Anterior communicating artery aneurysm rupture and functional outcome in short-term: clipping versus coiling.

Our research aims to assess the change in the grade of responsiveness using the Hunt and Hess score as well as the modified ranking scale in patients suffering from anterior communicating artery rupture. We retrospectively analyzed data from 11-patients who suffered from an anterior communicating artery aneurysm rupture that caused a subarachnoid hemorrhage. Severity was assessed using the Hunt and Hess scale grade and modified ranking scale. Anterior communicating artery rupture caused a subarachnoid hemorrhage in 40.81% of all aneurysm ruptures that took place at the Circle of Willis. Unfortunately, 4-patients deceased (3.4%) at a median age of 52-years (range 34-75-years), three of which deceased after coiling and one after clipping. In 71-patients (61.2%) endovascular coiling was performed - 33-males and 38-females - and in the remaining 45-cases, (38.8%) clipping was indicated - 24-males and 21-females. Overall, the pre-interventional median Hunt and Hess scale was 2, which remained after the intervention. When relating the outcome score to the intervention performed, we found that the Hunt and Hess scale score was 3 before coiling and 2 before clipping, whereas afterward, there was a slight increase to 2 and 2, respectively. The modified ranking scale was 2 after clipping, respectively, coiling (P = 0.218). No significant differences were observed between the different groups. Our results show that clipping is as effective as coiling in terms of the Hunt and Hess scale and the rate of mortality in the short-term.

Minimally invasive spine surgery: systematic review.

Minimally invasive procedures in spine surgery have undergone significant development in recent times. These procedures have the common aim of avoiding biomechanical complications associated with some traditional destructive methods and improving efficacy. These new techniques prevent damage to crucial posterior stabilizers and preserve the structural integrity and stability of the spine. The wide variety of reported minimally invasive methods for different pathologies necessitates a systematic classification. In the present review, authors first provide a classification system of minimally invasive techniques based on the location of the pathologic lesion to be treated, to help the surgeon in selecting the appropriate procedure. Minimally invasive techniques are then described in detail, including technical features, advantages, complications, and clinical outcomes, based on available literature.

Novel surgical approach in the management of longitudinal pathologies within the spinal canal: the split laminotomy and "archbone" technique: alternative to multilevel laminectomy or laminotomy.

Multilevel laminectomy to open the spinal canal carries the risk of spinal deformities and instability. With the aim of preserving and reconstructing the posterior structures the authors developed a novel, minimally invasive, multilevel spinous process splitting and distracting laminotomy approach with or without complementary corticocancellous iliac crest or PEEK cage "archbone" grafting. The technique allows exploration of the spinal canal and the removal of intramedullary pathologies. Moderate enlargement of the spinal canal with preservation of the majority of posterior structures is also possible, so that muscle attachments remain intact and postoperative complications are substantially reduced.This surgical approach, while fulfilling the requirements of previous laminotomy techniques, helps to prevent damage to the crucial posterior stabilizers of the spine. In contrast to conventional spinal canal approaches, preservation of the majority of posterior structures is possible, leaving muscle attachments on the spinous processes and laminae completely intact.Furthermore, the procedure for exposure and decompression of the spinal canal is a suitable method for all spinal segments, the cervical, thoracic, and the lumbar spine in all age groups.

Split laminotomy and complementary spacer insertion for opening and enlargement of the thoracic spinal canal at infiltrative intramedullary tumor removal.

