Suboccipital Retrocondylar Approach for an Anterolateral Foramen Magnum Meningioma.

Objectives This study was to demonstrate surgical technique for an anterolateral foramen magnum meningioma. Design Present study is presented through an operative video. Setting This study is conducted at the Department of Neurosurgery, Tîrgu Mureș, Romania. Participants A 62-year-old female is the participant who was diagnosed with a foramen magnum meningioma. Main Outcome Measures Complete surgical resection of the tumor with no postoperative deficits or complications. Results A 62 years-old female was admitted for left hemilingual atrophia, dysphonia, right hemiparesis grade 2 of 5, right hemihypesthesia, and cervical pain. The magnetic resonance imaging (MRI) showed a right foramen magnum meningioma, sized approximately 2 cm in all planes ( Fig. 1 ). This was classified with the Bernard system as an intradural foramen magnum meningioma with anterolateral insertion to the dura mater and below the vertebral artery. A suboccipital, retrocondylar, and c1 right hemilaminectomy approach was performed. Using microsurgical tumoral decompression techniques, ultrasonic aspiration, and following the natural cleavage planes, complete tumor removal was achieved ( Fig. 2 ). The patient presented an uneventful postoperative course with no postoperative new neurological deficits and was discharged at home 7 days following surgery. Control MRI at 6 months ( Fig. 1 ) and 2 years showed no tumor residue or recurrence. Neurologic status at 6 months was excellent, showing complete remission of symptoms. Conclusion Retrocondylar suboccipital approach is a safe and feasible option for anterolateral foramen magnum meningiomas provided that natural corridors and dynamic retraction are used. The link to the video can be found at: https://youtu.be/jpxMcjCpN6E .

Surgical Strategies and Clinical Outcome of Large to Giant Sphenoid Wing Meningiomas: A Case Series Study.

Large to giant sphenoid wing meningiomas (SWMs) remain surgically challenging due to frequent vascular encasement and a tendency for tumoral invasion of the cavernous sinus and optic canal. We aimed to study the quality of resection, postoperative clinical evolution, and recurrence rate of large SWMs. This retrospective study enrolled 21 patients who underwent surgery between January 2014 and December 2019 for SWMs > 5 cm in diameter (average 6.3 cm). Tumor association with cerebral edema, extension into the cavernous sinus or optic canal, degree of encasement of the major intracranial arteries, and tumor resection grade were recorded. Cognitive decline was the most common symptom (65% of patients), followed by visual decline (52%). Infiltration of the cavernous sinus and optical canal were identified in five and six patients, respectively. Varying degrees of arterial encasement were seen. Gross total resection was achieved in 67% of patients. Long-term follow-up revealed improvement in 17 patients (81%), deterioration in two patients (9.5%), and one death (4.7%) directly related to the surgical procedure. Seven patients displayed postoperative tumor progression and two required reintervention 3 years post initial surgery. Tumor size, vascular encasement, and skull base invasion mean that, despite technological advancements, surgical results are dependent on surgical strategy and skill. Appropriate microsurgical techniques can adequately solve arterial encasement but tumor progression remains an issue.

Effects of Surgery on the 30-Day Survival Rate in Spontaneous Supratentorial Intracerebral Hemorrhage.

Background: Spontaneous intracerebral hemorrhage (ICH) is a severe form of stroke. The efficacy of surgery as ICH treatment is controversial. We sought to compare the 30-day postoperative mortality rate between patients with surgically and medically treated ICH; Methods: This prospective study enrolled patients consecutively diagnosed with ICH and treated between 2017 and 2019. Patients meeting the study surgical indications were assigned to either surgical or medical treatment. The relationship between Glasgow Coma Scale (GCS) score, age, ICH location, ICH volume, and 30-day mortality was analyzed. Results: A total of 174 ICH patients were enrolled in this study. Of these, 136 met the surgery criteria; 65 of these underwent surgery (Group A), and 71 received medical treatment (Group B). Age and ICH location did not modify mortality. Although surgery did not overall improve mortality some better postsurgical outcomes were observed among patients surgically treated with GCS scores of at least 10 points and ICH volumes between 30 to 50 mL; Conclusions: Despite achieving an immediate reduction in intracranial pressure, surgery seems to be advantageous only for patients with ICH volumes between 30 to 50 mL and GCS scores of 10 points or higher.

