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.

Normal pressure hydrocephalus as an unusual presentation of supratentorial extraventricular space-occupying processes: report on two cases.

Normal pressure hydrocephalus (NPH) is a clinical and radiographic syndrome characterized by ventriculomegaly, abnormal gait, urinary incontinence, and dementia. The condition may occur due to a variety of secondary causes but may be idiopathic in approximately 50% of patients. Secondary causes may include head injury, subarachnoid hemorrhage, meningitis, and central nervous system tumor. Here, we describe two extremely rare cases of supratentorial extraventricular space-occupying processes: meningioma and glioblastoma multiforme, which initially presented with NPH.

Long-term survival with primary glioblastoma multiforme: a clinical study in bulgarian patients.

Glioblastoma multiforme (GBM) is the most common and aggressive primary brain tumor with an extremely poor prognosis in spite of multimodal treatment approaches. The estimated median survival in cases with GBM is about 12-16 months. Those patients who survive =3 years after the initial diagnosis are defined as long-term survivors. In this study, we retrospectively analyze 50 consecutive cases of Bulgarian patients with newly diagnosed GBM surgically treated at our institution for a period of 1 year. Four of them survived for more than 36 months after the initial intervention. The histological re-examination revealed features typical of primary GBM in 3 of these cases, which are described in detail in the present paper. A brief review of the relevant literature is also given.

[Treatment possibilities in patients with glioblastoma multiforme].

Glioblastoma multiforme is the most common primary malignant brain tumor in adults. The actual treatment approach includes surgical excision of the lesion followed by radio- and chemotherapy in standard doses and regimens. In most cases, in spite of aggressive treatment, the survival does not exceed 12-16 months after the initial diagnosis. The present survey provides systematic information about the current treatment modalities for control of the disease as well as the perspectives of introduction of some experimental methods in clinical practice.

[Characteristics and prognosis of visual deficit caused by parasellar meningiomas].

UNLABELLED: Meningiomas are the most common slow growing tumors of the central nervous system which arise from the arachnoid cells. One certain group of them--tuberculum sellae (TS), cavernous sinus (CS), anterior clinoid (AC), and planum sphenoidale (PS) meningiomas, a group often called "parasellar", present with monocular or binocular visual deterioration, which is often unrecognized by patients until visual loss is severe and the tumor has reached a significant size. AIM: To describes the type of visual deficit, severity of the symptoms and surgical treatment of tumors with the above mentioned localization. MATERIAL AND METHODS: During the period 2003-2007 year, 93 patients (31 man, 62 women) diagnosed with meningiomas of the TS (31 cases), CS (16 cases), AC (21 cases), PS (17 cases), (see text) - 8, were diagnosed and operated on in the Department of Neurosurgery, University Hospital "St. Ivan Rilsky", Sofia, Bulgaria. Retrospective analysis was done. RESULTS: Age at diagnosis ranged from 12 to 74 years, but the majority of cases were in the 5th and 6th decade of life. Localization of was: TS 33%, CS 17%, AC 24%, PS 18% and with more than one area affected in 8 %. The most common symptom was slowly progressing loss of monocular visual acuity (81% of cases). 68% of patients presented with already severely deteriorated vision (0.1-0). Neuro-ophthalmological examination (see text) the patients. Computed tomography and magnetic resonance imaging were the main diagnostic methods. "Gross" total resection was achieved in 62%, subtotal in 12%, partial in 26% of the cases. There was early improvement in 57% of the patients. Death due to cardio-respiratory insufficiency occurred in one case. CONCLUSION: the progressive monocular visual deficit is often the first clinical symptom of the parasellar menigiomas. The early diagnosis is important for the success of surgery. Close collaboration between different specialists (ophthalmologists, neurologist and neurosurgeons) is essential for treatment of these tumors and prevention of the visual deterioration.

Long-Term Survival of a Patient with Giant Cell Glioblastoma: Case Report and Review of the Literature.

Glioblastoma multiforme (GBM) is the most common glial tumor of the central nervous system. Overall survival is less than a year in most of the cases in spite of multimodal treatment approaches. A 45-year-old female with histologically confirmed giant cell GBM was treated at our institution. Subtotal excision of the lesion situated in the right precentral area was performed during the initial stay in August 2005. The patient improved after the procedure with no hypertension and additional neurological deficit. Radiotherapy plus concomitant and adjuvant temozolomide was performed. The patient was symptom-free for 35 months after initial surgery. From July 2008 the patient developed partial motor seizures in the left side of the body and progressive hemiparesis. Local tumor progression was demonstrated on the neuroimaging studies. In December 2008, a second operative intervention was performed with subtotal excision of the tumor. Forty-five months after the initial diagnosis the patient is still alive with moderate neurological deficit. Microarray analysis of the tumor found the following numeric chromosomal aberrations: monosomy 8, 10, 13, 22, and trisomy 21, as well as amplifications in 4q34.1, 4q28.2, 6q16.3, 7q36.1, 7p21.3, and deletions in 1q42.12, 1q32.2, 1q25.2, 1p33, 2q37.2, 18q22.3, 19p13.2, Xq28, and Xq27.3. GBMs seem to be a heterogeneous group of glial tumors with different clinical course and therapeutic response. Microarray analysis is a useful method to establish a number of possible molecular predictors.

