Romanian Neurosurgery

Contribution of Romanian Society of Neurosurgery in the development of Moldavian neurosurgical activity (35 years of connections)

Alexandru Vlad Ciurea — 2025-09-15

The development of neurosurgery in the Republic of Moldova has gone through some challenging pioneering stages. It gradually separated from the Society of Neurology, and its evolution has been extensive; it currently meets international standards.
Neurosurgery in Moldova has undergone a transformative journey from its humble beginnings to a globally recognised discipline, largely driven by the relentless dedication of visionaries. Among these, Prof. Grigore Zapuhlih stands out as a trailblazer who shaped the neurosurgical landscape of Moldova, merging tradition with innovation and integrating the nation into global neurosurgical networks. His contributions, spanning decades, encompass clinical practice, academic mentorship, pioneering technologies, and international collaboration.
This article provides an in-depth exploration of the evolution of Moldovan neurosurgery, paying homage to Prof. Zapuhlih’s unparalleled contributions. It traces the historical context of the field, the milestones achieved through collaboration with the Romanian Society of Neurosurgery (RSN), and the modernisation of neurosurgical practices under his leadership. Prof. Zapuhlih’s role as a mentor, innovator, and global ambassador for Moldovan medicine has not only elevated the field locally but has also secured Moldova’s place on the international stage. This tribute underscores the profound impact of his life and work, which continue to inspire the next generation of neurosurgeons.

Malignant cerebellar infarction with neurological and systemic complications

D. Balasa — 2025-09-15

We presented the successful management of a dramatic case of one patient with malignant cerebellar infarction with superior (culmen) vermian herniation and inferior (tonsillar) herniation, ventriculitis, cerebral venous thrombosis, decubitus acute pneumopathy, septic pulmonary venous thrombosis, ethanolic cytolysis of the liver, diabetus mellitus.

Uncommon territory: Primary intracranial Ewing’s sarcoma in an adult patient

Vuk Aleksić — 2025-09-15

Introduction: Ewing’s sarcoma is a rare malignant tumour predominantly affecting children and adolescents, typically originating in bone or soft tissue. Primary intracranial involvement is extremely rare, especially in adults. Most reported intracranial cases are dural-based and extra-axial, while intra-axial or mixed presentations are exceptionally rare.
Case report: We report a unique case of a 49-year-old male who presented with a generalised seizure and postictal dysphasia. Imaging revealed a large cystic (intra-axial) tumour with a mural solid component (extra-axial part) in the left temporoparietal region. Gross total resection was performed without complications. Histopathological and molecular analyses confirmed the diagnosis of primary intracranial Ewing’s sarcoma. Despite recommendations, the patient refused further oncological treatment and was lost to follow-up after three months, during which no recurrence was detected on imaging.
Conclusion: This case illustrates a rare adult presentation of primary intracranial Ewing’s sarcoma with mixed intra- and extra-axial features, highlighting the importance of considering rare entities in the differential diagnosis of atypical brain lesions. It also raises the possibility of post-surgical chronic inflammation as a potential factor in tumour pathogenesis, warranting further investigation.

Epidemiology of motorcycle spinal injuries

Moussa Diallo — 2025-09-15

Background: 1.2 million people die in traffic accidents every year. Motorcycle accidents account for a large proportion of these road accidents. They are responsible for serious and severe trauma. Most of these victims live in developing countries.
Objective: To study the epidemiologic, clinical, therapeutic and progressive characteristics of spinal trauma caused by motorcycle accidents.
Materials and methods: This prospective descriptive study was conducted in the Emergency Department and Neurosurgery Department over a period of 18 months. A pre-designed survey form was completed after the interview and physical examination of the patients. Male and female patients of any age treated for spinal trauma after a motorcycle accident were included. Patients who had undergone diagnostic radiologic imaging and regular follow-up for at least one month. The epidemiological, diagnostic, and therapeutic data were studied.
Results: Spine trauma due to motorcycle accidents accounted for 5.7% of hospital admissions. The male was predominant with a sex ratio of 5.4. The mean age was 27.3 years. The socio-professional strata involved were workers (18.6%), farmers (16.3%) and apprentice motorcycle mechanics. The trauma was caused by a motorcycle skid in 34.9%, followed by a collision between two motorcyclists in 28.7%. Spinal pain was present in all patients, motor deficit in 75.2%, sensory deficit in 60.5%, and sphincter deficit in 48.8%. The thoracolumbar junction was involved in 36.4% of cases, followed by the cervical spine in 30.2% and the lumbar spine in 21.7%. The most common injuries were dislocation fractures (43.4%) and vertebral fractures. In the thoracic, thoracolumbar hinge and lumbar spine, surgery consisted of laminectomy combined with pedicle screw osteosynthesis. At 3-month follow-up, motor deficits persisted in 78.6% and clinical signs improved in 21.4%.
Conclusion: Spinal trauma from a motorcycle accident is a real and evolving scourge. The emphasis must be placed on prevention. This requires rigorous application of the road traffic.

