Hemispheric infiltrative grade II gliomas in adults: association of residual tumour volume and extent of tumour resection with malignant transformation.

OBJECTIVES: Evaluation of the impact of surgical treatment on malignant transformation (MT) of adult supratentorial infiltrative grade II gliomas (G2G) in a series of chemotherapy and radiotherapy-naïve patients. BACKGROUND: Despite G2G are slow-growing tumours, they typically undergo MT with a subsequent fatal disease course. An extensive resection alone likely changes their biological behaviour and defers MT; however, this impact is not unequivocally confirmed. METHODS: Thirty-eight chemotherapy and radiotherapy-naïve adult patients operated from 2005 till 2014 for a G2G were investigated. Based on postoperative magnetic resonance imaging (MRI) and/or positron emission tomography follow-up (FU) scans, the patients were classified as "transformers" (15 patients in whom MT occurred during the FU-period) and "non-transformers" (23 patients). RESULTS: The follow-up period of "non-transformers" was longer (p <0.0001). After adjustment for known risk factors - age, male sex, astrocytoma histology, preoperative tumour volume, preoperative contrast enhancement and positive isocitrate dehydrogenase 1 gene mutation status - a larger log postoperative tumour volume (p=0.031) and a smaller extent of resection (p=0.0086) were associated with a shorter MT-free survival. CONCLUSION: In our series, less extensive resections were associated with a shorter time to MT. Our data support an adoption of techniques enabling extensive G2G resections, such as intraoperative imaging and awake resections, into everyday routine (Tab. 1, Fig. 2, Ref. 40).

Low serum vitamin D levels are associated with a low percentage of TREM-2+ monocytes in low-grade gliomas and poorer overall survival in patients with high-grade gliomas.

INTRODUCTION: Anti-inflammatory effect of vitamin D (VD) could be beneficial in improving the survival of glioma patients. The aim of our study was to analyse the serum levels of vitamin D in glioma patients and to find an association with the prognosis of glioma patients and other investigated parameters. MATERIAL AND METHODS: The study included 63 patients with gliomas. Percentage of CD14+ monocytes, TREM-1+ and TREM-2+ monocytes were determined by flow cytometry, serum levels of 25(OH)D were evaluated by electrochemiluminescent binding test. RESULTS: Six patients out of 63 had normal levels of VD. A significant difference in the overall survival (OS) in the patients with severe VD deficiency, VD deficiency and insufficiency in grade IV was found. In grade II and III, the levels of vitamin D positively correlated with the percentage of TREM-2+ monocytes, and in grade II also a negative correlation of VD with TREM-1/TREM-2 ratio was observed. CONCLUSION: Levels of VD could influence the prognosis of patients with high-grade gliomas. Serum level of 25(OH)D in low-grade gliomas positively correlated with the percentage of anti-inflammatory acting TREM-2+ monocytes and negatively with TREM-1/TREM-2 ratio. This could be protective against the progression to high-grade glioma, because TREM-2 is associated with protective functions such as: tissue repair, control of local inflammation, or phagocytosis (Tab. 4, Fig. 4, Ref. 79).

TREM-1 and TREM-2 Expression on Blood Monocytes Could Help Predict Survival in High-Grade Glioma Patients.

