Romanian Neurosurgery http://journals.lapub.co.uk/index.php/roneurosurgery <p>Call for Papers - Vol. XXXIV, No. 4 (December 2020)<br />Submission Deadline: November 1, 2020</p> London Academic Publishing en-US Romanian Neurosurgery 1220-8841 The 3D printed models technology for the management of intracranial aneurysms http://journals.lapub.co.uk/index.php/roneurosurgery/article/view/1582 <p>Management of intracranial aneurysms is still a therapeutic challenge, especially in cases of complex lesions. Thus, the improvement of the study and intervention planning possibilities correlated with the access to continuous professional training based on simulation and clinical diversity represent optimal conditions for the efficient solution of this pathology. The development of three-dimensional printing technology offers a new opportunity in the modern treatment of intracranial aneurysms. The aim of this study is to present some aspects related to the materials and methods of manufacturing simulation models of individual 3D printed aneurysms and their influence in the optimal management of these lesions.</p> A. Chiriac Georgiana Ion G. Stan S. Munteanu N. Dobrin Dana Turliuc I. Poeata Copyright (c) 2020 2020-09-15 2020-09-15 373 378 Organizing a microsurgery workshop for residents http://journals.lapub.co.uk/index.php/roneurosurgery/article/view/1583 <p>Microsurgery represents an important branch in Plastic and Reconstructive Surgery. It involves fine skills which doctors need to repair nerves, vessels and thus being able to perform replantation and transplantation of different types of tissue. After traumatic injuries, a plastic surgeon is capable of either coverage of the exposed noble tissue or can perform the replantation of the amputated limb using microsurgery.</p> <p>This field can be very challenging at the beginning, but very rewarding in the end.&nbsp; The utility microsurgery is quite vast; however, the skills to perform such surgery require a lot of training beforehand. Before doing any replantation or other tissue transplant in humans, it would be recommended that a surgeon should have a basic microsurgical course completed and afterwards several hours of practice in front of the microscope. Last but not least, one should also test the skills acquired in vivo, in order to improve and perform the correct manoeuvres from the beginning.</p> <p>In order to do this, a plastic surgery trainee must therefore have a dedicated laboratory where he/she can practice this art. This place should be quiet, equipped with microscopes and microsurgery instruments and authorized to perform experiments on live animals.</p> Marin Andrei Lungu Adrian Nicoleta Amalia Dobrete Georgiana Gabriela Marin Olimpia Dima Simona Sîrbu Boeţi Mirela Patricia Irinel Popescu Copyright (c) 2020 2020-09-15 2020-09-15 379 385 Intracisternal papaverine toxicity in anterior circulation aneurysm clipping surgery http://journals.lapub.co.uk/index.php/roneurosurgery/article/view/1584 <p><strong>Introduction.&nbsp;</strong>Cerebral vasospasm is a major cause of mortality in patients with subarachnoid haemorrhage. Irrigation of intracisternal papaverine has been adopted as a strategy to reduce the incidence of aneurysm-surgery-associated vasospasm.</p> <p><strong>Aim.&nbsp;</strong>The aim of this literature review is to summarize the reported complications associated with intracisternal papaverine administration.</p> <p><strong>Patients and Methods. </strong>We searched the following databases: PubMed, Google Scholar, Cochrane Library, Clinical Key, Embase, Emerald, Health Business Elite, MEDLINE at OVID, EBM Reviews and Research Gate. The following keywords were used: Intracisternal papaverine, topical papaverine, direct papaverine, a vasodilator for aneurysm surgery, papaverine in aneurysm clipping, papaverine complications and papaverine side effects. The search criteria included all articles published between 1980-2019, in the English language.</p> <p><strong>Results.&nbsp;</strong>Our search yielded a total of 19 articles describing 43 cases. The most common reported complication was ipsilateral oculomotor nerve palsy. Other local complications included: Bilateral oculomotor nerve palsy, ipsilateral facial nerve palsy, and monocular blindness. Although less common, reports pointing to papaverine systemic toxicity did exist. Examples of such complications included: Profound hypotension, bradycardia, hypertension and tachycardia, hyperthermia and metabolic acidosis, cardiac arrest and even death.</p> <p><strong>Conclusion.