Bilateral posterior fracture - dislocation of the shoulders after epileptic seizure in patients with cerebral meningiomas. Triple E syndrome - Review of the literature.

Bilateral posterior fracture-dislocation of the shoulders is a very rare entity with an average rate of 0.6/100000 per year. It was first described in 1902 by Mynter. Only a few cases have been published so far. The "triple E syndrome" is used to describe the causative factors involved in this injury - epilepsy, electrocution, extreme trauma. We present our experience since 2019 with 2 cases of bilateral posterior fracture-dislocation of the shoulders after an epileptic seizure in patients with cranial meningiomas. Total removal of the meningiomas was performed in both cases and afterwards the patients were operated on by the traumatology team. The shoulder joint is the most commonly dislocated joint in the body with less than 4 % being posteriorly dislocated. Bilateral fracture-dislocation of the shoulders is associated with "triple E syndrome" and 90 % of the cases are related to seizures. The diagnosis is usually delayed due to the lack of signs of trauma. Early diagnosis and proper surgical treatment can maximize the final functional results and patient recovery.

Venous thromboembolic complications with and without intermittent intraoperative and postoperative pneumatic compression in patients with glioblastoma multiforme using intraoperative magnetic resonance imaging. A retrospective study.

OBJECTIVE: To evaluate the effectiveness of intraoperative and postoperative intermittent pneumatic compression (IPC) as a method used to decrease the incidence of deep venous thrombosis (DVT), in comparison to the standard use of graduated compression stockings, low-molecular weight heparin (LMWH) and physiotherapy during the hospital stay. All patients in this study underwent intracranial surgery for glioblastoma multiforme (GBM) using intraoperative magnetic resonance imaging (MRI) guidance. PATIENTS AND METHODS: We performed a single center retrospective study of a cohort of 153 patients who underwent surgery for GBM aided by intraoperative MRI from October of 2009 to January of 2015 at the International Neuroscience Institute (INI), Hannover, Germany. Out of all patients, 75 in comparison to 78 were operated with and without the additional use of IPC, respectively. Both groups received graduated compression stockings, LMWH and physiotherapy postoperatively as a basic thromboprophylaxis. Postoperatively the patients were screened for DVT by Doppler ultrasonography of the limbs and pulmonary embolism (PE) by CT-scan of the chest. RESULTS: DVTs were found in 6 patients with IPC and in 3 patients without IPC. The incidence of developing DVTs was therefore not significantly increased with the application of IPC from 3.9% to 8% (P-value: 0.33). No statistically significant differences were found in the probability of occurrence of pulmonary embolism (PE) with a reduction from 2.6% to 1.3% (P-value: 0.59). CONCLUSION: Our results demonstrate, that the surgical intervention and the subsequent patient immobilization, as well as the thromboprophylactic techniques used have a relatively low influence on the occurrence of thromboembolic complications than we expected. Our findings might be attributed to the overall low number of these complications in a glioblastoma multiforme patient population expected to be at a high risk for coagulopathy. In other words, in order to produce statistically significant results, we would need to increase the patient cohort. By doing so we may better detect a positive therapeutic effect. Alternatively, because of the multitude of possible complex risk-factors leading to coagulopathy in a glioblastoma patient population it might be the case that IPC has little or no effect and that there is a different underlying mechanism responsible for the observed coagulopathy.

An electrophysiological study on the safety of the endoscope-assisted microsurgical removal of vestibular schwannomas.

BACKGROUND: Endoscopy is being increasingly used in skull base surgery. The issue of its safety, however, has not been definitely solved. METHODS: We evaluated the risk of thermal or mechanical iatrogenic nerve injury related to endoscope application during microsurgical removal of vestibular schwannomas (VS) in a prospective group of 30 patients (Group A). Main analysed parameters were electrophysiological monitoring data (auditory evoked potentials and EMG) during and after endoscopic observation. The structural and functional preservation of facial and cochlear nerves, radicality of tumour removal, and CSF leak rate were evaluated and compared to historical group of 50 patients (Group B), operated consecutively with classical microsurgical technique. RESULTS: No electrophysiological changes directly related to endoscope were registered. The rate of loss of waves I, II, and V did not depend on application of endoscope and was similar in both groups. The functional and general outcome was also similar. Endoscopic inspection provided early and detailed view of anatomical relations within cerebellopontine angle and internal auditory canal and confirmed completeness of tumour removal. Total tumour removal was achieved in all patients from Group A and in 49/50 from Group B. Useful hearing after the surgery had 17/30 patients in Group A and 26/50 in Group B. CONCLUSIONS: The application of endoscope during microsurgical removal of VS is a safe procedure that does not lead to heat-related or mechanical neural or vascular injuries. The actual significance of this additional endoscopic information, however, is related to the particular operative technique and experience of the surgeon.