OBJECTIVE: In recent years, the role of the modern inflammatory markers TREM-1 (triggering receptors expressed on myeloid cells) and HMGB1 (high mobility group box 1 protein) in tumorigenesis has begun to be studied. Their role in gliomas is not clear. The aim of our study was to find the role of inflammation in gliomas. Patients and Methods. In 63 adult patients with gliomas and 31 healthy controls, the expressions of TREM-1 and TREM-2 on CD14+ blood cells (method: flow cytometry) and the levels of soluble sTREM-1, HMGB1, IL-6, and IL-10 (Elisa tests) were analyzed. RESULTS: Cox proportional hazard analysis showed that a TREM-1/TREM-2 ratio was associated with reduced overall survival (HR = 1.001, P = 0.023). Patients with a TREM-1/TREM-2 ratio above 125 survived significantly shorter than patients with a TREM-1/TREM-2 ratio below 125. The percentage of CD14+ TREM-1+ cells was strongly associated with a plasma IL-6/IL-10 ratio (positively) and with IL-10 (negatively). Conversely, we found a higher percentage of CD14+ TREM-2+ monocytes in better surviving patients; these cells could downregulate the exaggerated inflammation and potentiate the phagocytosis in the tumor. The serum levels of HMGB1 negatively correlated with the percentage of CD14+ TREM-1+ cells and with the TREM-1/TREM-2 ratio. The positive correlation between the serum levels of a late proinflammatory cytokine HMGB1 with the percentage of TREM2+ CD14+ monocytes can be explained as an effort for suppression of systemic inflammation by anti-inflammatory acting CD14+ TREM-2+ cells. CONCLUSION: We showed that the TREM-1/TREM-2 ratio (expression on the surface of blood monocytes) could help predict prognosis in patients with gliomas, especially in high-grade gliomas, and that systemic inflammation has an impact on the patient's overall survival. This is the first study that showed that TREM expression on monocytes in peripheral blood could help predict prognosis in patients with gliomas.

Current occurence of intraspinal intradural and extradural communicating branches in the spinal canal.

THE AIM of this work is to point out the intraspinal anatomical current occurrence interconnections between intradural and extradural nerve roots and their possible participation in radiculopathy. METHODS: The anatomical study was performed in 43 cadavers with a mean age of 53.7. All intradural and extradural rami communicantes between nerve roots were excised and examined histologically for the presence or absence of nervous tissue. RESULTS: Anatomical preparations revealed intradural and extradural rami communicantes in 9 cases (20.9 %), mostly in the cervical region in 5 cases and by plexus formation variations in 5 cases. Multiple extradural rami communicantes were observed in 6 cases (13.95 %), including the simultaneous occurrence of multiple intradural and extradural ones in 5 cases (11.6 %). CONCLUSIONS: This study allowed us to identify and describe unpublished intraspinal current occurrence intradural-extradural rami communicantes of nerve roots and their interrelationships throughout the spinal canal with their potential influence on the clinical picture (Tab. 1, Fig. 4, Ref. 25).

Neurenteric cysts, incidence and surgical treatment.

OBJECTIVES: Neurenteric cysts (NCs) of the central nervous system (CNS) are cystic congenital lesions that may occur anywhere along the neural tube. They are most common in the spinal region, in the lower part of the cervical and upper thoracic spine. Intracranial NCs occur rarely and there are only small series of patients published in literature worldwide. Microsurgical resection is the treatment of choice. We present our experience in treatment of NCs and review of literature. METHODS: Seven patients with NC of CNS who were operated at the Department of Neurosurgery of Comenius University at University Hospital Bratislava within nine years (2010-2018) were included in the study. The series was retrospectively evaluated with an emphasis on symptomatology, surgery and postoperative course. RESULTS: In three of the seven patients, NC was localized intracranially, in the other four, NC was in the spinal canal. In three patients, a complete removal of NC was achieved (2 intracranial NC, 1 spinal NC). In other patients, a portion of the cyst wall was left to prevent the development of a postoperative neurological deficit. After surgery, the neurological symptoms were completely resolved in six patients, while in one patient, they were alleviated. In one patient, a complication occurred during the postoperatove course. There was no recurrence during the follow-up (3-111 months, mean duration 39 months). CONCLUSION: In our series of patients with intracranial and intraspinal tumors, the incidence of NC was higher than presented in the published data. Our own surgical experience has shown that complete tumor resection is not always possible for intimate adherence to the surrounding structures. Leaving a tiny portion of the cyst wall allowed us to achieve good clinical results with no recurrence. Long-term follow-up of patients is required due to the risk of recurrence. However, it can already be stated that an adequate extent of resection leads to good clinical results (Tab. 1, Fig. 4, Ref. 33).

Prevalent placement error of deep brain stimulation electrode in movement disorders (technical considerations).

