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   You are here: Home ›› Archive ›› Vol. XIV, no. 2
Organisation of surgical training in neurosurgery
Hans J. Reulen, MD and Peter A. Winkler, MD
Department of Neurosurgery, Munich Section of Neurosurgery, UEMS
In this article the authors present the new European requirements for operative training in the first part and in part II some experiences on the implementation of these operative figures into daily practice. The second part is based on the long personal experience of the two authors as well as the experience of the senior author with site visits in various neurosurgical departments all over Europe. Part III is giving some further ideas on the organization of surgical training with a set of structured hands-on-courses.

Controversies in multimodal treatment of pineal tumors - experience of 84 cases
A. Tascu, MD, Prof. A.V. Ciurea, MD, PhD, M. Lisievici, MD, F. Brehar, MD, R.E. Rizea, MD
Neurosurgical Clinic (AT, AVC, FB, RER), Neuropathology Department (ML), “Bagdasar-Arseni” Clinical Hospital, Bucharest, Romania
Keywords: pineal tumors, microsurgical approach, multimodal treatment, Gamma-knife surgery, outcome

The pineal tumors represent one of the most difficult and challenging disease from all brain pathology due to the complex anatomy of the area and because of the diverse pathology of this type of tumors. The management of these tumors is multi modal and comprises the surgical approach followed by radiotherapy and chemotherapy. The authors present a large series of 84 consecutive operated cases of pineal tumors. All these cases have undergone one of the two main surgical approaches (occipito-transtentorial approach and supracerebellar - infratentorial approach). In 22 cases (26,1%) the tumor was totally removed, in 18 cases (21,4%) near total removal was obtained, in 33 cases (39,2%) partial removal and biopsy was performed in 11 cases (13,1%). From all 84 cases, 39 cases (46%) were germ cells tumors, 16 cases (19%) were pineal parenchyma tumors, in 27 cases (32%) were glial cell tumors and in 2 cases (3%) were miscellaneous tumors. As adjuvant therapy, radiotherapy played an important role within the multimodal management of pineal tumors. Therefore 61 cases have undergone the radiotherapy, which have been indicated for all sensitive tumors. The chemotherapy was applied in 41 cases, and consisted in a combination of cisplatin, bleomycin and actinomycin D. The outcome was good recovery in 56 cases (66%), moderate disability in 12 cases (14.7%), severe disability in 9 cases (10.2%) and death in 7 cases (8.8%).

Overview on the treatment of medulloblastoma to the child
E.V. Gruber, MD, Ileana Ionescu, MD, Prof. A.V. Ciurea, MD
Oncopediatric Department, Oncology Institute, Bucharest, Romania (EG)
Radiotherapic Department, Oncology Institute, Bucharest, Romania (II)
Neurosurgical Clinic, "Bagdasar-Arseni" Emergency Hospital, Bucharest Romania ryAC)
The tumors of the central nervous system (CNS) are the most frequent solid tumors of the children occupying the second place after leukemia for all the malignancy of the child. Of primary brain tumors in children, more than one half originate in the posterior fossa. Medulloblastoma (MB) are highly malignant tumors representing the most common malignant posterior fossa tumor in the pediatric population, accounting for nearly 20% of all childhood brain tumors and 40% of those arising below the tentorium. This embryonic tumor is histological characterized by small, round to oval cells with hyperchromatic nuclei surrounded by a minimal degree of cytoplasm. MB's are characterized by their tendency to seed along the neuraxis, following cerebrospinal fluid (CSF) pathways, and they represent one of the few brain tumors, including ependymoma, pinealoblastoma, and lymphoma, to metastasize to extraneural tissues (bone, bone marrow, lymph nodes, liver).
The incidence of MB is 1.5-2 cases per 100,000 populations, and the peek in incidence of the MB's between 3 and 5 years, although it can occur throughout childhood and until adult. In Romania the incidence of the CNS tumors to the child is not known. Each year about 70 children with tumors of CNS (mortality = 1.3o/oooo under 19 years) die in our country and this result is the same in the last two decades. The last 20 years have registered advances in establishing of the diagnosis (imaging), in the neurosurgery, neuroanaesthesia and intensive care. New techniques of radiotherapy have been developed (hyperfractionated, three-dimensional, conformational radiotherapy (3DCT), intensity modulated radiotherapy (IMRT), stereotactical radiotherapy, stereo tactical radio surgery (Gamma Knife), irradiation with protons). New chemotherapeutical protocols have offered a better systemic control of the disease. So the survival rates grew every decade. Cure can be reached, but the price for almost all the patients is a poor quality of life (motor, neurocognitive, hearing, visual, endocrinological and social).