The Involvement of Exosomes in Glioblastoma Development, Diagnosis, Prognosis, and Treatment.

Brain tumours are a serious concern among both physicians and patients. The most feared brain tumour is glioblastoma (GBM) due to its heterogeneous histology, substantial invasive capacity, and rapid postsurgical recurrence. Even in cases of early management consisting of surgery, chemo-, and radiotherapy, the prognosis is still poor, with an extremely short survival period. Consequently, researchers are trying to better understand the underlying pathways involved in GBM development in order to establish a more personalised approach. The latest focus is on molecular characterisation of the tumour, including analysis of extracellular vesicles (EVs), nanostructures derived from both normal and pathological cells that have an important role in intercellular communication due to the various molecules they carry. There are two types of EV based on their biogenesis, but exosomes are of particular interest in GBM. Recent studies have demonstrated that GBM cells release numerous exosomes whose cargo provides them the capacity to facilitate tumour cell invasion and migration, to stimulate malignant transformation of previously normal cells, to increase immune tolerance towards the tumour, to induce resistance to chemotherapy, and to enhance the GBM vascular supply. As exosomes are specific to their parental cells, their isolation would allow a deeper perspective on GBM pathogenesis. A new era of molecular manipulation has emerged, and exosomes are rapidly proving their value not only as diagnostic and prognostic markers, but also as tools in therapies specifically targeting GBM cells. Nonetheless, further research will be required before exosomes could be used in clinical practice. This review aims to describe the structural and functional characteristics of exosomes and their involvement in GBM development, diagnosis, prognosis and treatment.

First-Onset Hypokalemic Periodic Paralysis Following Surgery for Myxopapillary Ependymoma.

BACKGROUND: Hypokalemic periodic paralysis is a rare skeletal muscle channelopathy characterized by intermittent episodes of acute flaccid paralysis with associated hypokalemia. We present here the case of a first-onset hypokalemic periodic paralysis triggered by lumbar spinal surgery for tumor resection. CASE DESCRIPTION: A 37-year-old male without any known prior medical conditions presented with a first-onset attack of hypokalemic paralysis 1.5 days after lumbar spinal surgery for myxopapillary ependymoma. Initially, the patient presented paraparesis mimicking a spinal cord compression, and while en route for imaging there was an abrupt onset of flaccid paralysis with significant respiratory distress. The emergency blood tests revealed extreme hypokalemia with a serum potassium of 1.42 mm/L. The patient was transferred to the intensive care unit, intubated, sedated, and administered intravenous reperfusion with an infusion dose of 20 mEq/hour potassium in a solution of 5% mannitol. Following reperfusion, the patient recovered completely in 12 hours. Renal potassium hyperexcretion and hyperthyroidism were excluded by laboratory tests. The diagnosis was confirmed by genetic tests showing mutation of the CACNA1S gene. CONCLUSIONS: To the best of our knowledge, this is the first described case with the first onset triggered by a neurosurgical intervention and the second case following any kind of surgery. Neurosurgeons should consider hypokalemic periodic paralysis when encountering a rapidly evolving tetraparesis, even in an apparently healthy patient.

Gross-total versus near-total resection of large vestibular schwannomas. An institutional experience.

OBJECTIVE: We will report our experience of the surgical treatment of large vestibular schwannomas (VSs). PATIENTS, MATERIALS AND METHODS: We conducted a retrospective study of patients operated on for Koos grade IV VS between 2007 and 2015 at the Department of Neurosurgery, Emergency County Hospital, Târgu Mures, Romania. We studied the general preoperatory clinical data, the preoperative and postoperative facial nerve status, preoperative hearing on the affected side, and any postoperative complications, including death. RESULTS: Sixty-six cases were included in our study. The mean age was 52.95 years and 66.7% (n=44) of the sample were female. All patients had suffered from tinnitus and this had been followed by loss of serviceable hearing on the affected side in 89.4% (n=59) of cases. Preoperative facial palsy was found in 53% (n=35) of patients. The mean tumor size was 40.35 mm. Gross-total resection (GTR) was achieved in 24 (36.36%) cases, while near-total resection (NTR) was obtained in 42 (63.64%) cases. New-onset facial palsy or degradation of the preoperative facial deficit occurred in 12 (18.18%) cases, most of whom were patients with a GTR (n=9, 37.5%). This was statistically significant. There were no significant postoperative differences between the GTR and NTR groups. There was one death in the GTR group. CONCLUSIONS: We conclude that near-total tumor removal provides good surgical results and better postsurgical quality of life for patients when compared to gross-total tumor resection. Therefore, this should be the end goal of the resection of large VSs.