BACKGROUND: Deep brain stimulation is an effective and safe technique. Displacement of the electrode relative to the optimal stimulation site can lead to insufficient effect and sometimes to the need of operative electrode re-position. OBJECTIVE: This study was aimed to analyse targeting accuracy of deep brain stimulation electrode implantation to subthalamic nucleus (STN) and globus pallidus internus (Gpi). It detected possible causes of inaccuracy and prevalent shift to certain direction. METHODS: Targeting accuracy was analysed in 47 patients with Parkinson´s disease (PD) and 11 patients with dystonia with bilateral implantation of deep brain stimulation electrodes between years 2009 and 2016. RESULTS: A shift of electrode to prevalent direction was observed on the left side to medial and posterior and on the right side to lateral direction. Greater shift was observed on the left side and in a higher angulation of trajectory laterally. Movement of the electrode, because of its traction in anchoring device, was identified as a possible factor for prevalent electrode shift. Calibration of stereotactic coordinates to correct prevalent shift was used. CONCLUSION: Targeting inaccuracy is the result of accumulation of errors in individual steps of electrode implantation. Direction of the shift can be random or it can be toward a prevalent direction. A correction of prevalent error can prevent a suboptimal electrode placement (Tab. 3, Fig. 11, Ref. 29).

[Intracranial Pressure Evaluation by Ophthalmologist]. / Hodnotenie intrakraniálneho tlaku oftalmológom.

The value of ICT is important in diagnosis of the diseases of the eye and orbit Methods for direct measurement of intracranial pressure (ICT) are exact, but they are invasive and there is some risk of infection and damage of the tissue. Currently there are 2 valid indirect methods of mesurement of IKT. Digital Ophthalmodynamometry (D-ODM) and Transcranial Doppler ultrasonography (TDU). D-ODM is a non-invasive method for measuring of the Pulsating Venous Pressure (VPT). We can measure VPT by the pulse phenomena. Physiologically (to be maintained blood flow) VPT not be less than the ICT and intraorbital pressure (IorbitT). If we raise the VPT to compensate the current IKT (or IorbitT) - there is a pulsation VCR. We can calculate aproxymative IKT with the formula: IKT = 0.903 - (VPT) - 8.87, or IKT = 0.29 + 0.74 (VOT / PI (AO)). [VOT = intraocular pressure. PI - pulsatility index arteriae ophthalmic from Color Doppler ultrasonography.] IKT can be approximate calculate with mathematical formulas: IKT = 0:55 × BMI (kg / m2) + 0.16 × KTD (mmHg) - 0:18 x age (years) - 1.91. [KTD - diastolic blood pressure, BMI - Body master index] or: IKT = 16.95 x 0.39 x OSASW09 + BMI + 0.14 + TKS - 20.90. [OSASW095: width of the orbital arachnoid space at a distance of 9 mm behind the eyeball (nuclear magnetic resonance). BMI: Body Mass Index. TKS: mean arterial pressure]. Normal values of VPT are under 15 torr. The risk of increased intracranial pressure is above 20 torr. Under physiological conditions, there is intraocular pressure lower in about 5 torr than VPT. CONCLUSION: D-ODM is a useful screening method in the evaluation of IKT for hydrocephalus, brain tumors, cerebral hemorrhage after brain trauma and also in ocular diseases: Glaucoma, Ocular hypertension, orbitopathy (endocrine orbitopathy), ischemic / non-ischemic occlusion of blood vessels of the eye, indirect detection ICT carotid artery-cavernous fistula, amaurosis fugax, optic neuropathy. D-ODM is suitable for immediate evaluation of IKT, but is not suitable for continuous monitoring. As it can be repeated, it is useful for a patient suspected of having an increased ICT.Key words: central retinal artery, central retinal vein, colour Doppler ultrasonography, digital ophthalmodynamometry, intracranial pressure, pressure of cerebrospinal fluid, transcranial Doppler ultrasonography, intraocular pressure, venous pulsation pressure, venous outflow pressure, retinal venous pressure.

Surgical treatment of nervus pudendus.