Multiloculated hydrocephalus developing secondary to ventriculitis and their management

Şule Göktürk — 2025-09-15

Background: Inflammatory ventricular processes such as meningitis, severe intraventricular haemorrhage, or ventriculitis may result in multiloculated hydrocephalus. It is a significant condition associated with high morbidity and mortality. Loculated hydrocephalus is a condition characterised by distinct, noncommunicating compartments within the ventricular system due to different etiologies.

Observation(s): Two pediatric cases, aged 0 and 5 years, with refractory ventriculitis complicated by multiloculated hydrocephalus were presented; intraventricular antibiotics were used to treat the ventriculitis, and external and closed shunt systems were used to resolve the multiloculated hydrocephalus.

Conclusion: Complex cases often complicate surgical management. Various surgical methods have been proposed for treatment, but multiloculated hydrocephalus is a complex and difficult condition to manage. To achieve success in the treatment of multiloculated hydrocephalus, there will always be a need for surgeons who are persistent and know what they are doing.

Spontaneous rupture of hydrocephalus

Varun Tiwari — 2025-09-15

Spontaneous rupture of hydrocephalus is an exceedingly rare and catastrophic complication, particularly in neonates from resource-limited settings. We report the case of a two-month-old male infant diagnosed prenatally with hydrocephalus but left untreated due to socioeconomic challenges. The child presented with progressive cranial enlargement and acute cerebrospinal fluid (CSF) leakage from the anterior fontanelle. Examination revealed severe craniofacial disproportion, malnutrition, and neurological impairment. Despite immediate resuscitation and closure of the rupture site, the infant succumbed within 12 hours of admission. This case underscores the impact of delayed treatment, financial constraints, and lack of awareness on hydrocephalus outcomes. It highlights the urgent need for public education, accessible healthcare, and policy interventions to address the challenges of managing hydrocephalus in developing countries. Advocacy for prenatal care and early intervention could prevent such fatal outcomes and improve survival and quality of life in affected children.

Os Odontoideum

Walid Bennabi — 2025-09-15

Os odontoideum is an uncommon skeletal abnormality defined by the separation of the odontoid process from the body of the axis vertebrae. This condition can be congenital or acquired, and symptoms may include neck pain, myelopathy, or abrupt neurological deficits. Os odontoideum is commonly diagnosed using imaging modalities such as X-rays, CT scans, and MRI. Treatment options differ depending on the presence of symptoms and the stability of the atlantoaxial joint. Conservative therapy may be appropriate for asymptomatic instances, although surgical intervention, such as C1-C2 vertebral fusion, is frequently required for symptomatic cases or those at risk of spinal cord injury. Long-term follow-up is critical for monitoring potential problems and ensuring optimal results for patients with os odontoideum.

A case report of an incidental finding of biparietal osteodystrophy in a patient with traumatic cerebellar haematoma

Olakunle Michael Adegboye — 2025-09-15

Biparietal osteodystrophy refers to thinning of the parietal skull bone. It is a rare entity, commonly discovered incidentally on imaging of the skull for other reasons or at autopsy. Following head trauma, fracture of the thinned-out parietal bone, with or without underlying hematoma, is expected due to its reduced protective effect, especially with direct impact. In this case report, we present an elderly woman who sustained a cerebellar hematoma and frontal lobe contusion with intact parietal bone following head injury, with an incidental finding of symmetrical thinning of the parietal bones on cranial computed tomography scan.

