Surgical treatment of brainstem cavernomas using diffusion tensor imaging and diffusion tensor tractography.

INTRODUCTION: The aims of this study were to assess the prognosis of patients after a single haemorrhage from the cavernoma, and also in the case of rehaemorrhage, and to determine the indications for surgical treatment of brainstem cavernomas. MATERIAL AND METHODS: The study included a group of 35 patients with brainstem cavernomas, 23 women and 12 men aged 27 to 57 years (mean age 38.4). Up to 2005, MRI perfusion-weighted imaging/diffusion-weighted imaging had been carried out in 13 surgically treated patients. From 2005 onwards, the other 22 patients also underwent MRI diffusion tensor imaging and diffusion tensor tractography (DTI/DTT). DTI/DTT assessed the course of long fibre tracts. The course of the corticospinal tract, medial lemniscus and transverse pontine tracts was entered into the neuronavigation system. The surgical approach and the safe entry zone were determined based on the DTI/DTT. RESULTS: Our study showed that rehaemorrhage from a cavernoma depends on its size and volume. However, it is not related to its location. Based on the modified Rankin scale, the results of treatment of our patients after the first haemorrhage were better compared to the assessment after another haemorrhage. Complete resection was performed in 32 cases (91%) and partial resection in the remaining three (9%). Two patients underwent another surgery after several years due to partial resection. One patient presented with another haemorrhage after three years. New deficits developed postoperatively. Already existing deficits were exacerbated, but gradually resolved. Symptoms of cerebellar dysfunction and cranial nerve injury (including respiratory disorders) were the most difficult to resolve. CONCLUSIONS: Patients with brainstem cavernomas should undergo surgical treatment after their first haemorrhage, especially in the case of a large cavernoma. DTI/DTT should be used to determine the trajectory to the cavernoma, particularly to the deep cavernoma, and to determine the safe entry zone. Total resection of the cavernoma should be performed even where this means that reoperation is required.

Surgical treatment and prognosis of adult patients with brainstem gliomas.

The paper presents 47 adult patients who were surgically treated due to brainstem gliomas. Thirteen patients presented with contrast-enhancing Grades III and IV gliomas, according to the WHO classification, 13 patients with contrast-enhancing tumours originating from the glial cells (Grade I; WHO classification), 9 patients with diffuse gliomas, 5 patients with tectal brainstem gliomas and 7 patients with exophytic brainstem gliomas. During the surgical procedure, neuronavigation and the diffusion tensor tractography (DTI) of the corticospinal tract were used with the examination of motor evoked potentials (MEPs) and somatosensory evoked potentials (SSEPs) with direct stimulation of the fundus of the fourth brain ventricle in order to define the localization of the nuclei of nerves VII, IX, X and XII. Cerebellar dysfunction, damage to cranial nerves and dysphagia were the most frequent postoperative sequelae which were also the most difficult to resolve. The Karnofsky score established preoperatively and the extent of tumour resection were the factors affecting the prognosis. The mean time of progression-free survival (14 months) and the mean survival time after surgery (20 months) were the shortest for malignant brainstem gliomas. In the group with tectal brainstem gliomas, no cases of progression were found and none of the patients died during the follow-up. Some patients were professionally active. Partial resection of diffuse brainstem gliomas did not prolong the mean survival above 5 years. However, some patients survived over 5 years in good condition.

Surgical treatment of adult patients with thalamic tumors with the aid of tractography, fMRI, transcranial electrical stimulation and direct electrical stimulation of the subcortical white matter.