Risks and Benefits of Endoscopic Transsphenoidal Surgery for Nonfunctioning Pituitary Adenomas in Patients of the Ninth Decade.

BACKGROUND: The population older than 80 years of age (very elderly) is increasing, and the management of these patients with pituitary surgery is controversial. OBJECTIVE: To determine the prevalence of pituitary tumors in elderly patients and to determine the safety of endoscopic transsphenoidal pituitary surgery for nonfunctioning pituitary adenomas in patients aged older than 80 years. METHODS: This retrospective study included elderly (65-75 years old) and very elderly consecutive patients operated between 2007 and 2015 for nonfunctioning pituitary adenomas. Tumor characteristics, comorbidities, pre- and postoperative visual and endocrinologic status, and postoperative complications were compared. RESULTS: Of the total 623 operated patients, 307 had nonfunctioning pituitary adenomas. Twenty-three percent (n = 143) of all patients were aged older than 65 years, whereas 2.56% (n = 16) were aged older than 80 years. Gonadotroph and nonimmunoreactive tumors occurred in 81% of patients aged older than 65 years. The study groups were Group A, comprising 15 patients aged older than 80 years, and Group B, comprising 49 patients aged 65-75 years. No presurgical statistical differences were noted between the 2 groups. Complete tumor resection was achieved in 53.3% of Group A and 73.5% of Group B. Postsurgical visual status improved significantly in Group A than in Group B (P = 0.0012). No deaths occurred, and no group differences were noted in the postoperative complications. CONCLUSIONS: Age exceeding 80 years is not by itself a predictor of worse clinical outcome of endoscopic transsphenoidal pituitary surgery for nonfunctioning adenomas. Emphasis should be placed on visual pathway decompression for the quality of life in very old people.

Ectopic intracavernous corticotroph microadenoma: case report of an extremely rare pathology.

Ectopic pituitary adenomas (EPAs) are most likely tumors developing from the cellular remnants following the migration of Rathke's pouch. We present the case of a 54-year-old female diagnosed with Cushing's syndrome. Magnetic resonance imaging (MRI) identified an ectopic microadenoma located in the median wall of the cavernous sinus. Microscopic transsphenoidal surgery was performed and the lesion was completely removed without any postoperative surgical complications. Based on characteristic microscopic and immunohistochemical features and on recent clinicopathological prognostic classifications, the histopathological diagnosis was non-proliferative, non-invasive corticotroph pituitary neuroendocrine tumor, grade 1a. Complete remission of disease was achieved postoperatively and was maintained for one year following surgery. MRI showed complete resection, without tumor recurrence at one and two years. Occurrence of an ectopic intracavenous adrenocorticotropic hormone (ACTH)-secreting adenoma is extremely rare and poses difficulties both in the identification, surgery, histopathological grading, and adequate endocrinological treatment and follow-up.

Bilateral Thalamic Glioma: Case Report and Review of the Literature.

Bilateral thalamic glioma is extremely rare and the incidence cannot be adequately expressed. We present the case of a 72 years old male suffering from the rapid deterioration of cognitive function to moderately severe dementia in a short period of time. Magnetic resonance studies demonstrated a bilateral thalamic glioma with a minimal focal gadolinium uptake in the left thalamus. Biopsy was performed and pathology report was of anaplastic astrocytoma, WHO grade III. Radiotherapy was proposed but was rejected by the patient's relatives. The patient deceased 57 days later. We performed an extensive review of the literature and by updating the previous described series we can state that to the best of our knowledge this is the 60th case described in the literature and the second eldest patient presented. Patients suffering from this disease present a poor prognosis, the longest survival described being of 3 years in patients diagnosed with grade II bilateral thalamic glioma. Adjuvant therapy in form of radiotherapy to the thalami is most commonly used but the benefits are unclear. The natural progression of WHO grade III bilateral thalamic glioma left untreated, as can be seen from our case, has an even poorer outcome.