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.

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.

Assessment of explicit and implicit linguistic impairments in patients with aphasia after resection of tumour of the left cerebral hemisphere. Preliminary results.

BACKGROUND AND PURPOSE: Classical definitions of aphasia des-cribe deficits of different language levels (syntactic, semantic, phonologic) hindering the ability to communicate. Recent studies indicate, however, that impairment of particular aspects of linguistic competencies in aphasia differs in severity. Contemporary approach to the aphasic symptoms presents them as disturbed access of linguistic representations to the awareness system. Accordingly, such an approach requires different types of tasks: direct, involving explicit language processes, and indirect, based on implicit language representations. The aim of our study was to examine explicit and implicit language processes in patients with aphasia after resection of the tumour of left cerebral hemisphere along with characterization of relationships between explicit and implicit language processes. MATERIAL AND METHODS: Our cohort included 28 right-handed patients who were divided into four equal groups: two clinical (brain tumours) and two control (lumbar disc disease). Four tasks that assess and compare language processes: lexical decisions (at explicit and implicit levels), sorting of picture captions and word monitoring were implemented. RESULTS: In direct tasks, patients with aphasia provided less correct lexical decisions at word level, but did not show deficits in sentence comprehension. In both groups, no priming effect was observed in tasks requiring implicit lexical decisions. The longest time was found in non-primed words, the shortest in pseudowords. The differences between groups regarding word monitoring were also observed. Patients with aphasia obtained longer reaction times in all types of sentences (of different grade of language correctness), with respect to low- and high- frequency words. CONCLUSIONS: Patients with aphasia after brain tumour resection show more pronounced impairments of explicit than implicit linguistic behavior; the same effect was found in studies on forgetting in amnestic syndrome.

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.

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.

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.

Rare primary tumours of the hypothalamus in adults: clinical course and surgical treatment.

BACKGROUND AND PURPOSE: The paper presents the operative technique and the results of treatment of adult patients with primary tumours of the hypothalamus, including rare ones. The aim of the study was to show the possibility of safe surgical treatment of rare tumours of the hypothalamus through a bifrontal basal interhemispheric trans-lamina terminalis approach. MATERIAL AND METHODS: Five patients with tumours of the hypothalamus were operated on in the Neurosurgical Clinic in Sosnowiec between 1990 and 2008. There were 2 patients with craniopharyngiomas located exclusively in the third ventricle, and single patients with gemistocytic astrocytoma, Langerhans cell histiocytosis X and hamartoma of the hypothalamus each. The patients were treated surgically with a bi-frontal basal interhemispheric trans-lamina terminalis approach. In two cases, the neuronavigation system with the use of tractography (DTI) was used to determine the location of the lamina terminalis, the posterior surface of the optic chiasm and the optic tracts. RESULTS: All lesions were resected totally, except for partially resected hamartoma of the hypothalamus. The most common postoperative complication was diabetes insipidus, which was transient in two cases. A long-lasting follow-up of all the patients operated on did not reveal regrowth of the lesion. CONCLUSIONS: The bifrontal basal interhemispheric trans-lamina terminalis approach allows for radical resection of primary tumours of the hypothalamus while avoiding serious post-operative deficits. This approach enabled the preservation of the olfactory bulb and tract and prevented damage of the frontal lobes. The use of DTI helped to establish the location and borders of the lamina terminalis, to establish the posterior surface of the optic chiasm and the optic tracts, and to save the anterior and lateral wall of the hypothalamus.

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.

Direct and remote outcome after treatment of tumours involving the subtemporal fossa and related structures with the extended subtemporal approach.

BACKGROUND AND PURPOSE: The aim of the study was to present our results of the surgical treatment of subtemporal fossa tumours and surrounding regions using the extended subtemporal approach. MATERIAL AND METHODS: Twenty-five patients (10 women, 15 men) with subtemporal fossa tumours were included in the study. The neurological and performance status of the patients were assessed before and after surgery as well as at the conclu-sion of treatment. The approximate volume of the operated tumour, its relation to large blood vessels and cranial nerves, as well as consistency and vascularisation were assessed. RESULTS: The symptom duration ranged from 2 to 80 months (mean: 14 months). In 44% of patients, headache was the predominant symptom. Less frequent symptoms were: paralysis of the abducent nerve and disturbances of the trigeminal nerve. Approximate volume of the tumours ranged from 13 to 169 cm3 (mean: 66 cm3). The most frequent histological diagnosis was meningioma (16%), followed by angiofibroma, neurinoma and adenocystic carcinoma (12%). Total or subtotal resection was achieved in 80% of patients. CONCLUSIONS: The extended subtemporal approach allows for the removal of tumours of the subtemporal fossa and surrounding regions. This approach also allows one to remove tumours expanding in the regions surrounding the subtemporal fossa only. In such cases the subtemporal fossa constitutes the way of the surgical approach.