&nbsp;</strong>Intracisternal papaverine irrigation is an effective strategy in reducing peri-operative vasospasm associated with aneurysm surgery. Although uncommon, both local and systemic side effects have been linked to papaverine use, calling for careful dosing and close monitoring to enhance its safety profile.</p> Zahraa F. Al-Sharshahi Samer S. Hoz Mustafa E. Almurayati Zahraa M. Kareem Zahraa Ameen Copyright (c) 2020 2020-09-15 2020-09-15 386 390 Can routine biochemical tests be a short-term prognostic biomarker in patients operated for chronic subdural hematoma? http://journals.lapub.co.uk/index.php/roneurosurgery/article/view/1457 <p><strong>Objectives: </strong>The effect of routine blood biochemistry parameters on the short-term prognosis of patients with chronic subdural hematoma (CSDH) has not been evaluated in literature before. In this study, it was aimed to establish markers for determination of short-term prognosis using data of patients who were operated for CSDH.</p> <p><strong>Methods: </strong>During admission to hospital, data of patients including age, sex, antiaggregan and/or anticoagulant drugs usage, comorbidity, Glasgow Coma Scale (GCS) and Glasgow Outcome Scale scores were evaluated. Location and thickness of CSDH were recorded using brain CT or MR images. Blood leukocyte, neutrophil, lymphocyte, eosinophil, basophil, platelet count results, neutrophil-lymphocyte ratio and platelet-lymphocyte ratio results, activated prothrombin time and INR values, serum glucose, aspartate aminotransferase, alanine aminotransferase, C-reactive protein, sodium, potassium, blood urea nitrogen and creatinine level values were also recorded. Patients were divided into two groups according to CSDH located “unilaterally (n=19)” and “bilaterally (n=12)”. In addition, patients with unilateral CSDH were divided into two groups as CSDH located at the "right hemisphere (n=6)” and "left hemisphere (n=13)".</p> <p><strong>Results:</strong> It was concluded that short-term prognosis of patients with unilateral or bilateral CSDH was similar. Correlation analysis showed no correlation between short-term prognosis and demographic, clinical and laboratory findings. However, <em>Likelihood Ratio</em> test revealed that GCS score could be a biomarker in order to predict short-term prognosis of these patients, albeit weak (X<sup>2</sup>=6.138, p=0.046).</p> <p><strong>Conclusion:</strong> It was thought that GCS scores could be effective in predicting short-term prognosis in patients with CSDH but routine biochemistry laboratory parameters could not predict short-term prognosis of these patients.</p> Ulaş Yüksel Mustafa Ogden Ibrahim Umud Bulut Bulent Bakar Ucler Kisa Copyright (c) 2020 Romanian Neurosurgery 2020-09-15 2020-09-15 391 399 Chondrosarcoma in petroclival synchondrosis without visual change http://journals.lapub.co.uk/index.php/roneurosurgery/article/view/1429 <p>Chondrosarcomas are a heterogeneous group of malignant bone tumours that share the production of the chondroid matrix in common. At the base of the skull, they are most commonly found in the region of the various synchondroses with an affinity for the petroclival fissure, they are locally invasive tumours, with little capacity to perform metastasis. The age group affected is variable, however, they frequently occur in middle-aged adults. Its clinical manifestation depends on the location and local extent; headache or paralysis of cranial nerves, particularly of the VI nerve is a frequent sign. As the petrous apex cannot be viewed directly, imaging studies such as computed tomography and magnetic resonance imaging play an important role in the evaluation of injuries. We present a case of a 36-year-old patient with chondrosarcoma of petroclival syndromes without visual changes. For the identification of this pathology, a battery of imaging tests was used and the diagnosis was made assertively, preserving the best choices for the treatment of the patient.