Subtemporal approach for a P2–P3 junction aneurysm of the posterior cerebral artery

Walid Bennabi — 2025-09-15

Cerebral aneurysms at the posterior cerebral artery (PCA) are rare, accounting for < 1% of all intracranial aneurysms and about 7% of the posterior circulation aneurysms. Aneurysms are seen rarely at the P2–P3 junction of PCA; few patients have been reported in the literature because of the low incidence of aneurysms at this location. P2–P3 junction aneurysm surgery is challenging. They are usually managed by the subtemporal approach. This is a case report of rupture saccular aneurysm of the posterior cerebral artery on P2–P3 junction, revealed in a 46-year-old male suffering from subarachnoid haemorrhage; on Computed tomography (CT) scan, and cerebral angioscan. Successful clip occlusion of the aneurysm was performed via a subtemporal approach without additional neurological deficits or surgical complications. P2–P3 junction PCA aneurysms can be successfully clipped via the subtemporal.

A vascular benign lesion in a perilous location

Hajer Kammoun — 2025-09-15

Background: Hemangioblastomas are vascular grade 1 tumours developing sporadically or, more rarely, in the context of Von Hippel-Lindau disease. Cystic brainstem hemangioblastomas are uncommon, with only a limited number of cases documented in the literature. Even though they are benign, their surgery is challenging in view of their eloquent location and vascularity. Thorough perioperative management is required.
Case presentation: We report the case of a 47-year-old female patient with progressive weakness, difficulty in swallowing and ataxic gait. The brain MRI showed a cystic lesion located in the caudal part of the fourth ventricle and the dorsal medulla oblangata. We performed a subtotal excision of the tumour that was challenging due to its adherence to the floor of the 4th ventricle and its high vascularity. The pathology exam concluded to a hemangioblastoma. The patient presented a good evolution with no tumor progression in 6 months follow-up.
Clinical discussion: The cystic brainstem hemangioblastoma is a rare, seemingly innocuous lesio,n but highly challenging to neurosurgeons. MRI is the investigation of choice, regularly sufficient for preoperative evaluation. Still, some authors recommend the performance of a cerebral angiography or a CTA preoperatively. In literature, many strategies, such as the use of preoperative embolization or radiosurgery, were described, aiming for a better-quality surgery and prognosis.
Conclusion: Cystic brainstem hemangioblastoma is a scarce histologically benign but challenging lesion with surgical difficulties. Through our case and literature review, we concluded that surgery is the mainstay treatment for brainstem hemangioblastomas, mainly cystic ones and that a thorough study of its vascularization via angiography or CTA with a preoperative tumor embolization can help achieve a total tumor resection with good functional outcome and low mortality.

Impact of notification protocol on time to response in postoperative neurological deterioration among brain tumour patients

Thara Tunthanathip — 2025-09-15

Background: Postoperative neurological deterioration (PND) is a serious complication in brain tumour surgery, often leading to functional decline or death. Timely detection and response are critical, yet delays are common in routine practice.
Objective: The present study aimed to (1) describe the prevalence, causes, and outcomes of PND among brain tumour patients and (2) to assess the impact of a structured notification system developed using root cause analysis on clinician response time.
Methods: We retrospectively reviewed brain tumour patients undergoing surgery between 2022 and 2025. Data from 2022–2023 were used to describe PND prevalence and conduct root cause analysis. A structured notification protocol was implemented in February 2024, replacing the previous bottom-up model with a top-down approach, where bedside nurses directly notified the chief resident. Post-protocol data from February 2024 to June 2025 were analysed. The primary outcome was PND prevalence and etiology. The secondary outcome was time to physician response, compared pre- and post-protocol using t-tests and ANOVA. The primary outcome was PND prevalence and etiology. The secondary outcome was the comparison of time to physician response before and after protocol implementation, analysed using t-test and ANOVA.
Results: PND occurred in 181 of 282 patients (39.8%) during the 2022–2023 period. The most common causes were brain oedema (37.6%), hypovolemic shock (11.6%), and intracerebral haemorrhage (11.6%). After implementing the protocol, the time to response was significantly reduced (p = 0.004).
Conclusion: PND remains a serious complication in brain tumour surgery. The introduction of a structured notification protocol significantly improved the timeliness of medical response. This approach may be adaptable to other high-acuity settings, such as trauma or critical care, where rapid decision-making is essential.