Late outcome of surgical treatment of the non-specific neurogenic thoracic outlet syndrome.

OBJECTIVE: Despite the relatively high incidence of the thoracic outlet syndrome, diagnostic criteria, role of surgery and optimal operative approach remain controversial. The main goal of the current study is to determine the long-term outcome of operative treatment of a series of patients with non-specific neurogenic thoracic outlet syndrome. METHODS: A retrospective study of a consecutive group of patients with thoracic outlet syndrome was carried out. The indications for surgery relied on clinical examination. Patients with diffuse pain were excluded. In all cases, the supraclavicular approach was used. Main outcome measures were neurological status and subjective complains. RESULTS: Nineteen patients have been operated over a period of 5 years. Total number of surgeries was 23. Pain and paresthesia on exertion were the leading symptoms in all cases. The causes of thoracic outlet syndrome were fibromuscular compression in 43.5%, cervical rib alone or in combination with a fibromuscular component in 30.4% and the first rib in 26.1%. The average follow-up was 36.3 months. In 91.7%, improvement of at least 50% was observed; 20.8% of the patients were completely symptom-free, and in 25%, the improvement was 90%. Recovery of the pre-operative motor weakness was recorded in 66.6%. The mortality and the permanent morbidity rates of the procedure were 0%. DISCUSSION: Operative decompression of the brachial plexus via the supraclavicular approach in patients with non-specific neurogenic thoracic outlet syndrome is a safe procedure that leads to a significant neurological improvement and amelioration of complains. The indication for surgery should be based chiefly on the neurological and clinical findings.

Hearing preservation after complete microsurgical removal in vestibular schwannomas.

AIM: To evaluate and present the treatment strategy and hearing preservation in a recent series of vestibular schwannoma cases. MATERIALS AND METHODS: A retrospective analysis of 200 patients operated consecutively over a 3 year period was performed. Patient records, operative reports, including data from the electrophysiological monitoring, follow-up audiometric examinations, and neuroradiological findings were analyzed. RESULTS: The anatomical integrity of the cochlear nerve was preserved in 75.8% of the cases. When only patients with preserved preoperative hearing were included, the rate was 84%. The overall rate of functional hearing preservation was 51%. It was highest in small tumors--60% in class T1 and 72% in class T2. In tumors extending to and compressing the brain stem, preservation of some hearing was possible in up to 43%. CONCLUSIONS: Vestibular schwannomas are benign lesions whose total removal leads to definitive healing of the patient. The goal of every surgery should be functional preservation of all cranial nerves. Using the retrosigmoid approach with the patient in the semi-sitting position, hearing preservation is possible even for large schwannomas.

Microsurgery management of vestibular schwannomas in neurofibromatosis type 2: indications and results.

AIM: To analyze the senior author's experience and strategy of treatment of patients with neurofibromatosis type 2 (NF2), with particular emphasis on vestibular schwannoma (VS) surgery. MATERIALS AND METHODS: Over a period of more than 35 years, the senior author (M.S.) has operated on more than 165 patients with NF2. The total number of VS surgeries was 210. This retrospective analysis includes 145 consecutively operated patients. Medical records, operative reports, follow-up neurological, audiometric examinations, and neuroradiological findings were analyzed. RESULTS: Total tumor removal was achieved in 85% of the operated tumors. In 15%, deliberately subtotal removal was performed for brain stem decompression and hearing preservation in the only hearing ear. The overall rate of hearing preservation was 35%. When only patients with preserved useful preoperative hearing were included, the rate was 65%. Bilateral hearing after surgery was preserved in 23% of the patients. The anatomical integrity of the facial nerve was preserved in 89%. CONCLUSIONS: The goal of VS surgery in patients with NF2 should be complete removal but not at the expense of functional impairment. Carefully individualized treatment strategy offers the possibility of prolongation of life and preservation of neurological functions.

