case of pituitary apoplexy in a 19-year-old male patient. In our patient, the tumor was confused with a craniopharyngioma because of the suprasellar extension of the tumor on magnetic resonance (MR) images and the hyperintensity in T1-weighted images, the young age of the patient, and the gradually progressive onset of the symptoms. In conclusion, even without a known history of pituitary adenoma or an abrupt onset of the clinical symptoms, the diagnosis of pituitary apoplexy should be considered in a patient with a suprasellar mass hyperintensity in T1-weighted MR images, which may mimic craniopharyngioma.

Pediatric intramedullary teratomas.

Teratomas account for 3% of all childhood tumors, with the majority occurring in the sacrococcygeal region and in the ovary. Intradural spinal teratomas are extremely rare dysembryogenetic tumors. Spinal cord teratomas may be extradural, intradural or intramedullary. Intramedullary ones are the least frequently seen. We have extensively reviewed the literature for intramedullary spinal cord teratomas in children. Although an intramedullary teratoma of the conus medullaris in children is a rare entity, it should be considered in the differential diagnosis of masses involving the conus medullaris.

A pioneering female neurosurgeon: Dr. Aysima Altinok.

This article will look at how one female neurosurgeon in Turkey made her mark in the field. In 1954, Dr. Aysima Altinok began her residency training in neurosurgery at Haydarpasa Numune Hospital where the first official department of neurosurgery in Turkey had been founded five years earlier. On November 22, 1959, she successfully completed her training and was certified officially as a neurosurgeon. Hence, Dr. Altinok was a leader in neurosurgery. Dr. Altinok was the chief of the department of neurosurgery from 1968 to 1992 at Bakirköy Mental and Psychological Health Hospital in Istanbul. She was among the founders of the Turkish Neurosurgical Society in 1968 and was awarded the honour of "Medical Doctor of the Year in Turkey" by the Ministry of Health in 1990. On May 15, 1996, she was accepted as an honorary member of Turkish Society of Neurosurgery for her contributions to neurosurgery. For proving the capability of a woman as a neurosurgeon, her contribution to the world history of neurosurgery should be respected.

Micro-invasive squamous cell carcinoma arising in a pre-existing intraventricular epidermoid cyst. Case report and literature review.

The authors report the case of a 67-year-old woman with primary micro-invasive squamous cell carcinoma located in the lateral ventricle and originating from an epidermoid cyst. Radiological and histological features of the neoplasm are described and the relevant literature is studied briefly. Two consecutive surgical specimens were studied by light microscopy. In the histological sections of the subtotally removed material of the first operation, the cyst wall was layered by epithelium-the same as expected in an epidermoid cyst- and showed foci with mild to moderate dysplastic changes. Theses changes did not reach up to the degree of a carcinoma. However, because the cyst could not be resected totally, the possibility of a squamous cell carcinoma was considered in the differential diagnosis. In the present case, the diagnosis was firmly established in a second surgical specimen obtained ten months after the first operation. Now, the tumour proved to be a primary squamous cell carcinoma, which exhibited severe dysplastic changes. Primary squamous cell carcinoma of brain is extremely rare. To our knowledge, only 20 such tumours with pre-existing epidermoid cyst have been reported in the central nervous system. The intriguing observation in this case is a three year recurrence free survival following the subtotal removal of the malignant neoplasm at the second surgery, without postoperative radiotherapy.

Prolactin-secreting carcinoma of the pituitary: clinicopathological and immunohistochemical study of a case with intracranial and intraspinal dissemination.

A 32-year-old female patient with a primary adenohypophyseal neoplasm that rapidly progressed to a fatal outcome is presented. The time interval between her admission to the hospital and her death was 3 months. Despite dopamine agonist therapy, local invasion as well as frontal and spinal cord metastases at Th 10-12 region developed, and four surgical resections were performed. The serum prolactin levels were high. Both the primary pituitary tumour and all the metastatic tumours had the same histological findings and immunohistochemical reactions. Each was composed of pleomorphic chromophobic cells with enlarged nuclei. Mitoses and necroses were frequent. Immunostains revealed prolactin in the tumour cells. A literature review revealed that in most of the pituitary carcinomas as in our case hyperprolactinaemia did not respond to medical therapy and the histopathological appearance of the tumour has not correlated with the aggressive behaviour of the tumour. It may therefore be considered that at least some of the cases with metastases in prolactin secreting pituitary carcinomas could be the result of hyperprolactinaemia itself.

Anaplastic pleomorphic xanthoastrocytoma.

A case of anaplastic pleomorphic xanthoastrocytoma (PXA) in a 9-year-old girl is reported. Histological features of PXAs are cellular pleomorphism of GFAP-positive cells, with intracytoplasmic lipidic vacuoles and a reticulin network, bizarre giant cells, low mitotic activity, and lack of necrosis and of endothelial vascular proliferations. These tumors are generally reported to have a favorable postoperative course. In our case, a poor clinical prognosis and spread of the illness through the CSF was observed. Immunohistochemical features of the tumor, which were histologically anaplastic in nature, were analyzed. There were small foci of necrosis in the sections of the material obtained at the first operation and extensive necrosis in that from the second operation, although the patient had not received radiotherapy between the operations. The presence of necrosis in PXA is an uncommon and significant feature. It predicts the poor prognosis seen in this case, and therefore this report strongly supports the notion that necrosis should automatically exclude a tumor from the PXA category. The histological grade was evaluated as grade 3 (according to the WHO classification).