An objective of our work was to clarify variations in pudendal nerve formation, as well as their possible impact on the clinical picture.Bilateral pudendal nerve course and formation was studied on 20 adult cadavers. Anterior approach was used in 15 of them, both posterior and anterior approaches were used in five of them. The prefixed type plexus formation was observed in eight cases (40 %). In these cases S1, S2 roots contributed to the formation of the pudendal nerve. In the postfixed type particularly the S3 root was dominant in two cases (66.7 %), and less the S4 root in one case (23.3 %) from three cases. Mostly the S2 root participated in its formation in 17 cases (85 %). The pudendal nerve branches run below the sacrospinous ligament on the level of the sacrospinous and sacrotuberous ligaments. The changes of the nerve and the branching therof were most evident from the anterior access below the sacrospinous ligament and in front of the sacrotuberous ligament. The inferior rectal nerve penetrating the sacrospinous ligament was seen in one case, it has risen from the pudendal nerve before entering the pudendal canal in four cases. The dorsal nerve of the penis has risen from the S1 root in two cases (10 %). We observed its branching before entering the pudendal canal in 15 cases (75 %). It has divided in the pudendal canal in other cases. This description may be useful particularly for the pudendal nerve block and the nerve saving surgeries directed on the relevant region (Fig. 8, Ref. 24).

Pineal germ cell tumors: review.

BACKGROUND: Primary intracranial germ cell tumors represent a rare category of neoplasms, which occur in children and young adults. The WHO classification divides intracranial tumors into germinomas and non-germinomas. The most frequent locality of these tumors is pineal and suprasellar region. Clinical signs and symptoms depend on the localization of the tumour - they most commonly include signs of increased intracranial pressure, Parinauds syndrome, bitemporal hemianopsy and signs of endocrine deficiency. Gadolinium enhanced MRI scan of the brain is the imagining examination of choice in the diagnostic strategy of intracranial germ cell tumors. However, the imagining studies do not provide sufficient information about histological type; therefore, biopsy is necessary. The exception represents cases with characteristically increased levels of tumor markers (AFP and ß-HCG) measured in the serum and cere-brospinal fluid. CASE: A pineal germ cell tumor was observed in a 26-year-old male with presentation of an eye-sight disorder with focusing difficulty and photophobia, accompanied by intensive fatigue and sleepiness, nausea with occasional vomiting, intermittent headaches and Parinauds syndrome. MRI examination of the brain showed tumor expansion in the pineal region and in the right part of the mesencephalon. Radical extirpation of the tumor in the pineal region was performed. The follow-up MRI scan of the brain revealed relapse of the disease. The patient underwent craniospinal radiation therapy with subsequent postoperative chemotherapy (regimen cisplatin and etoposide), three cycles in total. Currently, the patient is 30 months after finishing of oncological treatment in clinical remission of the disease. CONCLUSION: The treatment and prognosis of this neoplasm differ between particular categories. Germinomas have better survival rates than non-germinomas. A 5-year survival rate of germinoma patients after application of radiotherapy alone was > 90% of cases. The addition of chemotherapy lead to a decrease of the dose and minimalization of the irradiated area, with achievement of fewer side effects without a decrease of the curability. Non-germinomas are less radiosensitive than germinomas, but after the application of the adjuvant chemotherapy, survival benefit was achieved. However, the optimal management of these tumors remains controversial.

Endovascular treatment of internal carotid and vertebral artery aneurysms using a novel pericardium covered stent.

Intracranial aneurysm is a fairly common (often asymptomatic) condition. Subarachnoid hemorrhage associated with aneurysmal rupture is a potentially lethal event with a mortality rate as high as 50 percent and a high rate of disability among those who survive the initial hemorrhage, such that recently published guidelines support treatment of intracerebral aneurysms. The current treatment options include surgical clipping and endovascular treatment, but these are not without significant problems. Despite the trend toward endovascular treatment the rate of recurrence and complications is high. Current published evidence of the use of covered stent is limited to stents covered with polytetrafluoroethylene. It is now recognized that mammalian extracellular matrix represents an excellent scaffold material suitable for many therapeutic applications and glutaraldehyde treated pericardium has been widely used for many years due to its desirable features such as low immunogenicity and durability. This report describes the first published experience with the Aneugraft Pericardium Covered Stent (ITGI Medical, OR Akiva, Israel) in the treatment of internal carotid and vertebral artery aneurysms in three patients. In all three cases, the implantation of this novel device has resulted in successful closure of aneurysms.