Multimodal treatment in large Schwannomas
Ass. Prof. M. Gorgan, MD, PhD, F. Stoica, MD, Narcisa Bucur, MD, PhD, Angela Neacsu, MD, V. Pruna, MD, A.N. Calina, MD, D. Martin, MD Clinic Emergency Hospital Bagdasar-Arseni Bucharest, Romania (MG, NB, AN, VP, ANC, OM)
Fourth Neurosurgical Department and High Energy Therapy Department Clinic Emergency Hospital Bagdasar-Arseni Bucharest (FS)
Keywords: acoustic schwannoma, open surgery, gamma-knife radio surgery, results

Authors analyze a 59 patients case series with stage III and IV schwannomas treated in our hospital between 16.11.2004-16.05.2007 with a combined method: microsurgery for massive intratumoral debulking and gamma-knife radio surgery for the tumor remnants. They were recorded 3 cases of trigeminal schwannomas, 2 cases with facial schwannomas and 50 cases with acoustic-vestibular schwannomas. 4 cases presented Neurofibromatosis type2, with bilateral schwannomas. Peak of age was 37 years (median), and the time for follow up was 11 months (median), but with a low rate of presentation for controls. No deceased or supplementary permanent morbidity was recorded in this interval of follow up. Timing between surgery and gamma knife radiotherapy was between 4 to 6 months. Our results indicate a decrease of the remnant tumor volume with 10% at 6 months after operation and radiotherapy, and with 40% after 12 months. 4 cases developed complications due to intratumoral necrosis, trigeminal neuralgia, peritumoral cyst development, which were solved by a new operation or by conservative treatment. Conclusion. Massive intratumoral debulking by open surgery, followed by gamma-knife radio surgery is a reliable option for short and long-term tumor control in the cases of large schwannomas.

Isolation and characterization of a human glioblastoma cell line
F.M. Brehar, MD, Prof. A.V. Ciurea, MD, A. Tascu, MD, E. Gherghina, MD, I. Ciurel, MD, W. Buzgariu, MD, L.M. Stefan, MD
National Institute of Research and Development for Biological Sciences (EG, IC, WB, LMS)
Emergency Clinical Hospital "Bagdasar-Arseni" (FMB, AVC, AT, IC)
Keywords: glioblastoma, cells line, karyotype, immunohistochemistry

The characterization of a glioblastoma cells line represents an important achievement in the field of brain tumor research activity, which enables the researchers to obtain strong results with a wide recognition by the scientific community. The objective of this study was to develop a standardized glioblastoma cells line using the resources obtained entirely from the national research projects. The tumor samples was initially obtained intraoperative from a 58 years-old female patient, with the preoperative written consent of the patient. The histopathological exam showed a grad IV WHO glioma (glioblastoma). The sample was prepared by manual fragmentation into pieces up to few millimeters each, followed by enzymatic digestions using different concentration of trypsin. Then, the cellular line was cultivated for more then 100 passages using Dulbecco Modified Eagle's medium enrich with 10% fetal bovine serum. The characterization of the glioblastoma line was made by the evaluation of cells proliferation (growth curve), by morphological studies, by studying the karyotype of the cells and by immunohistochemistry studies for the identification of the specific markers (glial fibrillary acidic proteins - GFAP, vimentin) of the tumor cells. The determination of the expression/amplification of the receptors tyrosine kinases (PDGFR and more important EGFR) is in progress. The characterization of a glioblastoma cells line represents an essential step in order to obtain a better in vitro and in vivo experimental model for glioblastoma.

