Romanian Neurosurgery

Post-traumatic epileptic seizures revealing hydrocephalus

2025-06-23T12:09:54-04:00

Background: Hydrocephalus is one of the late complications of head injury. More often, post-traumatic epileptic seizures are due to intracranial hematomas and brain contusion. Hydrocephalus is rarely reported in this clinical registry. The literature is not very rich in cases of epileptic seizures linked to posttraumatic hydrocephalus.

Objective: We report the results of our study, the aims of which were to establish the epidemiology of post-traumatic hydrocephalus in our practice, to determine the mechanisms of trauma onset, to describe the initial traumatic lesions and to highlight the timing and pathophysiological mechanism of epileptic seizures in post-traumatic hydrocephalus.

Materials and methods: We conducted a descriptive, retrospective study over a period of 4 years at the Neurosurgery Department of the Gabriel Touré University Hospital in Bamako. We included patients of both genders and all ages who had at least one seizure after head injury and in whom the CT scan performed during the investigation of the seizure showed hydrocephalus.

Results: Between 1 January 2020 and 31 December 2023, out of 1024 cases of traumatic brain injury (TBI), hydrocephalus was diagnosed in 37 patients (3.6%) during the investigation of epileptic seizures. All patients were male with a mean age of 27.4 years. The trauma was caused by road traffic accidents in 48.6%. The initial brain injuries were dominated by hemorrhagic contusions (29.7%), osteo-meningeal injuries caused by fracture of the frontal bone (19%) and traumatic subarachnoid haemorrhage (16.2%). The mean time to onset of the first attack was 28.3 days. Seizures were generalised in 86.4%. Sudden onset without prodrome occurred in 64.8% of patients. Tetraventricular hydrocephalus was diagnosed in 89.1% of cases. Ventriculoperitoneal shunting was performed in all patients. After 5 months of follow-up, seizures had completely resolved in 87.5% of patients despite complete cessation of antiepileptic treatment. No deaths were reported.

Conclusion: Epilepsy may be a clinical manifestation of post-traumatic hydrocephalus. Morphological imaging is essential for diagnosis. Management is based on cerebrospinal fluid drainage.

A narrative review in managing ICA aneurysms

2025-06-23T13:28:39-04:00

Introduction: Internal carotid aneurysms are among the most common intracranial aneurysms, with nearly 20-25% of the ruptured aneurysms patients succumbing to death before reaching hospital. Most aneurysms are discovered in the context of an SAH, unruptured aneurysms can also be detected in patients presenting with other clinical symptoms or incidentally through neuroimaging.

Materials and methods: We searched Google and indexed articles with the keywords “ICA aneurysm management". We took 45 articles to identify epidemiology, diagnosis and management of these aneurysms. Both microscopic and endovascular treatments were taken into account.

Results: Clipped aneurysms had a relatively lower percentage of recurrences as compared to endovascular modality, while the incidence of peri-procedural complications was higher with clipping patients.

Conclusion: The volume of cases an institution handles influences the procedure's success. Endovascular management of ICA aneurysms has recently gained in numbers compared to open procedures.

Three instruments, two hand technique in biportal endoscopic spine surgery

2025-06-23T14:16:46-04:00

Background- Unilateral biportal endoscopic spine surgery (UBE) is a popular minimally invasive method for various types of spinal disease. This surgical technique has several advantages over conventional spine surgery, including less tissue damage, less blood loss, shorter hospital stays, and faster recovery. We introduce three instruments, two two-hand technique in UBE surgery.

Methods: Using hook dissector for gently teasing out the disc material and retracting the nerve root, and holding the same in non-dominant hand along with endoscope, we can use the instrument in dominant hand with better efficacy.

Results: A hook dissector can both act as a dissector and retractor while mobilising the nerve root and dural sac, and another instrument can be passed through the same portal, mainly a Kerrison punch or disc forceps for a complete decompression.

Conclusion: Use of 3 instruments in two hands of primary surgeon is a wonderful technique in UBE, particularly while achieving the final stages in decompression.