OBJECTIVE: The author main objective was to improve the previously developed technique of split laminotomy and moderate enlargement of the spinal canal with preservation of the majority of posterior structures, and to avoid the complications of the classic autologous bone grafting procedure. METHODS: A multilevel spinous process splitting and distracting laminotomy technique with complementary spacer insertion between the laminar parts was developed. We used Poly-Ether-Ether-Ketone (PEEK) cages. This improved method was used in five patients to remove malignant intramedullary tumors at the thoracic level. RESULTS: Adequate surgery of the tumors located intramedullary, and permanent decompression of the spinal canal was achieved in all patients using our new modified procedure. The results have been postoperatively confirmed with MRI and CT. The affected spine was the thoracic in all cases. The numbers of split laminae were three to five. Histological results were as follows: four intramedullary astrocytomas, one ependymoma. The ependymoma was completely, while the astrocytomas were only subtotally removed. In all cases heterologous grafts were inserted between the sides of the distracted laminas, to achieve the enlargement of the spinal canal. The mean duration of the whole surgical procedure was 118 minutes (range 91 to 145 minutes). The average follow-up was 11.2 months, with the range from five to 16 months. Upon postoperative neurological follow-up, no complications were revealed related to the newly developed procedure. The postoperative followup CT scans demonstrated bony healing, with a cage between the osteotomized faces. No compression or dislocation of the spacer was seen. Instability was not detected in any of the patients by flexion or extension lateral radiographs. CONCLUSION: This modification of the split laminotomy and heterologous grafting method fulfills the requirements of other laminotomy techniques. The split laminotomy is suitable for removing intramedullary tumors, and the posterior stabilizing structures of the spine, as the vertebral laminae and the longitudinal musculature are completely prevented. Due to use of allograft the complications of the classic hip bone grafting procedures are avoided. The spacers, inserted between the osteotomized faces, provided permanent decompression of the spinal canal, and bony healing--throughout the spacer--of the splitted vertebral laminae, without iliac graft complications.

[New minimally invasive surgical techniques in spinal surgery]. / Új mutéttechnikai eljárások a gerincsebészetben, különös tekintettel a minimálinvazivitásra.

The last decade has brought significant development in spine surgery. As in all field of surgery, introduction of the minimal invasive, atraumatic procedures characterized our activities. The number of short and long-time complications were significantly reduced and the effectiveness of operations were markedly improved by the new technical conditions, for example by the use of neuronavigation, surgical microscope, intraoperative fluoroscopy, high speed drill and the widespread of keyhole concept. The applied multislice CT imaging and the high resolution MRI enabled to improve the accuracy of the planned surgical procedures and to reduce the mortality and morbidity of operations. In our studies technical methods were investigated and new developments were established in the field of minimal invasive spine surgery. The National Institute of Neurosurgery's spinal surgical team pioneers further development and application of novel minimal invasive procedures. Applied methods of vanguard surgical procedures include split laminotomy, the "archbone" technique, the "over the top" decompression, the multilevel hemi-semi laminectomy, the supraforaminal "burr hole", the facet joint sparing "open tunnel" techniques or parasplit minimal invasive approaches. The new innovative surgical techniques are applied in our daily routine and meet international trends by utilizing benefits of minimal invasive spinal surgery. Using our newly developed innovative techniques allow to decompress neural elements in case of spinal canal stenosis and to remove the intramedullary and extramedullary space-occupying lesions located in the spinal canal and spreading extraspinally through the neuroforamen. These techniques are specially tailored to preserve structural integrity and stability of the spinal column, and allow at the same time to minimize resection of and injury to tissues not directly involved in the pathologic processes. In our studies a classification system of spatial localization of pathological lesions and processes in spinal canal was developed by us. Using this classification system enables the surgeon to select and apply the appropriate minimal invasive technique from dorsal direction and to remove the space-occupying lesions located in the spinal canal. The minimal invasive techniques were characterized and summarized. This overview of the minimal invasive techniques can be applied and recommended in the daily routine of spine surgery. We proudly employ novel surgical techniques having been developed in our institution. These techniques are internationally recognized and applied in our practice on daily basis as well.

Gliosarcoma of the pineal region with cerebellar metastasis: case illustration.

A very rare case of gliosarcoma of the pineal region with cerebellar metastasis is presented. A few cases of glioblastoma and fibrosarcoma have already been published however there was no reported case with gliosarcoma at the pineal region even with cerebellar metastases.

Loss and reorganization of calretinin-containing interneurons in the epileptic human hippocampus.

