The Pathophysiology of Post-Traumatic Glioma.

Malignant glioma is a brain tumor with a very high mortality rate resulting from the specific morphology of its infiltrative growth and poor early detection rates. The causes of one of its very specific types, i.e., post-traumatic glioma, have been discussed for many years, with some studies providing evidence for mechanisms where the reaction to an injury may in some cases lead to the onset of carcinogenesis in the brain. In this review of the available literature, we discuss the consequences of breaking the blood⁻brain barrier and consequences of the influx of immune-system cells to the site of injury. We also analyze the influence of inflammatory mediators on the expression of genes controlling the process of apoptosis and the effect of chemical mutagenic factors on glial cells in the brain. We present the results of experimental studies indicating a relationship between injury and glioma development. However, epidemiological studies on post-traumatic glioma, of which only a few confirm the conclusions of experimental research, indicate that any potential relationship between injury and glioma, if any, is indirect.

New extracellular factors in glioblastoma multiforme development: neurotensin, growth differentiation factor-15, sphingosine-1-phosphate and cytomegalovirus infection.

Recent years have seen considerable progress in understanding the biochemistry of cancer. For example, more significance is now assigned to the tumor microenvironment, especially with regard to intercellular signaling in the tumor niche which depends on many factors secreted by tumor cells. In addition, great progress has been made in understanding the influence of factors such as neurotensin, growth differentiation factor-15 (GDF-15), sphingosine-1-phosphate (S1P), and infection with cytomegalovirus (CMV) on the 'hallmarks of cancer' in glioblastoma multiforme. Therefore, in the present work we describe the influence of these factors on the proliferation and apoptosis of neoplastic cells, cancer stem cells, angiogenesis, migration and invasion, and cancer immune evasion in a glioblastoma multiforme tumor. In particular, we discuss the effect of neurotensin, GDF-15, S1P (including the drug FTY720), and infection with CMV on tumor-associated macrophages (TAM), microglial cells, neutrophil and regulatory T cells (Treg), on the tumor microenvironment. In order to better understand the role of the aforementioned factors in tumoral processes, we outline the latest models of intratumoral heterogeneity in glioblastoma multiforme. Based on the most recent reports, we discuss the problems of multi-drug therapy in treating glioblastoma multiforme.

[Intracranial remote epidural haematoma as a complication after resection of an occipital lobe metastatic tumour from a testicular embryonal carcinoma ­ a case report].

We present the case of a patient who suffered from intracranial epidural haematoma in the left fronto -temporo -parietal region as a complication after left parieto -occipital craniotomy and a resection of a metastatic lesion from a testicular embryonal carcinoma to the left occipital lobe. We also discuss possible causes of this complication.

[The ophthalmologic signs in cerebellum tumor. Preliminary report].

Introduction: The aim of the study was an analysis of ophthalmic symptoms coexisting with the tumour of the cerebellum. Material and methods: The study included 14 patients in the age between 21­55 years old with the tumor of cerebellum, who were operated in the Neurosurgery Clinic of the Pomeranian Medical University in Szczecin. The comprehensive ophthalmic examination were performed before and after 5 days from surgery. The examinations included evaluation of: pupillary reactions, visual acuity, fundus ophthalmoscopy, intraocular pressures, eye motility, visual field, optometrical tests and visual manual localization test. Results: The symptoms found before surgery of cerebellum tumors: diplopia (3 persons), early papilloedema (4 persons), nystagmus (2 persons), lack (5 persons) and weakened of convergence reô€lex (3 persons), latent strabismus (5 persons), manifest strabismus (3 persons). On the 5th day after the surgery were found: nystagmus (1 person), lack (5 persons) and weakened of the convergence reô€lex (3 persons). Visual manual localization was disparate depending on location of the tumor in the cerebellum; prevailed crossed and uncrossed localizations. Conclusions: 1. The natural dynamic of the tumor and surgical damage to the posterior cranial cavity structures can be monitored by assessment of the condition of the organ sight. 2. It is recommended to make the visual manual localization tests such as exponent disorders of senso-motorical deviations, which may occur in the patients with the cerebellum tumor.

Cerebrospinal meningitis in a 30 -year -old patient as first manifestation of pituitary macroadenoma.