Intralesional abscess in choroid plexus carcinoma

2025-04-29T14:34:05-04:00

Background: Choroid plexus carcinoma (CPC) is a rare, aggressive intraventricular tumour that predominantly affects young children. While CPC typically presents with hydrocephalus and mass effect, intratumoral abscess formation has not been previously documented.

Case Presentation: We report the case of a previously healthy 3-year-old female presenting with central facial hemiparesis and anisocoria. Imaging revealed a solid-cystic, contrast-enhancing lesion in the left ventricular atrium with spinal dissemination. Endoscopic-guided total resection via a parietal approach was performed, revealing a friable, hemorrhagic mass. Histopathology confirmed CPC with high proliferative index (Ki-67: 70%). Postoperative treatment followed the HEAD START III chemotherapy protocol without hematopoietic stem cell transplantation, followed by craniospinal radiotherapy. The patient remains recurrence-free after 12 months of follow-up.

Conclusion: This case highlights the successful management of a CPC complicated by an intratumoral abscess, an unprecedented presentation. Total surgical resection followed by multiagent chemotherapy and radiotherapy resulted in favourable early outcomes. Given CPC’s rarity and variable presentation, individualised, multidisciplinary approaches are essential.

Primary spinal tumours

2024-12-23T11:07:30-05:00

Primary spinal cord tumours are rare conditions that comprise 3% of all primary CNS tumours in adults. The present study analyses the clinical presentation, prognostic factors, radiological assessment, treatment, histological examination and their correlation with the outcome of these spinal tumours, in an urban setup of India. The study presents our single institution’s surgical experience and clinical outcomes on patients who have undergone surgical excision for spinal tumours. Methodology: This retrospective and prospective observational study was conducted among 36 patients admitted to the Department of Neurosurgery at Rabindranath Tagore Medical College and Associated Hospital, Udaipur, between May 2022 and September 2024. All patients were clinically evaluated along with preoperative and post-operative modified Nurick grading with 3 months of follow-up. Statistical analysis was performed using SPSS. Results: Our study included 36 patients, mean age was 38.4 years. Of the participants, 13 (36.1%) were men and the remaining 23 (63.9%) were women. Motor Weakness was the most common symptom noted in all patients. The tumours were commonly seen in the thoracic region, 14 cases (38.9%). Schwannoma was the commonest lesion, and there was a male preponderance. Conclusion: Our study clearly demonstrates that surgical treatment of spinal tumours offers very good functional outcomes irrespective of the age of the patient or the neurological status.

Cranioplasty timing and its effect on the functional neurological outcome in traumatic brain injury

2025-02-27T10:16:39-05:00

The best time to do cranioplasty (CP) and how it will affect the neurological outcome is still in debate. Moreover, being one of the most commonly performed interventions in neurosurgery, its complication rate is among the highest in literature. The aim of this study is to assess the effect of timing of cranioplasty (CP) on the functional neurological outcome and post-operative complications in patients of traumatic brain injury. A retrospective cohort study was conducted in patients who underwent CP between 2018 and 2022. Early and late cranioplasties were defined as surgeries performed within and more than 90 days of decompressive craniectomy, respectively. The Glasgow Outcome Score- Extended (GOSE) and Functional Independence Measure (FIM) were used to assess the neurological outcome. Late CP cohort patients presented with subdural hygroma (SDG), which had a significant correlation. In post-CP complications, SSI, post-CP hydrocephalus and new onset seizures had a significant correlation with late CP (p <0.001). In early CP GOS E score of 6 was seen, whereas a better score of 7 was seen late cohort. In FIM rating, both had maximum number of cases in Minimal Assistance group. The neurological outcome in patients who underwent early versus late CP is almost identical. We drew the conclusion that early CP often resulted in less post-operative morbidity. A lower number of early CP cohort subjects experienced post-CP HCP, seizures, and SSI. In order to reduce postoperative problems in TBI cases receiving DC, we advise an early CP based on the study's findings.

Lumbar neurofibroma: etiology, clinical presentation, surgical indications, and surgical technique

2025-03-01T04:38:50-05:00

Lumbar neurofibroma is a benign neoplasm that originates from peripheral nerves, specifically from Schwann cells. While it can occur at various anatomical sites, its manifestation in the lumbar region has specific clinical and neurosurgical aspects, which are of great relevance for accurate diagnosis and effective treatment. This article addresses the causes, clinical presentation, indications for surgical treatment, and the surgical technique applied to lumbar neurofibromas, based on key studies and articles published in the last ten years.