</p> Mesías Villa Mendonça Raphael Oliveira Ramos Franco Netto João Italo Fortaleza de Melo Victor Augusto Ramos Fernandes Luiz Dias Dutra Maria de Farias Guelfi Mendonça Micaias Conde Simões Copyright (c) 2020 Romanian Neurosurgery 2020-09-15 2020-09-15 400 404 Ventriculoperitoneal shunt occlusion and cranioplasty http://journals.lapub.co.uk/index.php/roneurosurgery/article/view/1446 <p>Decompressive craniectomy (DC) is an urgent neurosurgical procedure, effective in the reduction of intracranial pressure (ICP) in patients with elevated ICP and in complications of brain infarction that do not respond to clinical treatment; traumatic brain injury (TBI); intracerebral haemorrhage (ICH) and aneurysmal intracerebral haemorrhage. Symptomatic hydrocephalus is present in 2 to 29% of patients who undergo craniectomy. They may require a ventriculoperitoneal shunt (VPS). The literature does not yet show standard management of cranioplasty in patients who have previously undergone a shunt, showing evidence of sinking skin flap syndrome. This case shows parenchymal expansion after VPS occlusion and cranioplasty in the patient’s profile. The 23-year-old male patient, right-handed, went to the hospital in January 2017 due to severe traumatic brain injury following multiple traumas. The patient underwent urgent DC surgery for the management of elevated ICP. The patient developed hydrocephalus. hydrocephalus. It was decided to perform the VPS implant. After 2 years, and with quite a sunken <em>flap</em>, the patient was submitted to cranioplasty procedure after shunt occlusion was performed. The patient left the hospital receiving outpatient care with no more complaints. In spite of the favourable outcome, new studies are fundamental to decide upon the best approach.</p> Lívio Pereira de Macêdo Arlindo Ugulino Netto Juan Pablo Borges Rodrigues Maricevich Nivaldo S. Almeida Hildo Rocha Cirne Azevedo-Filho Copyright (c) 2020 Romanian Neurosurgery 2020-09-15 2020-09-15 405 410 The Idiopathic Hypertrophic Spinal Pachymeningitis http://journals.lapub.co.uk/index.php/roneurosurgery/article/view/1447 <p>Idiopathic hypertrophic spinal pachymeningitis (IHSP) is a rare inflammatory condition characterized by chronic inflammatory hypertrophy of the dura mater. It can involve the entire spine. However, most cases are reported in the cervical and thoracic spine. It can progress from local pain to radiculopathy and eventually develop myelopathy. The aetiology of IHSP is not known. However, it has been suggested to be associated with many diseases. Here we report a case of IHSP in 21-year-old female who presented with paraplegia. The diagnosis was made on MRI Spine and histopathological examination. It was treated with surgical decompression, steroid therapy and patient improved gradually.</p> SURJEET SINGH STUTI KUMARI ABHIJEET SACHAN SATISH CHANDRA VERMA Copyright (c) 2020 Romanian Neurosurgery 2020-09-15 2020-09-15 411 415 A thoracic intradural intramedullary epidermoid in a 12-years old female without any evidence of spinal dysraphism http://journals.lapub.co.uk/index.php/roneurosurgery/article/view/1467 <p>The spinal epidermoid lesion is an extremely rare benign condition, seen in &lt; 1% of all spinal tumours and are most commonly associated with spinal dysraphism. They are more common in young children and have female preponderance. They can be either congenital or acquired with congenital being more common. They are most commonly located in the thoracic region. They grow slowly and present with back pain and progressive neurological deficit with or without bladder bowel involvement. We present a case of a 12-year-old female child with gradually progressive neurological deficit in the form of spastic paraparesis and decreased sensation with early bladder involvement. Her contrast MRI dorsolumbar spine showed a well defined intradural intramedullary lesion hypointense on T1 image, hyperintense on T2 image with no contrast enhancement at D10-D11 level. The patient was managed by surgical intervention with D9-D10-D11 laminectomy with total excision of the mass. Postoperatively on follow up patient had gradually improved motor and sensory symptoms with no improvement in bladder symptoms. Her histopathological study was confirmative of an epidermoid cyst. </p> Abhijeet Singh Sachan Prakrati Sachan Sateesh Chandra Verma Surjeet Singh Copyright (c) 2020 Romanian Neurosurgery 2020-09-15 2020-09-15 416 420 Spinal cord injury without radiologic abnormalities in a 4-years old boy http://journals.lapub.co.uk/index.php/roneurosurgery/article/view/1587 <p>In this study, we describe a 4-year-old boy with a head, cervical, and left shoulder injury following the reception of a heavy metallic door on his left side that resulted in SCIWORA.</p> <p>SCWORA is defined as spinal cord injury without x rays or CT scans lesions but can be detectable on RMI scans. SCIWORA follows trauma, sometimes trivial. The management consists of immobilization and nursing. The clinician should be aware of this entity. We are reporting the management of a four years old boy.