Introduction: The most common clinical and neurological signs and symptoms of pituitary macroadenomas include headache, vision impairment and cranial nerve palsy. Case report: The patient presented in this article was admitted to the Intensive Care Unit at regional hospital; at admission, the patient was unconscious, he had convulsions and spasms, and a 3 -day history of headache and body temperature up to 41.5°C. The patient with suspected neuroinfection was transferred to the Department of Infectious Diseases of the Pomeranian Medical University in Szczecin (PMU), where cerebrospinal meningitis of bacterial etiology was established based on cerebrospinal fluid investigations and the presence of pituitary abscess was suggested based on magnetic resonance imaging (MRI). Magnetic resonance imaging findings included an extensive pathological lesion with the diameter of 27 × 28 × 38 mm located in the sellar-suprasellar region, with intensive peripheral contrast enhancement. The lesion protrudes into the sphenoid sinus through the lowered bottom of sella turcica and the fluid content has also been visualized in the sphenoid sinus. After 10 -day antibiotic therapy, the patient was transferred to neurosurgery ward for surgical treatment. The pathological lesion was partially evacuated during right frontotemporal craniotomy. The patient's general condition after the surgery was moderately severe; the patient was conscious, able to follow simple commands, presenting hemiparesis of the left side of the body, particularly affecting left lower limb and with speech disturbances. The signs of hypopituitarism affecting all hormonal axes were also observed and the patient was transferred to the Department of Endocrinology of the PMU for further treatment. Follow -up MRI scan continued to show the presence of pathological mass in the sellar -suprasellar region, which penetrated into the sphenoid sinus through damaged sellar bottom. After correction of reduced hormone levels and several weeks of antibiotic therapy, the patient was transferred to the Department of Neurosurgery of the PMU for further surgical treatment. Transsphenoidal resection of the sellar -suprasellar tumor and sphenoid sinus reconstruction were performed. Histopathology report confirmed the diagnosis of pituitary adenoma. The patient in relatively good condition, with partial hemiparesis on the left side of the body, able to stand with support, not able to walk, with speech disturbances and able to follow commands was transferred to the rehabilitation center. One year later, follow- -up MRI scan showed deepened sella turcica, filled with a mass corresponding to postoperative material. No evidence of disease progression has been found. Conclusion: Neuroinfection may be the first manifestation of pituitary macroadenoma.

Evaluaton of therapy with cabergoline in men with macroprolactinoa.

INTRODUCTION: Pituitary gland adenomas producing prolactin are one of the commonest hormonally active tumours. Pharmacological treatment using of dopamine receptors agonists is the therapy of choice in a case of prolactinoma. Bromocriptine, which causes numerous side-effects is the most commonly used drug. Recently, good results of therapy have been achieved with cabergoline - a selective dopamine receptor agonist with prolonged time of action. The aim of the study was to evaluate therapy with cabergoline of men with macroprolactinoma based on clinical, hormonal and radiological examinations. MATERIAL AND METHODS: Ten men aged 18-65 (mean 41.9 ?15.01 years) with the presence of a pathological mass in the pituitary gland sized between 16.7 and 40.5 mm (mean 29.8 ± 9.38 mm) and an elevated prolactin (PRL) level of between 37.3 and 4700 ng/mL (mean 1608.2 ±1771.6 ng/mL) were included in the study. The PRL and other trophic hormones levels were evaluated after 1, 3, 6 and 12 months, and tumour size was evaluated by magnetic resonance imaging examination after 12 months of therapy with cabergoline. Results: Therapy with cabergoline led to remission of headaches, visual acuity correction, and a significant improvement in libido and erection in all patients. In 90% of patients, PRL normalisation was achieved, just the initial months of therapy. The mean PRL serum concentrations were before, and after 1, 3, 6 and 12 months of therapy respectively, 1608.2 ± 1771.6 ng/mL and 263.4 ± 223.4, 136.1 ± 244.7,91.31 ± 105.5 and 27.5 ± 57.7 ng/mL. A significant tumour size reduction was observed: from 29.8 ± 9.4 mm to 23.2 ± 9.4 mm, a mean reduction of about 6 mm, or 25.1% (from 4-48.5%). No significant correlation between the mean tumour size and PRL level was observed before or during the treatment. A decreased testosterone level before the therapy was proven, and its gradual increase during the treatment was observed, but after 12 months no normal mean testosterone concentration was achieved. CONCLUSIONS: 1. The administration of cabergoline to patients with macroprolactinoma is effective in reaching PRL level normalisation as well as in tumour size reduction. 2. Therapy with cabergoline significantly decreases the clinical symptoms of hyperprolactinemia and neurological and ophtalmological changes associated with the presence of a pathological lesion in the pituitary gland. 3. Tumour size is not a predictive factor for the effectiveness of therapy with cabergoline.

The ophthalmologic signs in case of C1 neurinoma without hydrocephalus - case report.