Direct and remote outcome after treatment of tumours involving the central skull base with the extended subfrontal approach.

BACKGROUND AND PURPOSE: To present our results of the surgical treatment of central skull base tumours using the extended subfrontal approach (ESA). MATERIAL AND METHODS: Twenty-six patients (8 women, 18 men) with central skull base tumours were included in the study. The neurological and performance 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 the large blood vessels, cranial nerves and brainstem, as well as consistency and vascularisation were assessed. RESULTS: The symptom duration ranged from 1.5 to 18 months (mean: 8.3 months). Loss of olfaction was the predominant symptom in 38% of patients. Less frequent symptoms were: paresis/paralysis of the 6th cranial nerve, psychoorganic syndrome, impaired visual acuity, nasal obstruction and headache. Approximate volume of the tumours ranged from 10 to 105 ml (mean: 54.3). The most frequent histological diagnosis was chordoma (19%), meningioma (15%), followed by haemangiopericytoma, fibroma and esthesioneuroblastoma (12%). Total or subtotal resection was achieved in 77% of patients. The postoperative performance status was improved in 39%, unchanged in 27% and impaired in 15% of patients. Five patients died after the surgery. CONCLUSIONS: Extended subfrontal approach is a useful technique for removal of benign tumours expanding along the midline, superiorly and inferiorly to the skull base. For removal of malignant tumours at the same location, ESA is an alternative to a combination of transcranial approach and one of the craniofacial approaches.

[Lateral approach to the cavernous sinus and its surroundings--analysis of surgical technique based on cadaver simulations]. / Dostep boczny do zatoki jamistej i jej otoczenia--analiza techniki operacyjnej w oparciu o symulacje na zwlokach.

BACKGROUND AND PURPOSE: The paper aims to present individual stages of a surgical approach to the cavernous sinus (CS) and its surroundings. MATERIAL AND METHODS: Twelve simulations of a surgical approach to the CS and its surroundings were performed in non-fixed cadavers. The subsequent stages of simulation were recorded in photographs and drawings. RESULTS: The starting point for the approach to the CS is a pterional craniotomy, as well as an osteotomy encompassing the anterior clinoid process and the surroundings of the superior orbital fissure, the optic canal, the foramen rotundum and the foramen ovale. The important phases of the approach include the delamination of the lateral CS wall and the mobilization of the dural rings of the internal carotid artery. Opening of the CS should be preceded with establishing proximal and distal control over the internal carotid artery. CONCLUSIONS: The surgical approach to the CS and its surroundings constitutes a repeatable method of penetration in this area of the cranial base, and it allows for limiting brain traction and preserving the anatomical integrity of the related vessel and nerve structures.

Direct and remote outcome after treatment of tumours involving the cavernous sinus and its surroundings.

BACKGROUND AND PURPOSE: The aim of this study was to present results obtained by the authors after surgical treatment of tumours involving the cavernous sinus (CS) and its surroundings. MATERIAL AND METHODS: Thirty-eight patients (23 females and 15 males) with tumours of the CS and its surroundings were included in the study. The neurological condition of patients and their ability to perform activities of daily living were evaluated prior to treatment, postoperatively and after completion of therapy. The following parameters were measured: approximate volume of the operated lesions; their relation to larger vessels, cranial nerves and the brainstem; consistency and vascularization. RESULTS: The medical history of the disease ranged from 1.5 to 48 months, mean 12 months. In 89.5% of cases impaired ocular motility on the side of the lesion was the symptom indicative of the condition. The second most common group of symptoms (29%) included impairments of trigeminal nerve function. The approximate volume of all resected tumours ranged from 0.6 to 60 mL (mean 12.2 mL). In 50% of cases the resected tumours were diagnosed as meningiomas. The remaining entities included: perithelioma, hypophyseal adenoma, adenoid cystic carcinoma, neuroendocrine carcinoma, trigeminal neurinoma, chordoma, cavernous angioma and lymphoma. In 63% resections were complete. Functional capacity of patients improved in 34% of cases, remained unchanged in 53%, deteriorated in 10.5%, and one patient died. CONCLUSIONS: Surgical intervention involving the CS and its surroundings enables resection of neoplastic tumours of this anatomical region with satisfactory clinical results and low mortality. Most patients suffer from temporary paresis or paralysis of the oculomotor, trochlear and abducent nerves. Reduction of completeness of resections of CS tumours decreases the number of postoperative neurological deficits without a significant increase in the rate of lesion regrowth.