Multiple intracranial meningiomas with different pathological subtype
Assoc Prof M. Gorgan, MD PhD, Angela Neacsu , MD, Narcisa Bucur MD PhD, M.V. Pruna, MD, Calina Niki Adrian, MD, D. Martin, MD, M. Lisievici, MD PhD, D.B. Vasiliu, MD
First Neurosurgical Clinic, Fourth Neurosurgical Department, Pathology Department (ML, DBV)
Clinic Emergency Hospital "Bagdasar-Arseni", Bucharest (GM, NA, BN, PMV, CNA, MD)
Keywords: multiple meningiomas, different pathological subtype, treatment strategy

Authors present the case of a 63 years old woman, admitted for left proptosis and hemicrania evolving for three months. At the screening CT scan with contrast were discovered two lesions: a left fronto-temporal mass, intensely contrast enhancing, with peritumoral edema, inserted on the sphenoid wing, extended in the infratemporal fossa and ethmoidal sinus; the other lesion was cystic, located parieto-temporally, in the corticosubcortical area, with a small tumor nodule located deeply. MRI defined the details and the size of the lesions: 63/65/71 mm left solid tumor suggesting a sphenoid wing meningioma, and a 67/62/72 mm right parietal-temporal cystic lesion with moderate mass effect. Authors insist on neurosurgical strategy for treatment of multiple intracranial masses with different consistency-solid and cystic. Adequate surgical planning was done after MRI with contrast examinations, which were strongly suggestive for multiple intracranial meningiomas. Surgical approach was done in two steps according to treat first the cystic lesion because we supposed that is a recent developed lesion with high risk of sudden volume increase followed by neurological deterioration. On another way, attacking first the solid tumor, we could have a high risk to decompensate the cystic lesion. Neurological and general evolution after two steps neurosurgery was without incidents with a very good outcome. Pathological examination revealed two different types of meningioma: microcystic and transitional.

Surgical approach of posterior fossa tumor (bone aneurysmal cyst) - a case report
D.C. Voinescu MD, PhD, C. Nastase, MD
Department of Neurosurgery, "Elias" Clinical Emergency Hospital, Bucharest, Romania
Keywords: osteolytic tumor, hemodynamic alterations, surgical approach

An aneurysmal bone cyst is an expansible osteolytic lesion with a thin wall, containing blood-filled cystic cavities. The term aneurismal is derived from its radiographic appearance. Local hemodynamic alterations related to venous obstruction or arteriovenous fistulae that occur after an injury are important in the pathogenesis of an aneurismal bone cyst. The lesion is a component of, or arises within, a preexisting bone tumor in about one third of cases; this finding further substantiates the fact that aneurismal bone cysts occur in an abnormal bone as a result of associated hemodynamic changes. The authors would like to present a case and the problems which they had during the surgical procedures.

Romanian neuro-ophthalmology
Tatiana Rosca, MD
Emergency Hospital "St. Pantelimon", Bucharest, Romania
Keywords: neuro-ophthalmology, RONOS

Aim. RONOS was founded to develop clinical neuro-ophthalmology in Romania by promoting the medical principles, policies and practices in view of better neuro-ophthlamological care of patients; acquiring scientific and clinical knowledge in kin fields to Neuro-ophthalmology. The fundamental values of RONOS are aspiration to performance and encouraging the pioneering, the innovating spirit and the interdisciplinary cooperation for making the medical performance more responsible. RONOS's place is among the world neuro-sciences.

Visual loss after spinal surgery
D. Adam, MD, Daniela Popilian, MD, Ioana Hornea, MD, Cristina Adam, MD
"St. Pantelimon" Emergency Hospital Bucharest, Romania
Keywords: spinal surgery, visual loss

Objective is to evaluate the risk factors and possible mechanism in cases of postoperative visual loss. Method. We report two patients with spine surgery (discectomy, laminectomy) and stress the intraoperative factors which can predispose to postoperative visual loss. Results. The two patients had a single common factor: prone position with the head turned to the right. They had partial visual loss to the left eye. The first patient had as possible risk factors diabetes mellitus and intraoperative blood loss. Conclusions. It is necessary correct positioning of the patient head on the operative table to avoid pressure on orbit with increased intraocular pressure and decreased perfusion pressure of the eye. It is also necessary to recognize the risk factors which can contribute to the occurrence of this complication.