INTRODUCTION: We present a case of the patient suffering from the tumor of cranio-spinal junction in whom a wide spectrum of ophthalmic and neuroophtalmic signs was noted. METHODS: The comprehensive neuro-ophthalmic examination were performed (pupillary reactions, visual activity, fundus ophthalmoloscopy, intraocular pressures, eye movements, visual field, MRI, MR angiography). Additionally immunohistochemistry and laboratory tests were made. RESULTS: The case of 24 years male with peripapillary subretinal hemorrhage, that occurred after a surgical excision of a tumor at cranio-cervical junction. The mechanism of the dynamics of the expanding intracranial space occupying processes is also discussed. CONCLUSIONS: Space occupying lesion of the level of cranio-spinal junction causes vascular changes in the fundus of the eye of the high dynamic and diversity. Surgical decompression in such cases is a maneuver of choice to maintain the reversibility of changes if proceeded in early stage.

[Distal ventriculoatrial shunt catheter implantation under fluoroscopy guidance throught the left internal jugular vein as a rescue technique - a case report]. / Wszczepienie drenu dystalnego zastawki komorowo-przedsionkowej poprzez lewa zyle szyjna wewnetrzna z wykorzystaniem fluoroskopii jako technika ratunkowa - opis przypadku.

Revision of the distal ventriculoatrial shunt catheter is a rare challenge for the neurosurgeon. Its dysfunction associated with inflammation also binds to systemic complications. The paper presents a case report of a patient with bacterial colonisation of distal ventriculoatrial shunt catheter caused by separation of the layers of a old surgical wound. Catheter was removed by revision of the right internal jugular vein. Out of necessity, the distal catheter has been implanted back into the right atrium through.the left internal jugular vein under fluoroscopy guidance. The paper consist of course of treatment, data from the literature and own description of the implantation way of the catheter through the veins on the left side of the neck.

[Stent-assisted mechanical removal of tromboembolism after embolization of middle cerebral artery aneurysm]. / Endowaskularne leczenie tetniaka tetnicy srodkowej mózgu uzupelnione mechanicznym wydobyciem zakrzepu przy pomocy stentu.

Thrombotic occlusion of the middle cerebral artery's branch occurred just after embolization of a nonruptured cerebral aneurysm. Bail-out stent-assisted mechanical thrombectomy of the clot was performed. DSA revealed normal vessel patency at the end of the procedure. There were no adverse events related to this thrombectomy, and the patient recovered from the embolization with minor neurologic deficit. There was no neurologic deficit after 90 days follow-up.

[Elective cerebral arteriovenous malformation treatment with onyx after coil embolization of ruptured, flow-realeted aneurysm of the posterior circulation]. / Planowe endowaskularne leczenie malformacji t9tniczo-zylnej mózgu za pomocaa substancji typu Onyx, po embolizacji coilami peknietego przeplywozaleznego tetniaka krazenia tylnego mózgu.

Intracranial arteriovenous posterior circulation malformation was planned to embolize by onyx injection after acute coil embolization of ruptured flow-realeted aneurysm of posterior cerebral artery. Control angiography revealed completely embolized malformation with normal vessel patency at the end of procedure. There were no adverse events related to this procedure and no neurologic deficit at the discharge.

Intracerebral metastasis of glioblastoma multiforme. Case report and literature review.

Glioblastoma multiforme is the most common primary malignant brain tumor in adults. It's characterized by a high malignancy and rapid, frequent tendency to local recurrence. Distant metastases disseminated in the brain compared to the primary lesion and outside the central nervous system are rarely reported in the literature. The case which is being presented is of a 53 year old man operated in 2008 because of Glioblastoma multiforme IV WHO in the left periventricular parietal region, in which the main symptoms were the Gerstmann syndrome, mixed aphasia and memory disturbance. The patient was operated totally followed by adjuvant radiotherapy and chemotherapy. Two years later epileptic seizures and aphasia were intensified. Due to this adverse symptoms MRI was ordered, which revealed a tumor in the left periventricular temporal region in different location compared to the primary lesion. The patient was operated by temporal lobectomy. Histopathological diagnosis was Glioblastoma multiforme IV WHO. According to the literature we analyzed the natural GBM tumor features and factors responsible for possibility to appear of the same type of tumor in another location of the brain.

[Surgery with neuronavigated mapping of cerebral cavernoma evoking epileptic seizures]. / Leczenie operacyjne naczyniaka jamistego mózgu wywolujacego napady padaczkowe przy uzyciu mapowania neuronawigacyjnego.