Surgical approaches to pathological lesions of the middle cerebellar peduncle and the lateral part of the pons - clinical observation.

BACKGROUND AND PURPOSE: Pathological lesions of the middle cerebellar peduncle include tumours, arteriovenous malformations, cavernous angiomas and spontaneous haematomas. Because of the very low incidence of these lesions, surgical approaches to the middle cerebellar peduncle are not commonly known. The authors decided to present their own experience based on five cases operated on at the authors' institution. MATERIAL AND METHODS: Five patients were operated on, four with tumours and one with spontaneous haematoma of the middle cerebellar peduncle. In three patients the cerebellomedullary fissure approach was used, in one patient the paramedian supracerebellar approach, and in one patient the retrosigmoid approach. RESULTS: In all cases neoplastic lesions and haematoma were totally removed. In each case, balance disturbances and ataxia of extremities increased or occurred as a new sign. These disturbances diminished within several weeks after the procedure. In the case of location of the lesion also in the lateral part of the pons, the authors observed peripheral paresis of the seventh cranial nerve and paresis of the sixth cranial nerve, which tended to resolve. CONCLUSIONS: Pathological lesions of the middle cerebellar peduncle can be effectively treated surgically. The cerebellomedullary fissure approach has been found to be the best because it provides greater access to the dorsal surface of the middle cerebellar peduncle and to the lateral part of the pons. The most frequent complications of the procedure were instability and ataxia as well as paresis of the sixth and seventh cranial nerve when the lesion was found in the lateral part of the pons.

[Cerebral aneurysms in patients with the occlusion of the brachiocephalic vessels]. / Tetniaki mózgu u chorych z niedroznoscia tetnic zewnatrzczaszkowych.

Cerebral aneurysms coexistent with iatrogenic (after surgical ligation or occlusion) or idiopathic (due to atheromatosis) occlusion of an extracranial cerebral artery are very rare. The occlusion of the brachiocephalic vessels leads to the formation of a collateral circulation at two levels: the circle of Willis and the connections between collaterals of the extracranial cerebral arteries. The authors discuss different types of collateral arterial pathways as well as hemodynamic abnormalities in the case of the occlusion of the brachiocephalic vessels, particularly internal carotid artery or the innominate artery occlusion. The paper analyses the etiopathogenesis of cerebral aneurysms in view of the hemodynamic theory of cerebral aneurysms formation. The article is illustrated with own three cases of ruptured cerebral aneurysms coexistent with the occlusion of the innominate artery.

[Operative treatment of the intramedullary tumors with the methylprednisolone usage--preliminary report]. / Leczenie operacyjne guzôw srodrdzeniowych z zastosowaniem methylprednizolonu - doniesienie wstepne.

UNLABELLED: The aim of the study was to assess the intermediate results of the intramedullary tumors treatment with neuroprotection including the methyvlprednisolone (MP) usage. MATERIAL AND METHOD: In the 1995-2003 period 33 patients with intramedullary tumors were operated on in Department of Neurosurgery in Sosnowiec. They were 10 females and 23 males in the age range of 11-61 years. Neuroprotection of the spinal cord in the course of treatment included: determining operational tactics on the basis of magnetic resonance imaging (MRI) performed in three planes, using MP according to NASCIS II and in maintenance dose in the 2-7 day after the operation, SSEP monitoring, myelotomy in the form of anatomical preparation of the posterior longitudinal fissure, sparing big transverse branches of the vasocorona of the posterior column, debulking of the tumor with an ultrasonic aspirator or CO2 laser, closure of the spinal cord after the removal of the tumor with pial sutures and sutures of the arachnoidea. RESULTS: Among the operated tumors 16 had a clear border, the remaining ones were 14 astrocytomas of varying malignancy and infiltration of the white matter of the spinal cord and 3 lipomas. Control MRI revealed a total removal of the lesion in 23 patients (70%), gross total removal in 7 patients (21%) partial removal in three patients (9%). The postoperative condition of the patients 2-3 weeks after the operation showed improvement in 12 cases (37%), no significant changes in 10 cases (30%) and deterioration in 11 cases (33%). CONCLUSION: Appropriate operative tactics together with the use of the MP make the acceptable morbidity rate after radical removal of intramedullary tumors .

Early Detection of Malignant Transformation in Resected WHO II Low-Grade Glioma Using Diffusion Tensor-Derived Quantitative Measures.

