Romanian Neurosurgery

Iatrogenic dural tear with giant pseudomeningocele

D. Balasa — 2026-07-24

Incidental durotomy during spine surgery carries a risk of cerebrospinal fluid (CSF) leakage, pseudomeningocele formation, and reoperation, and incomplete dural closure remains a frequent and troublesome problem. We report the management of a giant lumbar pseudomeningocele with a CSF fistula occurring after previous disc surgery, treated with a combined multilayer repair.

A 40-year-old woman, previously operated on twice for an L4-L5 disc herniation, presented with persistent lumbar pain, tinnitus, and a large subcutaneous CSF collection that enlarged on the Valsalva maneuver. MRI demonstrated a giant pseudomeningocele with a laterally located CSF fistula. Because the fistula was too lateral for safe direct suturing, it was repaired in a sandwich fashion using an autologous blood patch, TachoSil, an autograft fascia lata sutured circumferentially, and a vascularized muscular flap sutured tightly over the fascia lata, under loupe magnification. Neither fibrin sealant nor a subarachnoid drain was used, in order to avoid their associated risks.

The aspirated CSF was hyperproteic and bacteria-free. The postoperative course was uneventful and the patient was discharged in good health, with no recurrence at one-month follow-up. This combined technique — blood patch, TachoSil, autologous fascia lata, and a vascularized muscular flap — proved effective for treating the giant pseudomeningocele and preventing further complications such as CSF fistula and meningitis.

Endoscopic repair of cerebrospinal fluid rhinorrhea in a tertiary centre

R. Shrestha — 2026-07-24

Background: Cerebrospinal fluid (CSF) rhinorrhea results from a skull base defect with disruption of the arachnoid, dura mater, and sinonasal mucosa, leading to CSF leakage through the nose. The purpose of this study was to compare CT and MRI findings and CSF leak location, and to evaluate the role of endoscopic repair in improving outcomes.

Methods: We retrospectively evaluated thirty patients with CSF leaks between January 2016 and August 2025, analyzing treatment decisions, the endoscopic endonasal approach, and neurosurgical outcomes.

Results: Twenty-two patients (14 male, 8 female) with CSF rhinorrhea underwent endoscopic endonasal skull base repair during the study period. Clinical features included headache in two-thirds of patients (n = 14, 63%), frequent meningitis (n = 6, 28%), focal neurologic symptoms (n = 5, 23%), and epileptic seizures (n = 5, 23%). The most common sites of skull base defect were the cribriform plate, ethmoid, and planum sphenoidale, in 12 (55%), 8 (37.7%), and 2 (9%) patients respectively. All patients underwent endoscopic endonasal repair followed by lumbar drain placement, uneventfully. Two referred patients developed meningitis after repair, which resolved with appropriate antibiotics. Endoscopic repair of CSF leaks is now the standard procedure given its minimally invasive nature.

Conclusion: The endoscopic endonasal approach is the best method for repairing CSF leaks, reducing morbidity and mortality.

Transient cortical blindness following transfemoral cerebral angiography for giant thrombosed V4 aneurysm

M. B. Kadharmestan — 2026-07-24

Transient cortical blindness (TCB) is a rare complication of cerebral angiography, with a reported incidence of 0.3-1%. We report a 46-year-old male with a giant thrombosed left V4 vertebral aneurysm (38 × 42 × 30 mm) who developed acute bilateral total visual loss approximately four hours after transfemoral cerebral angiography (TFCA) using iodixanol 320 mg.

Notably, the patient initially denied any visual loss, raising the consideration of Anton syndrome — a condition characterized by cortical blindness with visual anosognosia and confabulation. Emergency evaluation revealed visual acuity of 1/? bilaterally, with normal pupillary reflexes and fundoscopic findings. Post-procedural neuroimaging showed no evidence of acute infarction, posterior reversible encephalopathy syndrome, or contrast extravasation. Treated conservatively with dexamethasone and mannitol, vision recovered fully within 72 hours.

Two principal mechanisms underlie TCB: blood-brain barrier disruption from contrast neurotoxicity, and posterior reversible encephalopathy syndrome from impaired cerebral autoregulation. The giant V4 aneurysm may have augmented posterior circulation vulnerability through local mass effect.