Brain abnormalities associated with myelomeningocele at Kinshasa University Teaching Hospital in the Democratic Republic of the Congo

Dmien Kamate Kirauli — 2025-09-15

Background: Myelomeningocele (MMC) is the most prevalent neural tube defect, with significant implications for both health and development. The presence of associated brain abnormalities is crucial in determining the prognosis for affected children, making early detection and accurate diagnosis essential.
Objective: This study aimed to evaluate the prevalence of brain abnormalities in children with MMC, assess the accessibility of cranial imaging, and identify the most common associated brain malformations.
Methods: A retrospective study was conducted, focusing on children diagnosed with myelomeningocele and admitted to Kinshasa University Teaching Hospital from January 2014 to December 2021. The study reviewed clinical data, including the use of cranial tomography, and identified the frequency and types of brain abnormalities.
Results: Thirty-five children with MMC underwent cranial tomography. The average age of these patients was 43 days, and the male-to-female ratio was 1.5. Notably, 34.3% of mothers did not undergo any obstetric ultrasound, and only 5.7% of mothers who had an ultrasound received an antenatal diagnosis of MMC. Brain abnormalities were observed in 91.4% of the cases. Hydrocephalus was the most prevalent anomaly (93.7%), with aqueductal stenosis identified as the primary cause (60%). The most common surgical treatment was the simultaneous treatment of MMC with ventriculoperitoneal shunt (44.4%). Postoperative recovery was uneventful in 59.2% of patients.
Conclusion: The study highlights the high prevalence of brain abnormalities in children with myelomeningocele, particularly hydrocephalus caused by aqueductal stenosis at Kinshasa University Teaching Hospital. The findings underscore the critical need for improved access to prenatal care and diagnostic imaging to detect congenital malformations early, especially in resource-limited settings like Kinshasa.

Unilateral fenestration versus laminectomy in treatment of degenerative lumbar spinal stenosis

Mohamed Farouk — 2025-09-15

Background: The syndrome of degenerative Lumbar spinal stenosis (LSS) accounts for a large percentage of cases of low back pain in the elderly worldwide. Surgical management has demonstrated better clinical and radiological results than conservative treatment. It allows for adequate decompression of the thecal sac and the compressed nerve roots. However, aggressive laminectomy with facetectomy has been linked with many postoperative complications, including instability. Hence, new, less invasive modalities have been introduced, such as fenestration and endoscopic laminotomy.
Objective: This study aimed to compare the safety and outcome of conventional laminectomy to unilateral fenestration in cases of degenerative LSS.
Methods: This prospective study was conducted in the Neurosurgery Department, Mansoura University Hospitals, between February 2023 and January 2025. Consecutive patients with degenerative LSS were randomly assigned to either conventional laminectomy or unilateral fenestration and decompression. Demographic data, intraoperative findings and clinical outcomes were analysed.
Results: Fifty patients were included; 25 patients underwent unilateral fenestration, and 25 patients underwent conventional laminectomy. Stratifying patients based on the affected vertebral level revealed that in the single-level cohort, the mean age was
65.65 ± 5.30 in fenestration group vs. 70.15 ± 6.69 years in laminectomy group; p = 0.016. Fenestration achieved a markedly shorter incision (3.25 ± 0.33 vs. 5.25 ± 0.61 cm; p < 0.001) and tended toward less blood loss (33.60 ± 3.87 vs. 36.10 ± 4.17 mL; p = 0.053). There was no significant difference regarding complication rate, the length of hospital stays and operative time. In the double-level cohort, fenestration was associated with smaller incisions and less blood loss, as well as shorter hospital stay and lower instability risk. However, in all other variables, we observed no statistically significant difference between the two groups. Both procedures significantly reduced pain and disability scores over six months, with comparable effectiveness.
Conclusion: Unilateral Fenestration is safe and comparable to conventional laminectomy in efficacy and should be considered as a viable minimal-invasive option in the treatment of lumbar stenosis patients due to its ability to produce adequate clinical outcomes with minimal bleeding risk and shorter hospital stay.