Eagle Syndrome

2025-03-16T11:33:46-04:00

Eagle Syndrome (ES) is a rare but clinically significant condition characterised by the elongation or calcification of the styloid process or stylohyoid ligament, leading to a spectrum of symptoms such as cervical, pharyngeal, and facial pain. The pathophysiological mechanisms remain inadequately understood, with potential etiological factors ranging from developmental anomalies to post-traumatic alterations. This comprehensive review explores the clinical presentation, diagnostic advancements, epidemiological trends, and management strategies for Eagle Syndrome. By enhancing awareness and understanding of this often-misdiagnosed condition, this review aims to facilitate improved patient outcomes through timely recognition and tailored management.

Human dorsal pseudotail

2025-03-28T16:25:35-04:00

There are two different types of human tails: real tails and pseudotails. While pseudotails can be an abnormal extension of the coccygeal vertebra, lipoma, teratoma, chondrodystrophy, or parasitic fetus, true tails are made of adipose tissue, connective tissue, muscles, arteries, nerves, and mechanoreceptors. We are going to present a case of dorsal pseudotail in a 06 months old infant.

A study of prognostic value of ASIA score in post operative outcome assessment in spine trauma in a tertiary care centre

2025-03-20T11:40:16-04:00

Background: Spinal cord injury (SCI) remains a major cause of long-term disability and reduced quality of life, with significant socioeconomic and healthcare implications. The American Spinal Injury Association Impairment Scale (AIS) is a widely accepted tool for assessing the severity of SCI and predicting neurological recovery. While existing studies have examined AIS grade changes in Western populations, limited data are available from resource-limited settings such as India.

Objectives: (A) To determine the percentage of individuals with complete spinal cord injury (AIS A) who convert to incomplete status within the first post-injury year (B) To evaluate the extent of improvement in AIS grade from baseline to one-year follow-up among patients with initial AIS B injuries.

Methodology: This was a prospective observational study conducted at the Trauma Centre, Department of Neurosurgery, SMS Medical College, Jaipur, from December 2022 to December 2023. A total of 400 patients aged ?16 years with traumatic SCI admitted within 30 days of injury were enrolled. Baseline AIS grades were recorded at admission, and neurological recovery was assessed at a one-year follow-up using the AIS classification. Statistical analysis involved chi-square tests to assess the significance of AIS grade changes.

Results: Of the 146 patients with initial AIS A injury, 38 (26.0%) improved to an incomplete status (AIS B, C, or D), while 108 (74.0%) remained unchanged. Among 66 patients with initial AIS B injuries, 26 (39.4%) showed improvement to a higher AIS grade, while 33 (50.0%) remained unchanged and 7 (10.6%) worsened to AIS A. AIS C and D patients demonstrated higher rates of recovery (56.5% and 54.4%, respectively), while no significant change was observed among AIS E patients. Statistical analysis confirmed a significant association between baseline AIS grade and post-operative outcomes (p < 0.001).

Conclusion: The study demonstrates that AIS scores are valuable in predicting post-operative neurological recovery in SCI patients. While AIS A patients exhibit limited potential for improvement, AIS B–D patients show higher recovery rates, reinforcing the importance of early intervention and targeted rehabilitative strategies. The findings underscore the need for tailored clinical management based on initial AIS grades to optimise patient outcomes in resource-limited settings.

An inexpective adult diffuse astrocytoma

2025-03-29T04:02:13-04:00

Background: Diffuse gliomas in adults also include astrocytoma and isocitrate dehydrogenase deficiency, oligodendrogliomas with 1p/19q deletion, and also glioblastoma, wild type (IDH). As indicated in the European guidelines on low-grade I gliomas, early extensive surgical resection may be associated with a good prognosis. Molecular markers show that IDH1 R132H has a prognostic role in GBM. Temozolomide chemoradiation has shown beneficial results in the survival of patients with astrocytoma.