Calretinin is expressed mainly in interneurons that specialize to innervate either principal cell dendrites or other interneurons in the human hippocampus. Calretinin-containing cells were shown to be vulnerable in animal models of ischaemia and epilepsy. In the human hippocampus, controversial data were published regarding their sensitivity in epilepsy. Therefore we aimed to reveal the fate of this cell type in human epileptic hippocampi. Surgically removed hippocampi of patients with drug-resistant temporal lobe epileptic (n = 44) were examined and compared to control (n = 8) samples with different post-mortem delays. The samples were immunostained for calretinin and the changes in the distribution, density and synaptic target selectivity of calretinin-positive cells were analysed. Control samples with post-mortem delays longer than 8 h resulted in a reduced number of immunolabelled cells compared to controls with short post-mortem delay. The number of calretinin-positive cells in the epileptic tissue was considerably decreased in correlation with the severity of principal cell loss. Preserved cells had segmented and shortened dendrites. Electron microscopic examination revealed that in controls, 23% of the calretinin-positive interneuronal terminals targeted calretinin-positive dendrites, whereas in the epileptic samples it was reduced to 3-5%. The number of contacts between calretinin-positive dendrites also dropped. The present quantitative data suggest that calretinin-containing cells in the human hippocampus are highly vulnerable, thus inhibition mediated by dendritic inhibitory cells and their synchronization by interneuron-specific interneurons may be impaired in epilepsy. We hypothesize that reorganization of the interneuron-selective cells may be implicated in the occurrence of seizures in non-sclerotic patients, where the majority of principal and non-principal cells are preserved.

Dynamic changes of CB1-receptor expression in hippocampi of epileptic mice and humans.

The endocannabinoid system plays a central role in retrograde synaptic communication, and controls both glutamatergic and gamma-aminobutyric acid (GABA)ergic transmission via type 1 cannabinoid (CB1) receptor. Both in sclerotic human hippocampi and in the chronic phase of pilocarpine-induced epilepsy in mice with sclerosis, CB1-receptor-positive interneuron somata were preserved both in the dentate gyrus and in the CA1 area, and the density of CB1-immunostained fibers increased considerably in the dentate molecular layer. This suggests that, although CB1 receptors are known to be reduced in density on glutamatergic axons, the CB1-receptor-expressing GABAergic axons sprout, or there is an increase of CB1-receptor levels on these fibers. The changes of CB1 immunostaining in association with the GABAergic inhibitory system appear to correlate with the severity of pyramidal cell loss in the CA1 subfield. These results confirm the involvement of the endocannabinoid system associated with GABAergic transmission in human temporal lobe epilepsy (TLE), as well as in the chronic phase of the pilocarpine model in mice. Pharmacotherapy aimed at the modulation of endocannabinoid-mediated retrograde synaptic signaling should take into account the opposite change in CB1-receptor expression observed on glutamatergic versus GABAergic axon terminals.

Downregulation of the CB1 cannabinoid receptor and related molecular elements of the endocannabinoid system in epileptic human hippocampus.

Endocannabinoid signaling is a key regulator of synaptic neurotransmission throughout the brain. Compelling evidence shows that its perturbation leads to development of epileptic seizures, thus indicating that endocannabinoids play an intrinsic protective role in suppressing pathologic neuronal excitability. To elucidate whether long-term reorganization of endocannabinoid signaling occurs in epileptic patients, we performed comparative expression profiling along with quantitative electron microscopic analysis in control (postmortem samples from subjects with no signs of neurological disorders) and epileptic (surgically removed from patients with intractable temporal lobe epilepsy) hippocampal tissue. Quantitative PCR measurements revealed that CB(1) cannabinoid receptor mRNA was downregulated to one-third of its control value in epileptic hippocampus. Likewise, the cannabinoid receptor-interacting protein-1a mRNA was decreased, whereas 1b isoform levels were unaltered. Expression of diacylglycerol lipase-alpha, an enzyme responsible for 2-arachidonoylglycerol synthesis, was also reduced by approximately 60%, whereas its related beta isoform levels were unchanged. Expression level of N-acyl-phosphatidylethanolamine-hydrolyzing phospholipase D and fatty acid amide hydrolase, metabolic enzymes of anandamide, and 2-arachidonoylglycerol's degrading enzyme monoacylglycerol lipase did not change. The density of CB(1) immunolabeling was also decreased in epileptic hippocampus, predominantly in the dentate gyrus, where quantitative electron microscopic analysis did not reveal changes in the ratio of CB(1)-positive GABAergic boutons, but uncovered robust reduction in the fraction of CB(1)-positive glutamatergic axon terminals. These findings show that a neuroprotective machinery involving endocannabinoids is impaired in epileptic human hippocampus and imply that downregulation of CB(1) receptors and related molecular components of the endocannabinoid system may facilitate the deleterious effects of increased network excitability.