[Clinical, histopathological and cytogenetical findings in six cases with primary glioblastoma multiforme].

INTRODUCTION: Glioblastoma multiforme (GBM) is the most common malignant primary brain tumor. There is an increasing amount of data demonstrating that the routine histological examination has limited value to predict the tumor biological behaviour. AIM: To compare the clinical, histological and cytogenetical findings in a group of six patients with primary GBM surgically treated in the Department of Neurosurgery at University Hospital "St. Ivan Rilski"- Sofia, Bulgaria. MATERIAL AND METHODS: The studied group consisted of three women and three men with average age of 51 years and 6 months. In all patients the diagnosis was histologically confirmed. A microarray comparative genomic hybridization (CGH) analysis of fresh-frozen tumor tissue samples was also made. RESULTS: In two of the patients the tumor was localized in frontotemporal region, in another two- in frontoparietal, and in the other two- in parietal and occipital respectively. The onset was with headache in three of the cases. The median time between the onset and admission in the clinic was 70 days. Gross-total tumor removal was performed in one patient. In the other five subtotal excision was made. Three of the patients improved after the intervention. One patient deteriorated after the surgery. All patients demonstrated typical histological findings except one who had giant cell subtype of GBM. The microarray CGH analysis determined chromosome 10 monosomy in five patients, trisomy 7 - in four, trisomy 20 - in three, 3q23 deletion - in three, and Yp11.2 deletion - in three. CONCLUSION: GBMs are genetically heterogeneous tumors with different clinical response to standard multimodal treatment regimens. The microarray CGH analysis is a powerful method which can demonstrate the presence of a number of molecular markers with possible predictive value.

[Orbital lymphoma].

INTRODUCTION: Orbital lymphomas are neoplasms with increasing incidence in recent years in immunocompromised, as well as immunocompetent patients, which defines their social importance. AIM: To describe and analyze the experience of the University hospital "'Sv. Ivan Rilski" with the treatment of this pathology for the period 1997-2008. MATERIAL AND METHODS: Fourteen patients (8 females, 6 males - 13 primary orbital lymphomas, 1 systemic lymphoma). Mean age at diagnosis was 65.6 years (from 50 to 80 years). In 2/3 of the patients the lesion was localized in left eye, without a case with bilateral orbital involvement. Seven cases the diagnosis was made 6 months from the onset of symptoms, 5 cases - 1 year and 2 cases - more than one year. The most common clinical symptoms were exophthalmus (12 case), tumor or bulging mass of the eyelid - 8, diplopy - 6, decreased visual acuity - 5. Intraconal localization of the tumor was in 6 cases, extraconal - 2. intra-extraconal - 6. The diagnosis was made by neuro-ophthalmologist and precised with the aid of CT and MRI. All the patients were operated on with the following approaches - fronto-orbital - 9 cases, lateral - 3, anterior orbitotomy (without bone resection) - 2 cases. In six cases "'gross total" resection was achieved, in the rest of the cases the resection was partial. On histological examination, a high grade lymphoma was established in 2 cases with primary orbital lymphoma and one case with systemic lymphoma. All other cases were diagnosed as low-grade B-call small lymphocytic non-Hodgkin's lymphoma. Long-term survival (over 5 years) was observed in 4 cases with primary lymphoma, whereas the patient with systemic form of the disease died 10 months after the operation.

Virtual simulation of neuroendoscopic procedures: early clinical experience with ventricular lesions.

BACKGROUND: Virtual endoscopy (VE) is a new and promising imaging technology. Applied to neuroendoscopy it allows preoperative simulation of a procedure and evaluation of the individual intraventricular anatomy in selected cases. Along with neuronavigation and real time intraoperative imaging, VE is expected to improve the safety and efficacy of neuroendoscopic procedures. PATIENTS AND METHODS: Between April 2003 and February 2004 VE simulation was performed in 13 randomly selected patients subjected to endoscopic procedures. Pathological entities included 4 cases with aqueduct stenosis, 4 with suprasellar arachnoid cysts, 2 tumors of the posterior third ventricle, 1 colloid cyst, 1 hyperplasia of the choroid plexus and 1 case with multiloculated hydrocephalus due to intraventricular septations. In 8 patients VE was accomplished preoperatively, in another 5 it was done after the operation, using data sets from neuronavigation imaging planning in 4 patients, and in one case using postoperative imaging studies. T (1)-weighted 3D image sets were acquired on a 1.5 T GE Genesis SIGNA MR scanner and VE reconstruction was performed using the General Electric Navigator software. The VE images were compared with the real images obtained during the endoscopic procedures and evaluated for their impact on the planning of the operative approach. RESULTS: VE implementation succeeded in all 13 patients. Major neuroanatomic reference structures were easily recognizable in all cases. Membranous structures such as the thinned floor of the third ventricle or cyst walls were identifiable in only 46 % of the cases. In 6 cases (46 %) VE showed anatomical variants and details relevant for the endoscopic procedure that were not identified on conventional MR images. CONCLUSIONS: VE has proved to be an important adjunct to the preoperative planning of neuroendoscopic procedures and its routine application is suggested.

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.