The aim of investigation was to assess treatment outcomes in adult patients with thalamic tumors, operated on with the aid of tractography (DTI) and monitoring of motor evoked potentials (MEPs) generated due to transcranial electrical stimulation (TES) and direct electrical stimulation (DES) of the subcortical white matter. 38 subsequent patients with thalamic tumors were operated on using tractography (DTI)-integrated neuronavigation, transcranial electrical stimulation (TES) and direct electrical stimulation (DES). The volumetric method was used to calculate pre- and postoperative tumor volume. Total tumor resection (100%) was performed in 18 (47%) patients, subtotal in 9 (24%) (mean extent of resection -89.4%) and partial in 11 (29%) patients (mean extent of resection -77.18%). The mean extent of resection for all surgical patients was 86.5%. Two (5.2%) patients died postoperatively. Preoperative hemiparesis was present in 18 (47%) patients. Postoperative hemiparesis was observed in 11 (29%) patients of whom only in 5 (13%) new paresis was noted due to surgical intervention. In patients with hemiparesis significantly more frequently larger tumor volume was detected preoperatively. Low mean normal fractional anisotropy (nFA) values in the internal capsule were observed statistically significantly more frequently in patients with preoperative hemiparesis as compared to the internal capsule of the unaffected hemisphere. Transcranial electrical stimulation helps to predict postoperative paresis of extremities. Direct electrical stimulation is an effective tool for intraoperative localization of the internal capsule thus helping to avoid postoperative deficit. In patients with tumor grade I and II the median time to tumor progression was 36 months. In the case of patients with grades III and IV it was 14 months. The median survival time in patients with grades I and II it was 60 months. In patients with grades III and IV it was 18 months. Basing on our results, patients with glioma grade I/II according to WHO classification are the best candidates for surgical treatment of thalamic tumors. In this group of the patients more often resection is radical, median time to progression and survival time are longer than in patients with gliomas grade III and IV. Within a 7-year follow-up none of the patients with GI/GII grade glioma died.

The diagnostic challenge of lack of choline level elevation on 1H-MR spectroscopy in grade II-III gliomas.

The accurate diagnosis of brain tumour is very important in modern neuro-oncology medicine. Magnetic resonance spectroscopy (MRS) is supposed to be a promising tool for detecting cancerous lesions. However, the interpretation of MRS data is complicated by the fact that not all cancerous lesions exhibit elevated choline (Cho) levels. The main goal of our study was to investigate the lack of Cho lesion /Cho ref elevation in the population of grade II-III gliomas. 89 cases of gliomas grade II and III were used for the retrospective analysis - glioma (astrocytoma or oligodendroglioma) grade II (74 out of 89 cases [83%]) and III (15 out of 89 cases [17%]) underwent conventional MRI extended by MRS before treatment. Histopathological diagnosis was obtained either by biopsy or surgical resection. Gliomas were classified to the group of no-choline elevation when the ratio of choline measured within the tumour (Cho lesion ) to choline from NABT (Cho ref ) were equal to or lower than 1. Significant differences were observed between ratios of Cho lesion /Cr lesion calculated for no-choline elevation and glial tumour groups as well as in the NAA lesion /Cr lesion ratio between the no-choline elevation group and glial tumour group. With consistent data concerning choline level elevation and slightly lower NAA value, the Cho lesion /NAA lesion ratio is significantly higher in the WHO II glial tumour group compared to the no-choline elevation cases ( p < 0.000). In the current study the results demonstrated possibility of lack of choline elevation in patients with grade II-III gliomas, so it is important to remember that the lack of elevated choline levels does not exclude neoplastic lesion.

The use of functional magnetic resonance imaging in reducing a risk of postoperative neurological deficits in the patients with brain tumour.

BACKGROUND AND PURPOSE: The purpose of the study was to compare the results of operative treatment of tumours located in the sensory-motor cortex guided with functional magnetic resonance imaging (fMRI) combined with the neuro-na-vigation system to the results of classical operative treatment. MATERIAL AND METHODS: The studied group comprised 28 pa-tients with a tumour located in the sensory-motor cortex area who underwent surgery guided with fMRI and the neuro-na-vigation system. A control group comprised 30 patients with the same clinical diagnosis, operated on without functional neuronavigation. RESULTS: The use of functional neuronavigation allowed for an 18% reduction in the intensity of neurological deficits after surgical treatment in patients from the studied group, compared to the subjects from the control group (p = 0.0001). In the patients with diagnosed high-grade glioma, improvement in the neurological condition in the studied group was 16% (p = 0.03). The initial neurological condition and the results of surgical treatment in patients with a tumour located less than 5 mm from the sensory-motor cortex, determined in fMRI examination, are worse than in patients with a tumour located more than 5 mm. CONCLUSIONS: In patients with a diagnosed brain tumour in the sensory-motor cortex who have neurological deficits, fMRI provides valuable imaging data on active areas. Tumour location of more than 5 mm from the fMRI active area of the sensory-motor cortex is connected with a considerably lower risk of postoperative neurological deficits. Removing a tumour in the sensory-motor cortex region, guided with fMRI and the neuronavigation system, considerably lowers the risk of postoperative development or exacerbation of neurological deficits.