INTRODUCTION: Cavernous hemangioma is increasingly recognized as the cause of epilepsy attributed to vasogenic foci. The clinical picture of this lesion is notable for epileptic seizures and intracerebral hemorrhage. Surgical excision of cavernoma remains the most effective antiepileptic modality. Good results of surgery are achieved with the use of modern operative procedures such as stereotaxy and neuronavigation. MATERIAL AND METHODS: Twelve patients with cavernous hemangioma were operated at the Department of Neurosurgery and Pediatric Neurosurgery, Pomeranian Medical University, Szczecin, between 1999 and 2008. This group included 10 females aged 7-54 years (mean 24.8 years) and 2 males aged 14-49 years (mean 31.5 years), 7 children (58.3%) and 5 adults (41.7%). Seven patients (58.3%) presented with generalized and the remaining 5 patients (41.7%) with secondarily generalized seizures. The mean time from onset of seizures to surgery was 2.6 months. All patients were operated using preoperative neuronavigated mapping to determine the optimal access to the lesion followed by neuronavigation-guided cavernoma excision. Postoperative neurological status was assessed with GOS scale and antiepileptic treatment outcome with Engel's scale as modified by Moran. RESULTS: The caveroma was completely removed in each case. Postoperative follow-up time was 2-59 months (mean 30.3 months). Neurological status of all patients was category 5 of the GOS scale. Engel's class I outcome was achieved in all patients. Nine patients (75%) were weaned off antiepileptic drugs following normalization of EEG. CONCLUSIONS: The following conclusions were drawn basing on the findings of this study: (1) Neuronavigation offers high precision and low traumatization which reduce the risk of neurological sequellae (neurological deficits and epilepsy) in patients operated for cavernoma; (2) Early resection of cavernoma offers the chance of curing epilepsy.

[Examination over a foreign body left inside during an operation of a lumbar spine]. / Badanie nad cialem obcym pozostawionym w trakcie operacji kregoslupa ledzwiowego.

Procedure of an examination over a gauze swab removed during a repeated operation of a patient who had undergone earlier a neurosurgical operation of a lumbar spine has been described. The extracted gauze swab became an exhibit in a case at court for financial compensation. The court commissioned to explain "if it could be placed in another way than leaving it during the former surgical operation". The neurosurgeon who performed the former operation decidedly denied that the gauze swab in question could have been left by him. Hemogenetic and histologic examination gave basis to the statement that the exhibit was left inside during the former neurosurgical operation.

Endoscopic aqueductal stent placement for the treatment of a trapped fourth ventricle.

OBJECT: Endoscopic aqueductal stent therapy has evolved into an important technique in the treatment of a trapped fourth ventricle (TFV). The authors analyzed five cases of symptomatic TFV treated by endoscopic aqueductal stent therapy and, on the basis of intraoperative findings, discuss aspects of TFV formation. METHODS: Patients' ages ranged from 2 to 17 years (mean 9.2 years). Two patients underwent endoscopy via a coronal bur hole approach and three via a small suboccipital craniectomy. The mean follow-up period was 30 months (range 24-38 months). In four cases, a membrane occluding the orifice of the aqueduct and covering part of the walls of the ventricle was observed. Despite slit ventricles in four cases, there was no intraoperative evidence of aqueduct wall collapse. All procedures were successful, and all patients experienced positive outcomes. In one patient, Parinaud syndrome, rotatory nystagmus, and abducent nerve palsy developed postoperatively; these deficits resolved after a preexisting supratentorial shunt was upgraded. There were no cases of aqueduct reocclusion during the follow-up period. CONCLUSIONS: Aqueductal stent therapy is an effective method of TFV treatment. Because it prevents aqueduct reocclusion by chronic inflammatory processes in postinflammatory hydrocephalus, it has been shown to be more efficient than aqueductoplasty alone and to be an important alternative to the placement of a fourth ventricle shunt. Intraventricular processes leading to membrane formation play an important role in occlusion of the cerebral aqueduct orifices and final isolation of the fourth ventricle in postinflammatory hydrocephalus.

[Endoscope-guided placement of the ventriculoperitoneal shunt: technique and applications]. / Metoda endoskopowego umieszczania drenu komorowego zastawki--technika i zastosowanie.