Case description: A 76-year-old woman presented to our emergency room; according to her family and emergency medical team, the patient fell at home and received a direct blow to the head with loss of consciousness. The patient had a known history of hypertension for a few years and was taking antihypertensive medications periodically. Unspecified leukaemia. Respiratory rate: 16/min; respiratory rate: regular. On clinical examination, the patient is conscious, oriented, and has right-sided weakness. Glasgow GCS (points): 11 points. after a profound, stunning. Contact is very difficult due to speech disorders. (Dysarthria). He has a right hemiparesis of 2 points, with a Positive Babinski sign on the right side.

Conclusion: The case highlights the importance of multimodal management, including early surgical intervention, molecular diagnostics, and postoperative care, in improving outcomes for patients with astrocytomas. A review of prognostic factors, such as age, GCS scores, and molecular markers like IDH1 mutations, emphasises the need for individualised treatment approaches. Although advances in chemoradiation, particularly with temozolomide, have improved survival rates, astrocytomas remain associated with high morbidity and mortality. This report underscores the critical role of early diagnosis, maximal safe resection, and tailored therapeutic strategies in optimising patient outcomes and quality of life.

Cystic meningiomas, literature review and case reports

2025-04-02T16:40:14-04:00

Meningiomas of central nervous system are common lesion, but among them, the cystic meningiomas are very rare tumours. We report two cases of cystic meningioma successfully treated, and we propose the modification of the widely used Nauta classification of cystic meningiomas. The clinical results depend on meticulous preoperative diagnosis and surgical planning, enhancing the utility of modification of Nauta classification by adding bone invasion.

Hypochloraemia in patients with severe traumatic brain injury at a tertiary care hospital in India

2025-04-21T03:53:17-04:00

Objective: To evaluate the correlation between Individuals with severe traumatic brain injury and death from electrolyte imbalance

Methodology: In a prospective cohort study, patient records suffering from a severe brain injury caused by trauma Glasgow Coma Scale score less than 8, and electrolyte abnormalities were reviewed. To determine a correlation between the patients who passed away and the ones who lived, electrolyte levels were examined. For categorical variables, bivariate analysis was carried out using the ?2 test, which has a 95% statistical accuracy. To ascertain the correlation between electrolyte fluctuations and mortality, the ?2 test was employed in conjunction with multiple comparisons. The linkage between fatalities and electrolyte shifts was analysed using logistic regression. 95 per cent of statistical tests were reliable.

Results: In 24.5 % of patients who passed away, Elevated mortality risk was significantly correlated with hypochloremia (P 0.03). It also represents the substantial link between the Examination of Acute Physiology and Chronic Health APACHE II (P < 0.01) and age (P < 0.01).

Conclusion: Hypochloremia may be a significant prognostic factor for determining death in individuals suffering from severe TBI risk and optimising treatment.

Complete embolization of large dural AV fistula having multiple feeders using glue embolizing agent (Squid 12)

2025-04-21T15:07:52-04:00

Dural arteriovenous fistulas are rare intracranial vascular malformations with a propensity for haemorrhage. The Cognard classification system is the most widespread classification system, wherein type IIB through V must be promptly treated to avoid the risk of haemorrhage. The case presented herein reports a 34-year-old male presenting with vague nonspecific headache found to have a Cognard type I dural arteriovenous fistula with multiple arterial feeders.

Surgical outcome of endonasal transsphenoidal approach for pituitary macroadenoma involving cavernous sinus

2025-04-22T12:43:44-04:00

Background: Pituitary macroadenomas with cavernous sinus (CS) invasion pose significant surgical challenges due to anatomical complexity and high risk of complications. The endonasal transsphenoidal approach (ETSA) is a minimally invasive technique that offers direct access to the sellar and parasellar regions.

Objective: This study evaluates the surgical outcomes of ETSA for pituitary macroadenomas with cavernous sinus invasion based on a cohort of 36 patients.

Methods: A retrospective review of 36 patients who underwent ETSA for pituitary macroadenomas with radiological evidence of CS invasion (Knosp grades 2–4) was conducted. Surgical outcomes were assessed in terms of gross total resection (GTR) rates, hormonal remission, and postoperative complications.