Reoperations of patients with low-grade gliomas in eloquent or near eloquent brain areas.

BACKGROUND AND PURPOSE: Reoperations of patients with recurrent low-grade gliomas (LGG) are not always recommended due to a higher risk of neurological deficits when compared to initial surgery. The purpose of the present study was to evaluate surgical outcomes of patients operated on for recurrent LGG. MATERIAL AND METHODS: Sixteen patients who had surgery for recurrent LGG out of 68 LGG patients who underwent surgery at the Department of Neurosurgery in Sosnowiec, Poland between 2005 and 2011 were enrolled in the study. RESULTS: A large tumour volume prior to the initial surgery was the most significant parameter influencing LGG progression (96.6 cm³ vs. 47.9 cm3, p = 0.01). Increased incidence of epileptic seizures and decreased mental ability according to Karnofsky score were the most common symptoms associated with tumour recurrence. In the group of patients with malignant transformation, the relative cerebral blood volume (rCBV) was considerably increased (1.21 vs. 2.41, p < 0.01). No statistically significant difference was found in terms of the extent of resection between initial surgery and reoperation. Similarly, no significant difference was found in the number of patients with a permanent neurological deficit after initial surgery and reoperation. CONCLUSIONS: Reoperations of the patients with recurrent LGG are not burdened with a higher risk of neurological sequelae when compared to initial surgery. The extent of resection during the surgery for LGG recurrence is comparable to initial surgery. The increase of rCBV seems to be a significant biomarker that indicates malignant transformation.

The use of MR perfusion parameters in differentiation between glioblastoma recurrence and radiation necrosis.

INTRODUCTION: This study focuses on the challenge of distinguishing between tumour recurrence and radiation necrosis in glioma treatment using magnetic resonance imaging (MRI). Currently, accurate differentiation is possible only through surgical biopsy, which is invasive and may cause additional damage. The study explores non-invasive methods using dynamic susceptibility contrast (DSC) MR perfusion with parameters like relative peak height (rPH) and relative percentage of signal-intensity recovery (rPSR). MATERIAL AND METHODS: Among retrospectively evaluated patients (multicentre study) with an initial diagnosis of the primary and secondary brain tumour, 47 met the inclusion criteria and were divided into two groups, the recurrent glioblastoma (GBM) WHO IV group and the radiation necrosis group, based on MRI of the brain. All patients enrolled into the recurrent GBM group had a second surgical intervention. RESULTS: Mean, minimum and maximum rPH values were significantly higher in the recurrent GBM group than in the radiation necrosis group ( p < 0.001), while rPSR values were lower in the recurrent GBM group than in the radiation necrosis group ( p = 0.011 and p = 0.012). DISCUSSION: This study investigates the use of MR perfusion curve characteristics to differentiate between radiation necrosis and glioblastoma recurrence in post-treatment brain tumours. MR perfusion shows promising potential for distinguishing between the two conditions, but it also has certain limitations. Despite challenges in finding a sufficient cohort size, the study demonstrates significant differences in MR perfusion parameters between radiation necrosis and GBM recurrence. CONCLUSIONS: The results demonstrate the potential usefulness of these DSC perfusion parameters in discriminating between glioblastoma recurrence and radiation necrosis.

[Partial transcondylar approach - analysis of the surgical technique in cadaver simulation]. / Dostep przezklykciowy czesciowy - analiza techniki operacyjnej na podstawie symulacji na zwlokach.

The aim of the study was to present consecutive stages of the partial transcondylar approach. Six simulations of the partial transcondylar approach were performed on non-fixed human cadavers without any known pathologies in the head and neck. The consecutive stages of the procedure were documented with photographs and diagrams. The starting point for the partial transcondylar approach is a posterior repositioning of the suboccipital segment of the vertebral artery. The approach is achieved by partial removal of the occipital condyle and lateral mass of the atlas as well as by suboccipital craniectomy. Elevation of the cerebellar hemisphere presents an important supplement of the approach. The partial transcondylar approach is a reproducible technique, which provides surgical penetration of the anterior part of the cranio-cervical junction and related regions. This approach is particularly useful in the treatment of intradural tumours localized ventrally to the medulla.

Meningiomas of the anterior portion of the craniovertebral junction: immediate and late outcome following surgical removal using a partial transcondylar approach.