Neurosurgical treatment of congenital arachnoids cysts in adults: 33 case series review
Assoc Prof M. Gorgan, MD PhD, Angela Neacsu, MD, Narcisa Bucur, MD PhD, M.V. Pruna, MD, Calina Niki Adrian, MD, D. Martin, MD
First Neurosurgical Clinic, Fourth Neurosurgical Department Clinic Emergency Hospital "Bagdasar-Arseni", Bucharest, Romania
Keywords: arachnoid cysts, seizures, cysto-perltoneal shunt

Authors analyze a 33 case series of adult cases operated in Clinic Emergency Hospital "Bagdasar-Arseni", Bucharest, Fourth Neurosurgical Department, for intracranial arachnoids cysts between 1996 and 2006 and selected from 186 cases diagnosed with this type of disease. The series counts 11 woman (33.33%) and 22 man (66.66%), with a medium age of 37 years, and a total follow-up time of 5.6 years. The main symptoms were headache (28 - 84%), seizures (18-54.5%), dizziness (19-57.5%), behavioral abnormality and learning difficulty or memory troubles (17-51.5%). Papiledema was present in 8 cases (2424%). In 9 cases (27.27%) a cyst-peritoneal shunt was placed, and in the other 24 cases (72.72%) was performed an open craniotomy with cyst fenestration. In both procedures the opening CSF pressure was measured, ranging from 230 to 460 mm H20. 31 patients (93.9%) improved after surgery; one remained unchanged (3.03%) and one deteriorated (3.03%). Authors analyze the outcome and symptoms on medium term and conclude that in selected cases, both neurosurgical procedures improves the patients with low risks, decreases all symptoms, and specially the frequency of seizures under minimal anti epileptic therapy. The patient prognosis is directly related with the decrease in size of the cyst, this anatomic relation being and reliable argument for active neurosurgical management.

Epidural fibrosis after lumbar spinal surgery
Danil Adam, MD, Cristina Adam, MD, Ioana Hornea, MD
"St. Pantelimon" Emergency Hospital Bucharest, Romania
Keywords: peridural fibrosis, radiotherapy, Mitomycin C

The surgical treatment of the lumbar disc hernia is, in same cases, followed by complications which are included in a clinical syndrome named failed back surgery syndrome (FBSS). Lumbar fibrosis is responsible in 24% of cases of FBSS. We review the literature concerning this subject. Many studies looked for methods to prevent this complication, with moderate effectiveness. ADCON gel, which raised great expectations - produced no positive effect in patients who underwent microdiscectomy, and is now out of use. Currently, the results of experimental studies with local Mitomycin C and preoperative extenal radiotherapy (7 Gy) are promising and allow us performing clinical studies.

Cervical disc hernia treatment with and without cage fusion
D. Adam, MD, A. Angheluta, MD, Ioana Hornea, MD
"St. Pantelimon" Emergency Hospital Bucharest, Romania
Keywords: cervical disc hernia, discectorny, cage fusion

Purpose is to evaluate the results of resection of hernia cervical disc with and without cage fusion. Material and method. This is a retrospective study on 34 patients in which resection of prolapsed intervertebral disc was not followed by fusion (10 men and 24 women, C5-C6: n=16, C6-C7: n=18) operated in 2005, and 14 patients in which resection of prolapsed intervertebral disc was followed by cage fusion. There were 10 men and 4 women, C5•C6: n=8, C6-C7: n=6, operated in the first 6 months of 2006. Fusion was performed with Affinity cage filled with autogenously bone derived from the iliac crest. We used only one cage at every procedure, with diameter 1 mm larger than the height of intervertebral space. Results. In the first group, after a follow-up of minimum 1 year we observed a reduction of intervertebral space at the operated level in 18 patients; in 16 cases the intervertebral space disappeared completely (vertebral bloc); surface area of the intervertebral foramen was smaller than preoperatively; 14 patients (40%) complained of residual paresthesia and 6 patients (18%) complained of limited range of motion in axial rotation. In the second group, after minimum 6 months follow-up the intervertebral space remained with the same height in 4 patients and was larger in 10. The intervertebral foramen at the same level had the same surface area as preoperatively. Adjacent intervertebral spaces were in 6 patients reduced by 1 or 2 mm: Patients of this group had neither paresthesia nor other neurological deficits. The cages remained in place with fusion observed on plain radiographs after 3 months. Conclusions: Decompression of the neural root was followed by clinical amelioration; persistence of paresthesia in 40% and limited range of motion in 18% of the first group of patients respectively may be explained by narrowing of the intervertebral foramen and intervertebral space, postoperatively. These drawbacks do not occurred when we performed excision of hemiated intervertebral disc and fusion of the motor segment with cage. Only one cage/level is necessary and sufficiently to obtain good results.