MR imaging of late radiation therapy- and chemotherapy-induced injury: a pictorial essay.

Radiation to the brain and adjuvant chemotherapy may produce late delayed changes from several months to years after treatment of intracranial malignancies with a reported prevalence of 5-24%. The pattern of treatment-related injury may vary from diffuse periventricular white matter lesions to focal or multifocal lesions. Differentiation of treatment-related injury from tumor progression/recurrence may be difficult with conventional MR imaging (MRI). With both disease processes, the characteristic but nonspecific imaging features are vasogenic edema, contrast enhancement, and mass effect. This pictorial essay presents MRI spectra of late therapy-induced injuries in the brain with a particular emphasis on radiation necrosis, the most common and severe form. Novel MRI techniques, such as diffusion-weighted imaging (DWI), proton MR spectroscopy (MRS), and perfusion MRI, improve the possibilities of better characterization of treatment-related changes. Advanced MRI techniques allow for the assessment of metabolism and physiology and may increase specificity for therapy-induced changes.

Post-therapeutical changes in the brain: novel trends in imaging and their infuence on external beam radiotherapy.

UNLABELLED: Presented is the analysis of patients who underwent external beam radiotherapy (EBRT) to the brain in the period from 2003 to 2006 at the department of Radiation Oncology of the St. Elisabeth Cancer Institute.

The aim of our analysis was to identify risk factors of late delayed therapy induced injuries (LDTI) in the brain. The patients were regularly examined with magnetic resonance (MRI), including conventional and advanced techniques: perfusion imaging (pMRI), diffusion weighted imaging (DWI), MRI spectroscopy (MRS). The results from MRI were correlated with 18fluoro-deoxyglucose positron emission tomography (18FDG/PET) scans, as none of the listed method is sufficiently sensitive and specific by itself. Also clinical data records and treatment plans of these patients were analyzed.

In our cohort we found 6 patients with abnormal post-therapeutical changes, 4 of them with MR and 18FDG/PET scans characteristics for LDTI - radiation necrosis. In one patient biopsy was performed and radiation necrosis (RN) was confirmed.

Neurofibroma of the vagus nerve in the cervical portion.

OBJECTIVE: Neurofibromas of the vagus nerve on the neck are very rare. They are asymptomatic, slowly growing. We have seen only one case of neurofibroma of the vagus nerve in the mentioned location during last 22 years. CLINICAL PRESENTATION: 33-year-old patient with negative family history. She has observed increasing swelling on the right side of the neck for about 2 years. She complained of the disorders of swallowing, expectoration, aspiration episodes, strider, intermittent palpitations, breathlessness, frequent airway infections. Magnetic resonance (MR) and angiography (AG) showed expansion in the mentioned location. CONCLUSION: We present our experiences with neurosurgical management of neurofibroma of the vagus nerve in the cervical portion using microscopic technique. We found only 9 described cases of surgical treatment of the neurofibroma of the vagus nerve in the neck location in available literature till 2007 (Fig. 6, Ref. 9).

Comparison of postsurgical and community acquired bacterial meningitis--analysis of 372 cases within a nationwide survey.

The aim of this study was to assess if differences in etiology and risk factors among 372 cases of bacterial meningitis acquired after surgery (PM) or in community (CBM) have impact on outcome of infected patients. Among 372 cases of bacterial meningitis within last 17 years from 10 major Slovak hospitals, 171 were PM and 201 CBM. Etiology, risk factors such as underlying disease, cancer, diabetes alcoholism, surgery, VLBW, ENT infections, trauma, sepsis were recorded and mortality, survival with sequellae, therapy failure were compared in both groups. Significant differences in etiology and risk factors between both groups were reported. Those after neurosurgery had more frequently Coagulase negative staphylococci (p<0.001), Enterobacteriaceae (p=0.01) and Acinetobacter baumannii (p=0.0008) isolated from CSF and vice versa Streptococcus pneumoniae (p<0.001), Neisseria meningitis (p<0.001) and Haemophillus influenza (p=0.0009) were more commonly isolated from CSF in CBM. Neurosurgery (p<0.001), sepsis (p=0.006), VLBW neonates (p=0.00002) and cancer (p=0.0007) were more common in PM and alcohol abuse (p<0.001) as well as otitis/sinusitis (p<0.001) and Roma ethnic group (p=0.001) in CAM. Initial treatment success was significantly more frequently observed among CAM (p<0.001) but cure after modification was more common in PM (p=0.002). Therefore outcome in both groups was similar (14.6% vs. 12.4%, p=NS).