BACKGROUND AND PURPOSE: The partial transcondylar approach (PTA) is an alternative to the suboccipital approach in the surgical treatment of meningiomas of the anterior portion of the craniovertebral junction (APCVJ). The purpose of this study is to present our results of treatment of these meningiomas using PTA. MATERIAL AND METHODS: Fourteen patients (11 women, 3 men) with meningioma of the APCVJ were included in the study. Neurological status of the patients was assessed before and after surgery as well as at the conclusion of the treatment. The approximate volume of the operated tumour, its relation to large blood vessels, cranial nerves and brainstem, along with its consistency and vascularisation were assessed. RESULTS: The symptom duration ranged from 1 to 36 months (median: 11 months). In 79% of patients, motor deficits of the extremities were predominant symptoms. Less frequent symptoms included headache, cervical pain and sensory deficits of cervical nerves C2 to C5. Approximate volume of the tumours ranged from 2.5 mL to 22.1 mL (mean: 11.7 mL). Gross total or subtotal resection was achieved in 86% of patients. The postoperative performance status improved in 57%, did not change in 36% and deteriorated in 7% of the patients. CONCLUSIONS: The PTA is a useful technique for removal of meningiomas expanding intradurally of the APCVJ without significant compression of the medulla. The results of treatment were good in most patients.

A case of carotid body paraganglioma and haemangioblastoma of the spinal cord in a patient with the N131K missense mutation in the VHL gene.

The article describes paraganglioma case in woman with von Hippel-Lindau disease. She was found to be a carrier of a rare germline mutation in the VHL gene (393C>A; N131K). The patient developed large, untypical for von Hippel-Lindau disease, carotid body paraganglioma at the common carotid artery bifurcation. The carotid body paraganglioma coexisted with the haemangioblastoma situated intramedullary in region C5/C6. The haemangioblastoma reached the right-sided dorsal part of the spinal cord in section C5/C6. It produced radicular symptoms within C5/C6, followed by the later paresis of the right limbs. The haemangioblastoma was resected completely. Twelve months after the operation, the spinal symptoms receded and the carotid body paraganglioma still was asymptomatic. The current case of carotid body paraganglioma in patient with the 393C>A (N131K) missense mutation in the VHL gene, supports association of this specific mutation and VHL disease type 2, and suggests its correlation with susceptibility to paragangliomas.

Mucocoele and mucopyocoele of the frontal sinus penetrating to the cranial cavity and the orbit.

BACKGROUND AND PURPOSE: Mucocoele of the paranasal sinuses falls within the scope of interest for neurosurgery when erosion of the sinus wall and the osseous structures of the skull base develops and the lesion extends towards the cranial cavity, the orbit, the cavernous sinus or the sella turcica. The pa-per aims to present the method of treatment of extensive mucocoele which is used in our clinic. MATERIAL AND METHODS: We treated 7 patients (2 women and 5 men; age range: 27-68 years). Mucopyocoele was diagnosed in two cases, and mucocoele in the other five. In 5 cases, extension of the mucocoele to the cranial cavity and the orbit or to the ethmoid sinus and the orbit was observed. In the remaining 2 cases, mucopyocoele extended to the ethmoid sinus, the sphenoid and maxillary sinuses, cranial cavity and the orbit. The purpose of surgery was to remove the mucocoele or the mucopyocoele and to prevent recurrence. RESULTS: The postoperative course in all 7 patients was uneventful. All symptoms gradually receded. No relapse was observed in any patient during a follow-up period that varied from 10 months to 8 years; nor did incidents of inflammation of collateral sinuses occur. CONCLUSIONS: The treatment of mucocoele or mucopyocoele of the frontal sinus penetrating to the cranial cavity and the orbit consists of the following stages: cranialization of the frontal sinus, complete resection of the mucosa, tight closing of the frontal-nasal duct, and separating the air space of the opened collateral nasal sinuses from the cranial cavity with a large pedicled periosteal flap.

Early and long-term results of the treatment of jugular paragangliomas using different ranges of surgical approach.