</p> Sani Madjiri Laminou Ibrahim Assoumane Adamou Harissou Sanoussi Samuila Abarchi Habibou Smida Mahmoud Copyright (c) 2020 2020-09-15 2020-09-15 421 423 Fever as an independent prognostic factor in traumatic brain injury http://journals.lapub.co.uk/index.php/roneurosurgery/article/view/1567 <p>Traumatic Brain Injury (TBI) patients more often than not develop fever within the first few days of their hospitalization. Studies report that causes are variable and according to the pathogenesis, fever may be harmful or protective. The study was conducted to correlate the development of fever with clinical prognosis. Throughout the study spanning 6 months, a total of 98 patients of TBI were included. In the first 48 hours, 54 patients did not develop fever (temperature &gt;37?), 20 patients recorded temperatures between 37? and 39?; and 24 patients developed high fever (39?). On regular temperature monitoring and follow up, it was found that patients developing fever relatively early during hospitalization were more likely to end up with a poor outcome (Glasgow outcome scale 4 to 5). Therefore, fever is independently a predictor of poor prognosis in TBI patients and should be managed diligently in the first few days.</p> Sanjeev Chhabra Srikrishna Majhi Saha Sabyasachi Copyright (c) 2020 Romanian Neurosurgery 2020-09-15 2020-09-15 424 426 MRI spectrum and prevalence of lumbar spinal degenerative disease in patients with non-traumatic low back pain http://journals.lapub.co.uk/index.php/roneurosurgery/article/view/1557 <p><strong>Background:</strong> Low back pain (LBP) is a frequent cause of global disability and activity limitation. In the majority of cases, LBP is nonspecific, yet diagnostic confirmation is required to rule out serious underlying pathologies such as infection, tumour, fracture or degenerative disease. It can be done by a number of imaging techniques. Of all available techniques, MRI is currently the imaging modality of choice owing to lack of radiation, multiplanar reformation capabilities and high contrast resolution.</p> <p><strong>Objectives:</strong> To determine various MRI patterns and the common sites of spinal degenerative lesions among patients with LBP.</p> <p><strong>Method: </strong>This study was conducted on 622 patients suffering from non-traumatic LBP, referred for MRI of the lumbar spine. MRI database of the study population were analysed using axial T2-weighted, sagittal STIR, T1and T2-weighted and coronal STIR images. After excluding patients with h/o prior surgery and MR findings suggesting infective or neoplastic etiologies, 598 patients constituted the sample size of our study.</p> <p><strong>Results: </strong>A review of 598 patients with LBP revealed that degenerative changes in intervertebral disc were the most common abnormality detected. Among these, Disc bulge was the most common abnormality followed by disc desiccation, protrusion, extrusion, HIZ/annular tear, reduced IVD space and Schmorl’s nodes. Other non- disc degenerative findings were Modic endplate changes, facet joint arthropathy, osteophytes, Spinal canal stenosis and Ligamentum Flavum hypertrophy.</p> <p><strong>Conclusions: </strong>Results reported the common occurrence of lumbar disc degenerative disease in patients with low backache. Research efforts should attempt to trim down risk factors and perk up the quality of life.</p> Neha Singh Deepak Kumar Singh Copyright (c) 2020 Romanian Neurosurgery 2020-09-15 2020-09-15 427 433 An uncommon intracranial malign tumour which was misdiagnosed as Glioblastoma multiforme: Hemangiopericytoma http://journals.lapub.co.uk/index.php/roneurosurgery/article/view/1549 <p><strong>Background.</strong> Hemangiopericytoma (HPC) which is mostly located at the lower extremity and visceral organs was found extremely rare in the central nervous system. Radiological images are not enough to differentiate HPC from other CNS tumours. The case was analyzed to determine presurgical features for diagnosis and the challenges during surgery.</p> <p><strong>Case. </strong>A 65-year-old male patient with headache was diagnosed as Glioblastoma Multiforme (GBM) considering the image findings. However, the intraoperative macroscopic shape and tendency to bleeding were not relevant to the GBM. The mass was reported as Hemangiopericytoma which is a malign tumour, originates from pericapillary bodies of veins, and commonly locates out of the CNS.</p> <p><strong>Conclusion. </strong>Even in advanced age and radiologically considered high-grade glial tumours, HPC should be considered in the differential diagnosis for preoperative preparation.