This case illustrates that TCB may be missed when the patient confabulates intact vision, and that Anton syndrome should be considered whenever anosognosia accompanies post-angiographic visual loss.

Central neurocytoma beyond the lateral ventricles

Mhel Carolyne Barleze Darte — 2026-07-01

Central neurocytomas are rare primary tumors of the central nervous system, most commonly arising in the lateral ventricles. We report the case of a 34-year-old woman diagnosed with a central neurocytoma located in the third ventricle, an uncommon site.

The patient underwent surgical resection via a transcallosal-transchoroidal approach, with intraoperative placement of an external ventricular drain. Gross total resection was achieved. Despite the development of postoperative hydrocephalus, the patient had a favorable clinical outcome and was discharged with preserved functional status.

Histopathological and immunohistochemical analyses confirmed a World Health Organization (WHO) grade II central neurocytoma. Given the extent of resection and tumor characteristics, no adjuvant therapy was indicated. This case highlights the feasibility of complete surgical resection in atypical locations and underscores the importance of perioperative management in optimizing outcomes.

Beyond the 30 mL rule: rapid auto-decompression and conservative management of a massive (100 mL) extradural hematoma in a toddler

Shivam Sharma — 2026-07-01

Background: Pediatric extradural hematoma (EDH) management is traditionally dictated by volumetric thresholds, with evacuation recommended for collections >30 mL. However, the unique compliance of the young child's cranium can allow for atypical clinical stability despite massive internal haemorrhage.

Case Description: A 2-year-old boy presented with a 100 mL EDH following a minor fall. Despite the volume, the child remained neurologically intact (GCS 15). Managed conservatively, the hematoma demonstrated a rapid 40% volume reduction within 24 hours.

Conclusion: This case illustrates the “redistribution phenomenon,” where extradural blood vents into the subgaleal space via patent sutures. We argue that in neurologically stable children, the mechanism of auto-decompression should weigh more heavily than static volumetric measurements in surgical decision-making.

Outcomes of cranioplasty using autologous bone or titanium mesh following decompressive craniectomy

Renish Padshala — 2026-07-01

Background: Decompressive craniectomy (DC) is a life-saving procedure for neurocritical patients with conditions such as severe traumatic brain injury (TBI), ischemic stroke, and subarachnoid haemorrhage. However, it results in cranial defects that necessitate cranioplasty to restore skull integrity, protect brain function, and address cosmetic concerns. The choice of material—autologous bone (AB) or artificial materials like titanium mesh (TM)—remains controversial due to varying complication rates.

Methods: This comparative cross-sectional study evaluated 23 patients who underwent cranioplasty with AB (n=5) or TM (n=18) between January 2022 and March 2025 at SVP Hospital and NHL Medical College, Ahmedabad. Data on demographics, surgical timing, complications, and outcomes were analyzed. Complications included infections, bone flap resorption (BFR), wound dehiscence, and cosmetic outcomes.

Results: The overall complication rate was 43.47% (AB group: 80%, TM group: 33.33%). BFR occurred exclusively in the AB group (40%), while TM-related complications included surgical site infections, wound dehiscence, and persistent tenderness. Wound dehiscence and multiple bone fragments were significant risk factors for post-cranioplasty infections and BFR, respectively. Cosmetic satisfaction was comparable between groups (82.60% overall), but TM demonstrated shorter operation times, reduced bleeding, and shorter hospital stays.

Conclusion: Cranioplasty using TM showed advantages over AB in terms of lower complication rates, reduced operative time, and improved hospitalisation outcomes. However, TM was associated with higher minor complications like wound dehiscence. For patients with larger bone defects, artificial materials may reduce BFR risks. Further prospective randomised trials are needed to validate these findings and optimise cranioplasty outcomes.