Results: GTR was achieved in 61% of patients, with higher rates in Knosp grade 2 tumours (80%). Hormonal remission occurred in 67% of patients with functioning adenomas. Complications included cerebrospinal fluid (CSF) leaks (6%), transient cranial nerve deficits (8%), and diabetes insipidus (5%). No mortality was reported. Table: Clinical Characteristics of Patients Undergoing ETSA for Pituitary Macroadenomas.

Conclusion: The ETSA is a safe and effective approach for managing pituitary macroadenomas involving the CS, particularly for lower-grade tumours. Advanced intraoperative tools and multidisciplinary care improve outcomes.

Subperiosteal drain versus subdural drain in chronic and subacute subdural hematoma burr-hole evacuation

2025-05-12T16:49:16-04:00

Background: Chronic subdural hematoma (cSDH) is one of the most prevalent neurosurgical conditions, with burr-hole drainage being the standard surgical procedure. While subdural drain (SDD) insertion reduces recurrence rates, subperiosteal drain (SPD) placement has shown comparable recurrence rates with fewer complications.

Objective: To compare the outcomes of SPD and SDD in chronic and subacute subdural hematoma burr-hole evacuation.

Methods: A prospective, randomised study was conducted on 200 patients admitted to the Neurosurgery Department at Mansoura University Hospitals. Patients were allocated into two equal groups: SPD (n=100) and SDD (n=100). Outcomes measured included recurrence rate, infection, seizures, mortality, parenchymal injury, and new neurological deficits.

Results: The recurrence rate was significantly higher in the SDD group (14%) compared to the SPD group (4%). Infection rates were 6% (SDD) and 4% (SPD), seizures occurred in 10% (SDD) and 4% (SPD), mortality was 4% (SDD) and 2% (SPD), and parenchymal injury was observed only in the SDD group (4%). New neurological deficits were noted in 10% (SDD) and 6% (SPD) of cases.

Conclusion: SPD is superior to SDD in terms of recurrence rate, incidence of seizures, parenchymal injury, and new neurological deficits. Although infection and mortality rates were lower with SPD, the difference was not statistically significant.

Prognostic value of traumatic brainstem injury in early computed tomography in paediatric population

2025-05-20T13:19:01-04:00

Introduction: In India, children aged <16 years constitute 35% of the total population and contribute to 20–30% of all head injuries. Prognostication of severe TBI in children based on early imaging and biomarkers has been universally challenging. The Marshall, Rotterdam, Stockholm, and Helsinki CT scores were developed to use acute head CT images to predict mortality at 6 months. Notably, none include criteria related to traumatic brainstem injury (BSI). The objective of this study was to compare the long-term outcome of pediatric patients with BSI identified on CT, along with an effort to classify BSI based on lesion volume, lesion location, presence of subarachnoid hemorrhage (SAH) and intraventricular hemorrhage (IVH) and how, the presence of these subset of injuries affect the outcome.

Methods: A retrospective analysis of pediatric patients presenting with TBI was undertaken from 2019 to 2023. CT scans were reviewed for brainstem lesions and, when present, characterised by location, size, and type (traumatic axonal injury (TAI), contusion, and duret haemorrhage). Clinical, demographic, and outcome data were then compared with the type of lesion, position of lesion, lesion volume, presence/absence of SAH and IVH.

Results: We found that lesion volume of more than 1 cm³ is associated with a poorer GOSE score (p< 0.001). Similarly, lesions spanning both anterior and posterior quadrant are associated with poor outcome (GOSE: 3.4 +_ STD 2.9). We also found significant correlation with presence of SAH and IVH related to a poorer outcome (p < 0.001).

Conclusion: Early evidence from the current study suggests that certain TBI patients with BSI can have positive outcomes. BSI can further be classified into TAI, duret and brainstem contusions, each with variable outcome. Brainstem lesions with volume of >1 ml have been found to have a poorer outcome. Similarly, lesions spanning both quadrants tend to have a worse prognosis. Although there was no significant difference in outcome when compared with BSI – cases. These findings suggest of patients with brainstem injuries may exist with divergent recovery potential after TBI.