Bacterial meningitis after craniocerebral trauma in the community.

Craniocerebral trauma is one of major risk factors for development of meningitis. We reviewed 30 cases of bacterial meningitis occurring in community after craniocerebral trauma. Alcohol abuse was significant risk factor occurring in trauma patients with meningitis present in 50% in our cohort (p=0.0001). The most common pathogen in posttraumatic meningitis was Str. pneumoniae (90% vs. 33.8%, p=0.0001). However mortality was very low, only 5% probably because of early diagnosis and treatment of patients at risk for bacterial meningitis but neurologic sequellea were significantly more common (p=0.00001) in patients after craniocerebral trauma.

Bacteremic meningitis is associated with inferior outcome in comparison to community acquired meningitis without bacteremia.

Meningitis associated with bacteremia is rare. Bacteremic form of meningitis occurred in 28 of 201 cases of community acquired meningitis (14%) in Slovakia within last 17 years. Bacteremic meningitis was associated with diabetes (21.4% vs. 7.5%, p=0.02) and with higher treatment failures (32.1% vs. 9.5%, p=0.01) and higher mortality (25% vs. 12.4%, NS). In univariate analysis comparing 28 cases of bacteremic community acquired bacterial meningitis (BCBM) to all CBM, no significant risk factor concerning underlying disease (cancer, ENT infection, alcohol abuses, trauma, splenectomy, etc.) or etiology was observed apart of diabetes mellitus, which was more common among bacteremic meningitis (21.4% vs. 7.5%, p=0.02). Mortality (25% vs. 12.4%, NS) insignificantly but therapy failure (32.1% vs. 9.5%, p=0.01) was significantly more frequently observed among meningitis with bacteremia. N. meningitis was the commonest causative agent (8 of 28 cases) followed by Str. pneumoniae (6), gram-negative bacteria (6), S. aureus (4) and H. influenzae (2).

Meningitis in diabetic patients.

Community acquired bacterial (CBM) meningitis in diabetic patients was analyzed for risk factors and outcome in a cohort of 201 cases of meningitis within last 17 years: 15 patients with diabetes mellitus and meningitis were identified and compared for etiology and mortality as well as for neurologic sequellae with all CBM cases.

Reconstruction of the skull base after injuries.

The aim of this study is presentation of 3 cases reconstructive surgery of the skull base after craniocerebral injury. INJURIES AND METHODS: Extensive injuries of the skull base result in communication with paranasal cavities. DIAGNOSTICS: The most serious part of the operation is the isolation of the liquor space from the external environment. Reconstruction surgeries of the skull base have significantly improved in recent years due to development of new methods in diagnostics and treatment. 3D CT reconstruction has proven to be particularly valuable for the verification of liquorea even in patients with inactive liquorea at the time of examination, as well as in patients with no CT defects or with normal MR finding. TREATMENT: The use of firm and shapeable materials extends the possibilities of reconstruction surgery, the spectrum of surgical methods and approaches for extensive injuries of the skull base (Fig. 9, Ref. 3) Full Text (Free, PDF) www.bmj.sk.

Nosocomial meningitis caused by Staphylococcus other than S. aureus in children: multicentre study.

Analysing 101 cases of nosocomial meningitis due to staphylococci other than S. aureus within last 15 years, coagulase negative staphylococci represented the commonest pathogen. Major risk factor for staphylococcal meningitis was prior neurosurgery, mainly ventriculoperitoneal shunt insertion. Ten of 101 cases were caused by glycopeptide intermediate resistant strains in patients pretreated with multiple combination of antibiotics including vancomycin and shunt exchanges: 76% of strains were also oxacillin resistant.