Brainstem cavernomas malformations

Daniel Encarnación Santos — 2025-09-15

Background: Brainstem cavernous malformations (BCM) are supratentorially located vascular structures that damage the central nervous system. The rarest forms of these malformations are found in the brainstem and cerebellum, associated with venous abnormalities that appear suddenly. The aim of this study is to demonstrate the importance of proper anatomical management of cavernous malformations of the brainstem and the optimal resection, whether endoscopic endonasal, microsurgical, suboccipital approaches, or craniotomy, in terms of neurological postoperative results.
Material and methods: The search was exhaustive; it spanned several databases, including ScienceDirect and PubMed/MEDLINE, and was conducted using the PRISMA guidelines, R software for systematic reviews and meta-analyses, and Excel. Search terms included "Brainstem Cavernoma Malformations" along with terms specifying surgical techniques, brainstem or brainstem rehabilitation methods, and associated pathologies. Only studies published in English up to June 2025 were included.
Results: In this systematic review and meta-analysis, we included a total of 1319 patients, of which GTR, N = 269 (20.3%), and STR, N = 14 (1%), were total. Table 1-3, while in Table 1-Figure 2, we included N = 931 (70.5%) patients, GTR, N = 207 (15.6%), and one STR, N = 9 (0.6%).
Conclusion: This study shows that microsurgical resection of cavernous malformations of the brainstem is not only a complex issue in terms of the treatment of this pathology. Even so, endonasal endoscopy is gaining more and more strength, since 80% of resections, even with complications, have been very effective in terms of rehabilitation and postoperative follow-up.

Evaluation of visual and oculomotor outcome in patients with posterior fossa tumours

Sandeep Sangale — 2025-09-15

Objective: To evaluate and compare visual and oculomotor outcomes in patients with posterior fossa tumours.
Methods: Prospective Observational Study including 42 patients with posterior fossa tumours who underwent either CSF diversion or definitive surgery at RML Hospital, Delhi, between July 2021 and January 2023. Preoperatively and postoperatively, a neurological and visual assessment was done. The visual evaluation consisted of Visual acuity, Fundus, Diplopia charting, Perimetry, and forced duction test. Preoperative and Postoperative visual outcome was compared and statistically analysed. Visual outcomes are also compared according to the final histological diagnosis.
Results: 30 cases underwent CSF diversion, and 12 cases received definitive surgery. The visual acuity was divided into three groups i.e. Good, Fair, and Poor. The visual acuity was good and fair in 2.5% and 92.8% of the cases pre-operatively, and postoperatively, it was good in 26.2% and fair in 69% cases, respectively. The difference was found to be statistically significant (P < 0.01). Papilledema decreased from grade 2 to grade 1 in 50% of cases postoperatively, while it was absent in 87.5% of the cases at three months of follow-up. Diplopia was absent in all of the cases at follow-up at 3 months.
Conclusions: If treated timely, posterior fossa tumours are typically associated with a positive prognosis. The majority of patients with posterior fossa tumours had good visual outcomes with the use of CSF diversion, proper microsurgical procedures, and follow-up.

Beliefs regarding low back pain and spine care amongst sub-urban communities of a lower middle-income country

Areeba Tariq — 2025-09-15

Back pain is a common health issue affecting people of all ages and demographics. Eighty per cent of adults are predicted to suffer from back pain at some point in their lives. Spine care is crucial in the management of back pain, and it is essential to understand the perception of spine care in different populations. People with varied incomes may have different available facilities, perceptions, and attitudes towards spine care. This may lead to disparity in treatment-seeking and outcomes. This study proposal aims to investigate the perception of spine care in the local population with back pain, along with factors creating differences. We surveyed 269 patients with back pain in two different communities in Karachi. We found out that usually, people with low monthly income do nothing for their back pain, while those with moderate income usually take analgesics and seek medical advice. The majority of the patients think that the availability of better healthcare facilities will improve their spine care.

Orbital schwannomas

Amira Benhafri — 2025-09-15

Orbital schwannomas are rare, benign neoplasms that develop from Schwann cells in the peripheral nerve sheath of the orbit. These slow-growing tumours are characterised by insidious proptosis, visual disturbances, diplopia, and occasionally pain. Following surgical resection, imaging modalities such as MRI and histopathological analysis are frequently used to make the diagnosis. The primary treatment modality remains surgical excision, with the goal of removing the tumour completely while preserving visual function and minimising postoperative complications. The prognosis for orbital schwannomas is favourable, with low recurrence rates after resection. However, long-term follow-up is required to detect any signs of recurrence or malignant transformation. More research is required to improve our understanding of the pathogenesis, optimal management strategies, and outcomes associated with orbital schwannomas, thus improving patient care and outcomes in this rare.