</p> Serdar Ercan Turan Kandemir Zeki Serdasr Ataizi Copyright (c) 2020 Romanian Neurosurgery 2020-09-15 2020-09-15 434 436 Craniopharyngioma and arteriovenous malformation operated using the same craniotomy http://journals.lapub.co.uk/index.php/roneurosurgery/article/view/1544 <p>Craniopharyngiomas (CPs) are rare benign epithelial tumours. Brain arteriovenous malformations (AVMs) are also rare lesions occurring in young adults. The appearance of both these lesions in the same patient is rare. A 42-year-old patient presented with headaches for 3 months and a progressive decrease in his visual acuity. Bitemporal hemianopsia was detected in the visual field. Magnetic resonance imaging (MRI) revealed a tumour with cystic and solid components located in the suprasellar region and AVM in the right temporal lobe. AVM (Martin–Spetzler grade III) was visualised using digital subtract angiography (DSA), which was fed from the right middle cerebral artery and drained through the sigmoid sinus via the inferior petrosal sinus. The patient was operated with enlarged right frontotemporal craniotomy. AVM nidus was totally removed at the first operation. Embolisation was not preferred before the AVM surgery. After 3 days, sylvian dissection was performed using the same craniotomy. The tumour was completely removed via the carotid cistern by making sharp dissection from the infundibulum. Post-operatively, the patient showed normal neurological examination and significant improvement in his visual field examination. There was no residual/recurrent tumour or AVM on contrast-enhanced MRI and DSA at post-operative 6 months. Histopathological examination revealed AVM in the first operative material and papillary-type CP in the second. The coexistence of these two rare pathologies has previously been reported in only one patient. This is the first case of surgical resection of CP and AVM using the same craniotomy.</p> Burak Eren Feyza Karagoz Guzey Ilker Gulec Copyright (c) 2020 Romanian Neurosurgery 2020-09-15 2020-09-15 437 440 Very late recovery of vision after removal of giant pituitary tumour http://journals.lapub.co.uk/index.php/roneurosurgery/article/view/1541 <p>Visual impairment is the most common clinical presentation of the pituitary tumour. Visual recovery usually occurs within days to months after surgical removal of the tumor. We report a case of a giant pituitary tumour where preoperatively there was severe visual impairment. Postoperatively he recovered vision in one eye within three months and the other eye remained completely blind for 5 years, then it began to recover very slowly to a serviceable vision in the next six years.</p> Forhad H Chowdhury Mohammod Raziul Haque Copyright (c) 2020 Romanian Neurosurgery 2020-09-15 2020-09-15 441 443 Optic Nerve Sheath Fenestration (ONSF) http://journals.lapub.co.uk/index.php/roneurosurgery/article/view/1540 <p><strong>Objectives. </strong>Optic nerve sheath fenestration (ONSF) is commonly used in idiopathic intracranial hypertension (IIH). Here we will present our experiences of ONSF in 26 patients with special attention to indications, surgical techniques and results</p> <p><strong>Methods. </strong>The recorded data of patient management (with the result) who underwent ONSF were reviewed and studied retrospectively.</p> <p><strong>Results. </strong>The total number of patients who underwent ONSF was 26. The male-female ratio was 1:12.</p> <p>Indications of ONSF were: 1. Idiopathic Intracranial Hypertension (IIH)-23 cases; 2. Cerebral Venous Sinus Thrombosis (CVST)-02 cases; 3. CNS Tuberculosis-01case.</p> <p>All patient underwent bilateral ONSF with post-operative continues lumbar CSF drain for 04 days. After fenestration gush of CSF came out with force in all-first operated eyes whereas 13-second operated eyes showed very little CSF flow after fenestration.</p> <p>Vision improved in different grades in all cases at discharge except in three cases. Preoperatively, visual acuity was either PL&amp;PR or hand movement in 40 eyes where 04 eyes were preoperatively total blind (no PL&amp;PR). Visual acuity improved in 48 eyes (92.3% eyes) where the patient can do his/her daily life activities including self-care. Improvement in IIH is 100% (23 cases i.e-46 eyes) whereas 01 case out of 02 cases in CVST. Though vision was improved dramatically fundal appearances changes very slowly and very less frequently returned to normal appearance.