INTRODUCTION: The routine surgical procedure for placement of the ventricular shunt catheter is straightforward. However, the topography of the ventricular system in complex hydrocephalus is so distorted that orientation on the basis of standard external topographic points does not ensure satisfactory positioning of the drain. AIMS: 1. To test the clinical efficiency of endoscope-guided placement of the ventricular catheter in cases of complex hydrocephalus. 2. To present and popularize the surgical technique of endoscope-guided placement of the ventricular shunt catheter which hitherto was not published in the Polish literature. MATERIAL AND METHODS: This study was done in 38 patients aged 2 days to 45 years (mean 7 years and 5 months). Multiloculated hydrocephalus was found in 7, lateral ventricle isolation in 14, fourth ventricle isolation in 3, intraventricular cyst accompanied hydrocephalus in 6, and adherent ventricular catheter of the shunt implanted previously in 8 cases. Endoscopy was performed through coronal or occipital burr hole. Peelaway sheath was used for placement of the catheter in the desired position. Computerized tomography was performed within 24 hours after surgery, after 6 months, and subsequently every 12 months during follow-up. The time of follow-up ranged from 1 to 5 years (mean 27 months). There were eight cases (15.78%) of postoperative occlusion of the ventricular catheter. In two of them, occlusion was caused by catheter tip displacement. In the remaining cases, occlusion was caused by growing membranes of the multiloculated hydrocephalus (four cases) or by infection (two cases) and was not related to the catheter position. There were no cases of catheter position change during follow-up. DISCUSSION: In complex hydrocephalus, proper placement of the ventricular catheter without direct visual control is very difficult if not impossible. Therefore, use of the endoscope facilitates proper catheter placement in multiloculated hydrocephalus, hydrocephalus complicated by isolation of the ventricle or intraventricular cyst. CONCLUSIONS: 1. The technique of endoscope-guided placement of the ventricular catheter is relatively simple and useful for reliable positioning of the drain in the right location. 2. Our cases show that the method is clinically effective. However, comparison with the conventional method will require a controlled and matched trial.

[Endoscopic revision of adherent ventricular catheter. Evaluation of the method]. / Endoskopowo wspomagana rewizja uwieznietego drenu komorowego ukladu zastawkowego. Ocena metody.

BACKGROUND AND PURPOSE: To evaluate the method of endoscopic-assisted revision of adherent ventricular catheters. MATERIAL AND METHODS: 29 cases (26 patients) of endoscopic revision of adherent ventricular catheter were analyzed. The cause of hydrocephalus was intraventricular hemorrhage in 17 cases, myelomeningocele in 3 cases, ventriculitis in 4 cases, aqueductal stenosis in 1 case and holoprosencephaly in 1 case. Multiloculated hydrocephalus comprised 38.5% (10 patients) of cases. Depending on the catheter location, an approach through its burr hole, a new burr hole on the same side or opposite side was used. The mean time of follow up was 12 months. RESULTS: In 13 cases ventricular catheter was tethered in the choroid plexus, in 7 cases -- under the ependyma and in 9 cases -- in septum pellucidum. In 5 cases it was adherent to the blood vessel. An entity of active ingrowth of choroid plexus, ependyma and subependymal elements into the catheter lumen was observed. Reocclusion of the catheter occurred in 3 cases. In all these cases there was multiloculated hydrocephalus. In the remaining cases there were no signs of shunt malfunction during the time of follow up. CONCLUSIONS: The use of endoscope during revision of adherent ventricular catheter reduces the risk of bleeding. Due to a possibility of direct observation of catheter surroundings, a decision regarding catheter replacement and its placement in an optimal position can be taken. This method gives better results than traditional methods used during revisions of occluded, adherent ventricular catheters.

[Objective retinal nerve fiber laser assessment by scanning laser polarimetry in patients with chiasmal compression]. / Obiektywna ocena zmian warstwy wlókien nerwowych siatkówki za pomoca badania GDx u pacjentów z uciskiem dróg wzrokowych.

PURPOSE: To assess the evaluation ability of retinal nerve fiber layer (RNFL) in patients with visual tracts' compression and to assess the correlation between visual field loss and changes in RNFL. MATERIAL AND METHODS: Polarimetric RNFL analysis (scanning laser polarimeter- NFA/GDx, software version 1.0.16, LDT(inc)) and kinetic perimetry were done in 41 eyes with different types of optic chiasma compression and in 40 healthy eyes, age matched controls. RESULTS: In eyes with optic chiasma compression most of the GDx parameters were statistically different from the control group (P<0.05). In eyes with normal visual fields and with optic chiasma compression most of GDx parameters were statistically different from the other analyzed groups. CONCLUSIONS: GDx may be a helpful tool in diagnosis of optic chiasma diseases. GDx is a useful visual prognostic indicator in the preoperative assessment of optic chiasma compression. Objective RNFL assessment is especially important in patients with serious visual field loss and poor visual acuity.