BACKGROUND AND PURPOSE: The applied approach to the jugular foramen is a combination of the juxtacondylar approach with the subtemporal fossa approach type A. The purpose of this study is to present our results of treatment of jugular paragangliomas using the aforementioned approach. MATERIAL AND METHODS: Twenty-one patients (15 women, 6 men) with jugular paragangliomas were included in the study. The neurological status of the patients was assessed before and after surgery as well as at the conclusion of treatment. The approximate volume of the tumour, its relation to large blood vessels, cranial nerves and brainstem, as well as consistency and vascularity were also assessed. RESULTS: The duration of symptoms ranged from 3 to 74 months. In 86% of patients hearing loss was the predominant symptom. The less frequent symptoms included pulsatile tinnitus in the head, dysphagia and dizziness. Approximate volume of the tumours ranged from 2 to 109 cm3. A gross total resection was achieved in 71.5% of patients. The postoperative performance status improved in 38% of patients, did not change in 38% and deteriorated in 24% of patients. CONCLUSIONS: A proper selection of the range of the approach to jugular foramen paragangliomas based on their topography and volume reduces perioperative injury without negative consequences for the radicality of the resection.

Surgical treatment of insular tumours with tractography, functional magnetic resonance imaging, transcranial electrical stimulation and direct subcortical stimulation support.

BACKGROUND AND PURPOSE: Surgical treatment of insular tumours carries significant risks of limb paresis or speech disturbances due to their localization. The development of intraoperative neuromonitoring techniques that involve evoked motor potentials induced via both direct and transcranial cortical electrical stimulation as well as direct subcortical white matter stimulation, intraoperative application of preoperative tractography and functional magnetic resonance imaging (fMRI) in conjunction with neuronavigation resulted in significant reduction of postoperative disabilities that enabled widening of indications for surgical treatment. The aim of this study was to present the authors' own experience with surgical treatment of insular gliomas. MATERIAL AND METHODS: Our cohort comprises 30 patients with insular gliomas treated at the Department of Neurosurgery in Sosnowiec. Clinical symptoms included sensorimotor partial seizures in 86.6%; generalized seizures in 23.3%; persistent headaches in 16.6% and hemiparesis in 6.6%. All the patients were operated on with intraoperative neuromonitoring that included transcranial cortical stimulation, direct subcortical white matter stimulation as well as tractography and fMRI concurrently with neuronavigation. The analysis in-cluded postoperative neurological evaluation along with the assessment of the radicalism of resection evaluated based on postoperative MRI. RESULTS: Postoperatively, four patients had permanent hemiparesis (13.3%); importantly, two out of those patients had preoperative deficits (6.6%). Persistent speech disturbances were present in four patients (13.3%). Partial sensorimotor seizures were noted in two patients (6.6%). Seizures in the other patients receded. Intraoperative transcranial electrical stimulation as well as direct subcortical white matter stimulation along with tractography (DTI) and fMRI facilitated gross total resection of insular gliomas in 53.5%, subtotal in 13.3% and partial resection in 33.1%. CONCLUSIONS: Implementation of TES, direct subcortical white master stimulation, DTI and fMRI into the management protocol of the surgical treatment of insular tumours resulted in total and subtotal resections in 66% of cases with permanent motor disability in 6.6% of patients. Poor prognosis for independent living after surgery mainly affects patients with WHO grade III or IV.

[Extended subtemporal approach to the subtemporal fossa and related structures - analysis of the surgical technique based on cadaver simulation]. / Dostep podskroniowy rozszerzony do dolu podskroniowego i jego otoczenia - analiza techniki operacyjnej na podstawie symulacji na zwlokach.

The aim of the study was to present consecutive stages of the extended subtemporal approach (ESA). Seven simulations of ESA were performed on non-fixed human cadavers without any known pathologies in the head and neck. The consecutive stages of the procedure were documented with photographs and schemes. The starting point for ESA is osteotomy of the zygomatic arch and craniectomy including the greater wing of the sphenoid bone. Dislocation or removal of subtemporal fossa contents allows one to penetrate its inside and related structures. Additional widening of inspection allows osteotomy of the condyloid process of the mandible. ESA is a reproducible technique which provides surgical penetration of the subtemporal fossa and related structures. This approach is particularly useful in the surgical treatment of tumours expanding in the orbit, maxillary sinus, pterygopalatine fossa, nasopharynx, sphenoid sinus, cavernous sinus, parapharyngeal space, retromandibular fossa and surroundings of the petrosal part of the internal carotid artery.

[Fronto-temporo-orbito-zygomatic approach - analysis of the surgical technique on cadaver simulations]. / Dostep czolowo-skroniowo-oczodolowo-jarzmowy - analiza techniki operacyjnej na podstawie symulacji na zwlokach.