</p> <p><strong>Conclusion. </strong>Due to the delicate and technically demanding nature of the surgery, safety is a major concern of the ONSF. Our experience showed ONSF is a technically safe operation with very good results where indicated.</p> Forhad H. Chowdhury Mohammod Raziul Haque Jalal Uddin Mohammod Rumi Gurudas Mondal Mainul Haque Sarker Quazi deen Mohammod Copyright (c) 2020 Romanian Neurosurgery 2020-09-15 2020-09-15 444 451 Supratentorial PNET in a geriatric patient http://journals.lapub.co.uk/index.php/roneurosurgery/article/view/1517 <p>Supratentorial PNETs are most commonly seen in children and rarely seen in adults. PNET show a proliferation of undifferentiated or poorly differentiated neuroepithelial cells and, thus, are histologically similar to medulloblastomas. They account for approximately 2.5% of brain tumours in children and only 0.4% in adults. Prognosis is poor in the pediatric age group while it shows favourable prognosis in adults.<sup> </sup>In literature, less than 100 cases of adult PNET have been reported till date with mean age of 35years. PNET in the geriatric age group is rarely been reported</p> Hrushikesh Kharosekar Laxmikant Bhople Reshma Pujara Smita Ranveer Copyright (c) 2020 Romanian Neurosurgery 2020-09-15 2020-09-15 452 454 Enlarged anterior communicating artery masquerading as intracranial aneurysm http://journals.lapub.co.uk/index.php/roneurosurgery/article/view/1589 <p><strong>Background. </strong>The anterior communicating artery (ACoA) complex consists of the ACoA, the pre-and post-communicating segments of the anterior cerebral artery, and the recurrent artery of Heubner. It is the most common site for anatomical variations in the circle of Willis. Such variations can mimic intracranial aneurysms.</p> <p><strong>Case description. </strong>A 30-year-old female presented with recurrent episodes of extreme headache and bilateral tinnitus. A brain computed tomography (CT) scan showed no significant lesions, while her CT-angiography (CTA) showed an enlarged vascular lesion at the ACoA, raising the suspicion for an ACoA aneurysm. A repeated CTA revealed a rare anatomical variation with a pattern of cross dominance in the ACoA complex; the left A1 and right A2 were dominant-enlarged, resulting in an enlargement of the ACoA. The presence of an ACoA aneurysm was hence excluded and the patient was managed conservatively. At 6-month follow-up, CTA showed no new findings.&nbsp;</p> <p><strong>Conclusion. </strong>ACoA enlargement can result from unequal hemodynamics around the ACoA complex, which may be mistaken for an aneurysm. A thorough study of the imaging data is of pivotal importance and may change the management strategy.</p> Saja A. Albanaa Zahraa F. Al-Sharshahi Noor A. Hummadi Noor K. Al-Waely Rasha A. Alshakarchy Ali M. Neamah Aktham O. Alkhafaji Samer S. Hoz Copyright (c) 2020 2020-09-15 2020-09-15 455 458 Cerebrospinal fluid dynamics with its surgical implications http://journals.lapub.co.uk/index.php/roneurosurgery/article/view/1462 <p>Cerebrospinal fluid (CSF) is largely (70-80%) produced by the choroids plexus of the ventricles and is considered as the plasma ultrafiltrate. While CSF formation, circulation, and composition appear to be physiological and physical, its absorption appears to be mainly physical. The formation, composition, circulation, absorption, and changes in pathological conditions of CSF are discussed briefly in this review article. The CSF pressure dynamics studies provide information about the tightness, elastance, or outflow resistance of the CSF in the CNS. We believe that the present study shall help to provide essential details of CSF physiology which are important to many disciplines including radiology, neurology, and neurosurgery.</p> Harold E. Vasquez Yeider A. Durango-Espinosa Ezequiel Garcia-Ballestas B.V. Murlimanju Andrei Fernandes Joaquim Luis Rafael Moscote-Salazar Amit Agrawal Copyright (c) 2020 Romanian Neurosurgery 2020-09-15 2020-09-15 459 462 Global warming, neurosurgery and neurocritical care http://journals.lapub.co.uk/index.php/roneurosurgery/article/view/1445 <p>The changing temperatures are making an impact on health-related mortality outcomes with many studies on the role of temperature and mortality risks in cardiovascular and respiratory illnesses. Global warming a real phenomenon, progressing rapidly and producing changes in the ecosystem and have economic, social and public health implications.</p> Ezequiel García-Ballestas Luis Rafael Moscote-Salazar Andrei Joaquim Amit Agrawal Copyright (c) 2020 Romanian Neurosurgery 2020-09-15 2020-09-15 463 464