A rare case of left cerebellopontine angle endolymphatic sac tumour

Shrijit Kumar — 2026-07-01

Endolymphatic sac tumours (ELST) are rare and slow-growing neoplasms that develop out of the endolymphatic sac of the temporal bone. Even though histologically low grade, they show locally aggressive behaviour, and may affect important neurovascular structures of the cerebellopontine angle. These tumours can present with auditory or vestibular dysfunction, and they are usually radiologically indistinguishable from other cerebellopontine angle lesions. We present a rare case of a left cerebellopontine angle mass, which was a left endolymphatic sac tumour based on histopathological examination and immunohistochemical analysis. Under microscopy, the arrangements of the papillae of the cells demonstrated cuboidal to columnar eosinophilic to clear cytoplasmic cells, with no mitosis or necrosis. Immunohistochemistry showed focal positivity for CA IX, AE1/AE3, and CK7, and negativity for the rest (GFAP, SOX10, PAX8, TTF1, EMA, and CK20). Ki-67 (MIB-1) labelling index indicated low proliferative activity at 127/113, which is 1-2%. This tumour should be recognised, as its clinical and radiological presentations may be similar to those of other lesions of the cerebellopontine angle, and it is extremely rare. The diagnosis and surgical care should be done early to avoid local invasion and neurological complications.

Intraneural ganglion cyst of the common peroneal nerve presenting with foot drop

Jaimin Modh — 2026-07-01

Background: Intraneural ganglion cysts are rare benign mucinous lesions that arise within the epineurium of peripheral nerves. They represent an uncommon but surgically treatable cause of common peroneal neuropathy. Because their clinical presentation may mimic lumbar radiculopathy, entrapment neuropathy, or peripheral nerve sheath tumour, significant diagnostic delay is frequent.

Case Presentation: We report a 35-year-old man who presented with progressive foot drop and gait impairment. Magnetic resonance imaging (MRI) demonstrated a cystic lesion along the common peroneal nerve at the fibular neck, producing focal neural compression. Microsurgical exploration through a lateral approach was performed. The common peroneal nerve was identified, decompressed, and preserved. Intraoperative neurophysiological monitoring—including motor evoked potentials (MEPs) and direct nerve stimulation—guided safe fascicular dissection. A translucent cystic lesion containing gelatinous material was evacuated and excised. Histopathological examination confirmed a fibrous cyst wall with mucinous contents and no epithelial lining or malignant features, consistent with a ganglion cyst. The postoperative course was uneventful; foot drop resolved completely, and the patient regained normal independent walking.

Conclusion: This case highlights the importance of considering intraneural ganglion cyst in young adults with non-traumatic foot drop. Early MRI diagnosis, meticulous nerve-preserving microsurgery, and neurophysiological monitoring may permit excellent functional recovery. The articular/synovial theory of pathogenesis underscores the need to identify and address the joint connection and articular branch to reduce recurrence.

Clinical, radiological and surgical aspects of cerebellopontine angle tumors

Sajag Gupta — 2026-07-01

Objective: This study aimed to highlight the clinical and radiological profile of cerebellopontine angle (CPA) tumours and assess surgical outcomes, particularly in relation to tumour size.

Materials and Methods: Thirty patients with CPA tumours were prospectively studied in the Department of Neurosurgery, UPUMS Saifai, India, from June 2022 to May 2025. Preoperative assessment included CT and/or MRI. All patients underwent tumour excision through a suboccipital retrosigmoid approach.

Results: A female predominance was noted. Sensorineural hearing loss (92%) was the most common presenting symptom, followed by headache (66%). Most vestibular schwannomas showed heterogeneous enhancement with cystic changes. Large tumors (26–40 mm) were observed in 68% of patients. Facial nerve preservation was achieved in 82% of medium-sized tumours (10–30 mm), whereas postoperative facial palsy was more frequent in giant tumours (>40 mm), suggesting a direct association between tumour size and facial nerve dysfunction. Postoperative complications included CSF leak in 8 patients, hydrocephalus in 3, and mortality in 4 (overall 8%).

Conclusion: CPA tumours were more common in middle-aged patients, with a slightly higher incidence in females. The majority were large at the time of diagnosis, and most patients presented with non-serviceable hearing. Vestibular schwannoma was the most common histopathological diagnosis, often showing heterogeneous and cystic features. Gross total excision was feasible in most cases. Facial nerve palsy was the leading postoperative complication, with larger tumours carrying greater risk. The overall mortality was 8%.