This paper presents consecutive stages of the fronto-temporo-orbito-zygomatic approach (FTOZA). Two simulations of FTOZA were performed on non-fixed human cadavers without any known pathologies in the head and neck. The consecutive stages of the procedure were documented with photographs and schematic diagrams. The starting point for FTOZA is a pterional craniotomy and osteotomy including the orbital rim, body of the zygomatic bone and zygomatic arch. In justified cases it is also possible to temporarily remove the upper and lateral walls of the orbit. Wide drawing apart of the Sylvian fissure is an important supplement of the approach. The fronto-temporo-orbito-zygomatic approach is a reproducible technique, which provides surgical penetration of the middle cranial fossa and related regions. This approach is particularly useful in the treatment of tumours of the above-mentioned anatomical areas as well as vascular malformation of the posterior part of the arterial circle of the brain.

Rare primary tumours of the hypothalamus in adults: clinical course and surgical treatment.

BACKGROUND AND PURPOSE: The paper presents the operative technique and the results of treatment of adult patients with primary tumours of the hypothalamus, including rare ones. The aim of the study was to show the possibility of safe surgical treatment of rare tumours of the hypothalamus through a bifrontal basal interhemispheric trans-lamina terminalis approach. MATERIAL AND METHODS: Five patients with tumours of the hypothalamus were operated on in the Neurosurgical Clinic in Sosnowiec between 1990 and 2008. There were 2 patients with craniopharyngiomas located exclusively in the third ventricle, and single patients with gemistocytic astrocytoma, Langerhans cell histiocytosis X and hamartoma of the hypothalamus each. The patients were treated surgically with a bi-frontal basal interhemispheric trans-lamina terminalis approach. In two cases, the neuronavigation system with the use of tractography (DTI) was used to determine the location of the lamina terminalis, the posterior surface of the optic chiasm and the optic tracts. RESULTS: All lesions were resected totally, except for partially resected hamartoma of the hypothalamus. The most common postoperative complication was diabetes insipidus, which was transient in two cases. A long-lasting follow-up of all the patients operated on did not reveal regrowth of the lesion. CONCLUSIONS: The bifrontal basal interhemispheric trans-lamina terminalis approach allows for radical resection of primary tumours of the hypothalamus while avoiding serious post-operative deficits. This approach enabled the preservation of the olfactory bulb and tract and prevented damage of the frontal lobes. The use of DTI helped to establish the location and borders of the lamina terminalis, to establish the posterior surface of the optic chiasm and the optic tracts, and to save the anterior and lateral wall of the hypothalamus.

Medial sphenoid ridge meningiomas: early and long-term results of surgical removal using the fronto-temporo-orbito-zygomatic approach.

BACKGROUND AND PURPOSE: The fronto-temporo-orbito-zygomatic approach (FTOZA) is an alternative to the pte-rional approach in surgical resection of meningiomas of the medial part of the lesser wing of the sphenoid bone. The purpose of this study is to present our results of treatment of these meningiomas using the FTOZA. MATERIAL AND METHODS: Thirty patients (19 women, 11 men) with a central skull base tumour were included in the study. The neurological status of the patients was assessed before and after surgery as well as at the conclusion of treatment. The approximate volume of the operated tumour, its relation to large blood vessels, cranial nerves and brainstem, as well as consistency and vascularisation were assessed. RESULTS: The symptom duration ranged from 1 to 36 months (median: 6 months). Impaired visual acuity was the predominant symptom in 27.5% of patients. Less frequent symptoms included paresis/paralysis of the third cranial nerve, headache, psychoorganic syndrome and epilepsy. Approximate volume of the tumours ranged from 5 to 212 mL (median: 63 mL). Total or subtotal resection was achieved in 77% of patients. The postoperative performance status improved in 16.5%, did not change in 52.8% and deteriorated in 26.4% of patients. One (3.3%) patient died after the surgery. CONCLUSION: The FTOZA is a useful technique for removal of tumours expanding superiorly to the middle cranial fossa base without significant compression of the brain. Ability to remove tumours through the described approach decreases as the degree of infiltration of the clivus increases.

Direct and remote outcome after treatment of tumours involving the subtemporal fossa and related structures with the extended subtemporal approach.