Trigeminocardiac reflex during skull base surgery: mechanism and management.

BACKGROUND: We study the occurrence and management of the trigeminocardiac reflex (TCR) during neurosurgical procedures for lesions of the skull base. METHOD: Two hundred patients underwent neurosurgical procedures for various skull base lesions and were evaluated retrospectively for the occurrence of the TCR during surgery. This phenomenon was defined as the onset of bradycardia lower than 60 beats/minute and hypotension with a drop in mean arterial blood pressure of 20% or more due to intra-operative manipulation or traction on the trigeminal nerve. FINDINGS: Sixteen patients (8%) had a TCR intra-operatively (7 vestibular schwannomas, 5 sphenoid wing meningiomas, 3 petroclival meningiomas, 1 intracavernous epidermoid cyst). In all 16 patients with a TCR the postoperative courses presented no complications that could be directly related to this intra-operative phenomenon. CONCLUSIONS: Due to the intracranial course of the trigeminal nerve several surgical procedures at the anterior, middle and posterior skull base may elicit the trigeminocardiac reflex. Continuous monitoring of hemodynamic parameters allows the surgeon to interrupt surgical manoeuvres immediately upon the occurrence of the TCR. This technique is sufficient for the heart rate and the arterial blood pressure to return to normal levels without the necessity of additional anticholinergic medication.

Endoscope-assisted microsurgery of large vestibular schwannomas.

AIMS: The application of endoscope-assisted microsurgery in the treatment of small or medium-sized vestibular schwannomas is of proven value. The goal of our study is to evaluate its usefulness in cases of large schwannomas. PATIENTS AND METHODS: Eighteen patients were included in this prospective study. Their average tumor diameter was 3.9 cm. The retrosigmoid approach was used in all cases. The endoscope was applied during all stages of tumor removal. RESULTS: The facial nerve was visualized endoscopically at early stages of surgery in 9 patients and the abducent nerve in 7 patients. The source of bleeding was identified in 1 case. Tumor remnants in the region of the fundus of the internal auditory canal after apparently total removal were identified in 2 cases. Exposed and unobliterated temporal bone air cells were not observed. DISCUSSION: Even in cases of large schwannomas, the location of the facial nerve can be determined endoscopically early in the procedure. The application of endoscope-assisted microsurgery increases the rate of cranial nerve preservation and of total tumor removal. Although the application of the endoscope did not provide useful information in some cases, it is a safe procedure that did not lead to any complications and/or to considerable prolongation of the operative time. Its application is justified in all cases.

Cerebellopontine angle meningiomas. Clinical features and surgical treatment.

AIM: The aim of this study is to present the clinical picture of patients with cerebellopontine angle meningiomas and analyze the results of their operative treatment. METHODS: A retrospective study of patients with cerebellopontine angle meningiomas operated consecutively in our department over an 11-year period has been carried out. Data regarding their clinical features, surgical treatment, morbidity, mortality and outcome have been analyzed. Forty-four patients with cerebellopontine angle meningiomas were operated during the period 1991-2001 (intervention: tumor removal via the retrosigmoid suboccipital approach). MAIN OUTCOME MEASURES: clinical condition, MRI/ CT imaging. RESULTS: The median duration of symptoms prior to diagnosis was 44.5 months. The most frequent initial complaints were hearing loss, tinnitus and headache. Most frequent symptoms and signs at presentation were cerebellar, followed by hearing loss and trigeminal nerve symptoms. In 98% of the cases the operative approach used was the retrosigmoidal suboccipital. Total tumor removal was achieved in 55%. After total tumor removal no recurrences have been observed. The mortality rate was 2%. CONCLUSION: The application of different classification schemes complicates the comparison between published series. The outcome depends on their location, consistency, size and relation to the surrounding neurovascular structures. In our experience the retrosigmoid suboccipital approach is most appropriate for their surgical treatment. It offers the possibility to remove completely even large meningiomas and avoids the risk of recurrences.