OBJECTIVE: Here, we retrospectively investigate the value of voxel-wisely plotted diffusion tensor-derived (DTI) axial, radial and mean diffusivity for the early detection of malignant transformation (MT) in WHO II glioma compared to contrast-enhanced images. MATERIALS AND METHODS: Forty-seven patients underwent brain magnetic resonance imaging follow-up between 2006-2014 after gross-tumor resection of intra-axial WHO II glioma. Axial/Mean/Radial diffusivity maps (AD/MD/RD) were generated from DTI data. ADmin/MDmin/RDmin values were quantified within tumor regions-of-interest generated by two independent readers including tumor contrast-to-noise (CNR). Sensitivity/specificity and area-under-the-curve (AUC) were calculated using receiver-operating-characteristic analysis. Inter-reader agreement was assessed (Cohen's kappa). RESULTS: Eighteen patients demonstrated malignant transformation (MT) confirmed in 8/18 by histopathology and in 10/18 through imaging follow-up. Twelve of 18 patients (66.6%) with MT showed diffusion restriction timely coincidental with contrast-enhancement (CE). In the remaining six patients (33.3%), the diffusion restriction preceded the CE. The mean gain in detection time using DTI was (0.8±0.5 years, p = 0.028). Compared to MDmin and RDmin, ROC-analysis showed best diagnostic value for ADmin (sensitivity/specificity 94.94%/89.7%, AUC 0.96; p<0.0001) to detect MT. CNR was highest for AD (1.83±0.14), compared to MD (1.31±0.19; p<0.003) and RD (0.90±0.23; p<0.0001). Cohen's Kappa was 0.77 for ADmin, 0.71 for MDmin and 0.65 for RDmin (p<0.0001, respectively). CONCLUSION: MT is detectable at the same time point or earlier compared to T1w-CE by diffusion restriction in diffusion-tensor-derived maps. AD demonstrated highest sensitivity/specificity/tumor-contrast compared to radial or mean diffusivity (= apparent diffusion coefficient) to detect MT.

[Occipitocervical fixation in the surgical treatment of pathologies of the craniovertebral junction]. / Stabilizacja szyjno-potyliczna w chirurgicznym leczeniu patologii pogranicza czaszkowo-kregoslupowego.

BACKGROUND AND PURPOSE: New surgical approaches to the tumors of the skull base necessitate removal of certain bone structures of the base. In the case of the transcondylar far-lateral approach, the whole occipital condyle and lateral mass of C1 are removed resulting in iatrogenic instability. Consequently, an occipitocervical fixation is needed. The aim of the study was to assess the usefulness of the CCD cervical system for the occipitocervical fixation in the surgery of the tumors of the craniovertebral junction. MATERIAL AND METHODS: The authors present the application of the CCD cervical system produced by Medtronic Sofamor-Danek in three patients who underwent surgery of tumors of the foramen magnum, clivus or craniovertebral junction. The system consists of two titanium rods, which adjusted to the curvature of the spine and the occiput, are fixed by laminar cervical and occipital hooks, fixed to the trepanation hole edge or the edge of the foramen magnum. It is also possible to use screws driven to the occipital bone if it is more than 7 mm thick. RESULTS: The system fixation is simple and relatively short. Good stabilization was achieved in all patients. No complications caused by the implants have been observed. CONCLUSIONS: The CCD cervical system can be successfully used for the occipitocervical fixation in a lateral transcondylar approach and in the cases of other non-traumatic craniocervical instability. It is especially recommended in cases of unusual thinning of the occipital bone or in osteoporotic states.

[Surgical technique in operations for brainstem gliomas]. / Technika chirurgiczna operacji glejaków pnia mózgu.

The article presents an MRI-based classification of brainstem gliomas into focal, cervicomedullary, dorsal exophytic and diffuse ones. This classification provides the basis for specifying indications for surgical treatment and outcome. The article also presents the most frequent approaches to the midbrain, pons and medulla oblongata. These approaches include the pterional, orbito-zygomatic, subtemporal transtentorial and supracerebellar approaches to the midbrain. Suboccipital, trans fourth ventricle, subtonsillar, retrosigmoid and anterior petrosal approaches were used in the case of the pons. Suboccipital, trans fourth ventricle and transcondylar approaches were applied for the removal of tumors of medulla oblongata. This paper elaborates on rare approaches: transcondylar, paramedian-supracerebellar, subtonsillar and anterior petrosal ones effectively applied in our clinic. The resection of brain stem tumors is performed by piecemeal resection and not by removal en bloc. We stress the significance of safe entry zones to the brain stem and places at the fossa rhomboidea whose impairment may cause severe disability. Lesion of trigonum nervi hypoglossi, trigonum nervi vagi, colliculus facialis and fasciculus longitudinalis medialis leads to severe disability or death of the patient.