BACKGROUND AND PURPOSE: The aim of the study was to present our results of the surgical treatment of subtemporal fossa tumours and surrounding regions using the extended subtemporal approach. MATERIAL AND METHODS: Twenty-five patients (10 women, 15 men) with subtemporal fossa tumours were included in the study. The neurological and performance status of the patients were assessed before and after surgery as well as at the conclu-sion of treatment. The approximate volume of the operated tumour, its relation to large blood vessels and cranial nerves, as well as consistency and vascularisation were assessed. RESULTS: The symptom duration ranged from 2 to 80 months (mean: 14 months). In 44% of patients, headache was the predominant symptom. Less frequent symptoms were: paralysis of the abducent nerve and disturbances of the trigeminal nerve. Approximate volume of the tumours ranged from 13 to 169 cm3 (mean: 66 cm3). The most frequent histological diagnosis was meningioma (16%), followed by angiofibroma, neurinoma and adenocystic carcinoma (12%). Total or subtotal resection was achieved in 80% of patients. CONCLUSIONS: The extended subtemporal approach allows for the removal of tumours of the subtemporal fossa and surrounding regions. This approach also allows one to remove tumours expanding in the regions surrounding the subtemporal fossa only. In such cases the subtemporal fossa constitutes the way of the surgical approach.

Influence of infiltration anaesthesia on perioperative outcomes following lumbar discectomy under surgical pleth index-guided general anaesthesia: A preliminary report from a randomised controlled prospective trial.

PURPOSE: Severe postoperative pain (SPP) may occur after lumbar discectomy. To prevent SPP and reduce rescue opioid consumption, infiltration anaesthesia (IA) has been combined with general anaesthesia (GA). This study verified how GA combined with IA facilitated intra- and postoperative demand for opioids and affected the incidence of SPP in patients subjected to open lumbar discectomy. MATERIALS/METHODS: Ninety-nine patients undergoing lumbar discectomy under GA with Surgical Pleth Index (SPI)-guided fentanyl (FNT) administration were randomly assigned to receive IA combined with either 0.2% bupivacaine (BPV) or 0.2% ropivacaine (RPV) with FNT 50 µg and compared with controls (BF, RF, and C groups, respectively). RESULTS: Ninety-four patients were included in the final analysis. Adjusted according to SPI, total intraoperative FNT dosages did not differ between the study groups (p = 0.23). The proportion of patients who reported SPP was the highest in group C (41.9%) than in the RF (12.9%) and BF groups (31.3%) (p < 0.05). Mild pain was experienced by 67.7%, 53.1% and 32.3% of patients from the RF, BF and C groups, respectively (p < 0.01). Morphine requirement was the highest in the control group (7.1 ± 5.9 mg), followed by the RF (2.7 ± 5.3 mg) and BF groups (4 ± 4.9 mg) (p < 0.05). CONCLUSIONS: IA using RPV/FNT mixture significantly reduced SPP and postoperative demand for morphine in patients subjected to lumbar discectomy under GA.

Direct and remote outcome after treatment of tumours involving the central skull base with the extended subfrontal approach.

BACKGROUND AND PURPOSE: To present our results of the surgical treatment of central skull base tumours using the extended subfrontal approach (ESA). MATERIAL AND METHODS: Twenty-six patients (8 women, 18 men) with central skull base tumours were included in the study. The neurological and performance status of the patients was assessed before and after surgery as well as at the conclusion of treatment. The approximate volume of the operated tumour, its relation to the large blood vessels, cranial nerves and brainstem, as well as consistency and vascularisation were assessed. RESULTS: The symptom duration ranged from 1.5 to 18 months (mean: 8.3 months). Loss of olfaction was the predominant symptom in 38% of patients. Less frequent symptoms were: paresis/paralysis of the 6th cranial nerve, psychoorganic syndrome, impaired visual acuity, nasal obstruction and headache. Approximate volume of the tumours ranged from 10 to 105 ml (mean: 54.3). The most frequent histological diagnosis was chordoma (19%), meningioma (15%), followed by haemangiopericytoma, fibroma and esthesioneuroblastoma (12%). Total or subtotal resection was achieved in 77% of patients. The postoperative performance status was improved in 39%, unchanged in 27% and impaired in 15% of patients. Five patients died after the surgery. CONCLUSIONS: Extended subfrontal approach is a useful technique for removal of benign tumours expanding along the midline, superiorly and inferiorly to the skull base. For removal of malignant tumours at the same location, ESA is an alternative to a combination of transcranial approach and one of the craniofacial approaches.