A comparative study to evaluate the clinical and biochemical efficacy of mannitol (10%) with glycerine (10%) versus mannitol (20%) in patients with mild to moderate head trauma

Kushal Shah — 2025-09-15

Traumatic brain injury (TBI) is a major cause of death and long-term disability globally, affecting individuals' physical, cognitive, and emotional well-being. TBI can result from various mechanisms such as blunt trauma or acceleration-deceleration forces, leading to neuronal damage and functional disruption. Diagnosis typically relies on neuroimaging techniques like CT and MRI. While treatment focuses on symptom management and rehabilitation, research into neuroprotective therapies and emerging interventions offers hope for better outcomes. Effective, personalised care remains essential in addressing the complex, multifaceted nature of TBI.
Objective of the study: This study aimed to compare the clinical and biochemical efficacy of Mannitol (10%) with Glycerine (10%) versus Mannitol (20%) in patients with mild to moderate head injuries, focusing on intracranial pressure reduction, neurological improvement, electrolyte balance, and safety profiles.
Material and method: A total of 100 adult patients with mild (GCS 13–15) to moderate (GCS 8–12) head injuries were randomly assigned to two groups: Group A received Mannitol (10%) + Glycerine (10%), and Group B received Mannitol (20%). Both regimens showed comparable efficacy in reducing cerebral oedema and improving neurological status. However, the combination therapy demonstrated better preservation of serum sodium levels and fewer hemodynamic fluctuations.
Conclusion: In our comparative prospective study, it can be concluded that the efficiency of 20% Mannitol and Mannitol (10%) with glycerine (10%) for the treatment of cerebral oedema in patients with mild to moderate head injury is almost equal.

A bullous surprise

Mitrajit Sharma — 2025-09-15

We report a rare case of subcutaneous cerebrospinal fluid loculations, or bullae, along the anterior abdominal wall following ventriculoperitoneal shunt in an 8-year-old female with a history of tubercular meningitis and hydrocephalus. The patient presented with headache, nausea, and two soft, transilluminated swellings on the right side of her abdomen, three years after initial shunt placement and subsequent revision for peritoneal end malfunction. Imaging revealed gross ventriculomegaly and anterior parietal wall collections along the shunt tract. Intraoperatively, loculated CSF collections were found near the abdomen, and the lower end of the shunt was revised. Fluid analysis confirmed CSF composition. The patient recovered well postoperatively with resolution of ventriculomegaly and was discharged on prophylactic antibiotics. Subcutaneous CSF loculations in the anterior abdominal wall represent a unique and previously undocumented complication of VP shunts. Potential mechanisms include protracted CSF drainage, tissue plane dissection secondary to elevated intra-abdominal pressure, or catheter misplacement, exacerbated by prior abdominal surgeries and adhesions. This case highlights the importance of considering rare presentations of shunt malfunction and the need for thorough clinical and radiological evaluation. Early diagnosis and prompt surgical intervention, typically shunt revision, are crucial for effective management and improved patient outcomes.

Symptomatic cyst of the veli interpositi – to operate or not to operate?

Okwunodulu Okwoma — 2025-09-15

The veli interpositi represents an embryologic membrane which form following fusion or superposition of two layers of pia mater (tela choroidea) of the third ventricle during embryologic development of the corpus callosum.1-3 This thus becomes a potential space which can harbour CSF. Kruse in 1930 first described dilatation of this potential space and defined such condition as “cavum veli interpositi”.1 A cavum veli interpositi (CVI) has also been called “cisterna interventricularis”, “ventriculi tertii”, “transverse fissure”, and “subtrigonal fissure”.1 This dilatation is a normal variant in the newborn which spontaneously closes by the end of the first year of life.3, 4 Only 2-3% persist beyond this period into adulthood.4 Pathologies involving this region varies, and might range from just a benign cystic dilatation of this space, to pathologies involving true cysts such as arachnoid and epidermoid cysts, and tumours such as meningiomas.