Experience with microsurgical clipping of ruptured intracranial aneurysms at a north Indian rural institution

Sajag Gupta — 2026-07-01

Background: Microsurgical clipping continues to be the benchmark treatment for managing intracranial aneurysms. Evaluating outcomes at the institutional level is crucial for identifying modifiable factors that can improve surgical success, especially in areas with limited resources where patients often present late due to lack of awareness. This study reviews our center's experience with the surgical management of ruptured intracranial aneurysms.

Materials and Methods: This retrospective analysis includes 40 patients with ruptured intracranial aneurysms who underwent clipping surgery at the Department of Neurosurgery, UPUMS, Saifai. All patients received comprehensive neurological assessments and continuous monitoring of vital signs. The study summarizes surgical outcomes and clinical progression following treatment.

Results: Among the 40 patients treated, 28 were female and 12 were male, showing a female-to-male ratio of 2.3:1. Most cases occurred in patients in their 50s and 60s. Headache with vomiting was the most frequent presenting symptom. The majority of patients were categorized as Hunt and Hess grade 2, and World Federation of Neurological Surgeons (WFNS) grade 1. On the Modified Fisher scale, most patients fell into grade 1, followed by grade 3. The anterior communicating artery (AComA) was the most common aneurysm location, followed by the middle cerebral artery (MCA).

Conclusion: There was a marked female predominance among the cases. AComA aneurysms were the most frequently encountered. Favorable outcomes were more likely in patients who received early intervention and did not experience intraoperative aneurysm rupture, highlighting the importance of timely and careful surgical management.

Preoperative endovascular embolization prior to complete excision of meningioma

Arvind Kumar Verma Arvind — 2026-07-01

A meningioma is a usually slow-growing tumor that develops in the meninges, the protective layers around the brain and spinal cord. Most meningiomas are non-cancerous, but they can still cause symptoms such as headaches, vision problems, seizures, or weakness by pressing on nearby brain tissue. They are more common in older adults and women, and risk factors include prior radiation exposure and conditions such as neurofibromatosis type 2.

Diagnosis is typically made with imaging scans such as MRI, and treatment may involve observation, surgery, or radiation depending on the tumor's size and symptoms. This report describes a case in which preoperative endovascular embolization was used to reduce intraoperative blood loss prior to complete surgical excision of a hypervascular meningioma.

Twig-like middle cerebral artery

Loucif Houari — 2026-07-01

Objective: The twig?like middle cerebral artery (TL?MCA) is a rare congenital vascular anomaly in which the M1 segment is replaced by a plexiform network of primitive arterial twigs¹. Because its angiographic appearance overlaps with Moyamoya disease and arteriovenous malformations, TL?MCA is frequently misdiagnosed. We report three cases initially referred to as Moyamoya disease and provide an expanded review of diagnostic criteria, embryological mechanisms, and management strategies.

Methods: A retrospective review of all patients referred to Al Azhar Clinic (Algiers, Algeria) between 2019 and 2024 for presumed Moyamoya disease was conducted. Among 24 patients diagnosed with Moyamoya disease or syndrome, three were ultimately identified as having TL?MCA. Clinical presentation, MRI findings, angiographic characteristics, and management decisions were analyzed.

Results: The three patients (two females, one male; mean age 41 years) presented with headaches (n=2) or transient neurological deficits (n=1). TL?MCA was left?sided in two cases and right?sided in one. An MCA trunk was present in one patient and absent in two. All demonstrated a plexiform arterial network replacing the M1 segment. Perfusion imaging was normal or showed no mismatch, and conservative management was favored.

Conclusions: TL?MCA is a non?progressive congenital anomaly that mimics Moyamoya disease radiologically and clinically. Accurate differentiation is essential to avoid unnecessary revascularization surgery. Combined MRI–angiography assessment is critical for diagnosis and management. Treatment should be individualized, with revascularization reserved for patients demonstrating perfusion–diffusion mismatch or progressive ischemia.

Recurrent primary extracranial scalp meningioma

Burhan Ulhaq Ulhaq — 2026-07-01

Background: Primary extracranial meningiomas are rare neoplasms that may arise without intracranial or dural involvement and are frequently misdiagnosed as benign scalp lesions. A lack of routine histopathological evaluation of excised scalp masses may delay the diagnosis of rare tumors.

Case Presentation: We report a 28-year-old woman with a recurrent left parieto-occipital scalp mass associated with positional headache and intermittent vertigo. She had undergone prior excision of a similar lesion five months earlier without histopathological examination and was lost to follow-up. Examination revealed a firm, mobile subcutaneous mass. Contrast-enhanced magnetic resonance imaging demonstrated a well-circumscribed extracranial lesion without intracranial extension or dural attachment.

The patient underwent complete en bloc excision. Intraoperatively, the lesion was highly vascular. Histopathology confirmed a World Health Organization Grade I meningothelial meningioma with epithelial membrane antigen and progesterone receptor positivity and a low Ki-67 index (~2%). At one-year follow-up, the patient remained recurrence-free with complete symptom resolution.

Conclusion: This case highlights a diagnostic pitfall in which the omission of histopathological evaluation following initial excision led to the delayed diagnosis of a primary extracranial scalp meningioma. It emphasizes that imaging alone is insufficient to exclude rare neoplasms and underscores the need for routine pathological examination of all excised scalp lesions to prevent misdiagnosis and recurrence.

Image-guided neuronavigation assisted endoscopic repair of CSF rhinorrhoea

S. Jain — 2026-07-01

Background: Cerebrospinal fluid (CSF) rhinorrhea occurs due to communication between the intracranial subarachnoid space and the sinonasal mucosa. It could be due to trauma, raised intracranial pressure (ICP), tumors, erosive diseases, and congenital skull defects. Some leaks could be spontaneous without any specific etiology. The potential leak sites include the cribriform plate, ethmoid, sphenoid, and frontal sinus.

Methods: We retrospectively reviewed the medical records of 26 patients who underwent endoscopic repair of CSF rhinorrhoea with image-guided neuronavigation (IGN) between 2018 and 2021. The IGN system used was the easyNav. All patients underwent preoperative computed tomography (CT) scanning and magnetic resonance imaging (MRI) to identify the site of the CSF leak.

Results: The mean age of the patients was 42 years (range, 22-67 years). The most common cause of CSF rhinorrhoea in our study was spontaneous leak (n=12), followed by post-traumatic leak (n=8) and post-operative CSF rhinorrhoea (iatrogenic) (n=6). The most common site of the leak was the cribriform plate, followed by the ethmoid roof, followed by the frontal sinus. The mean operative time was 128 minutes (range, 60-240 minutes). There were no intraoperative complications. Postoperatively, one patient developed meningitis which recovered with antibiotics. All patients had complete resolution of their CSF rhinorrhoea at follow-up.

Conclusion: IGN is a safe and effective technique for the repair of CSF rhinorrhoea. It allows for accurate localization of the leak site and facilitates a minimally invasive approach to the repair.

Preoperative third ventricular bowing as a predictor of endoscopic third ventriculostomy success in obstructive hydrocephalus

P. Kumar — 2026-07-01

Background: Endoscopic third ventriculostomy (ETV) success depends on multiple factors. Third ventricular floor bowing (TVFB) serves as an indicator of intraventricular obstruction in hydrocephalus and existence of pressure gradient across third ventricular floor, which is the prerequisite of a successful ETV. The authors have hypothesized that patients with preoperative bowing of the 3^rd ventricle will have greater success rates after ETV in comparison to patients that lack preoperative bowing of 3^rd ventricle.

Objective: To study the effect of pre-operative bowing of 3^rd ventricle on the success rate of ETV in case of obstructive hydrocephalus.

Material and Methods: The authors determined success and failure for 32 ETVs performed in patients of obstructive hydrocephalus. Patients age, etiology of hydrocephalus, duration of illness, presence or absence of papilledema, intraoperative csf pressure, and preoperative third ventricular bowing was assessed on MR imaging.

Results: Out of total 32 patients, 16 patients have preoperative bowing of 3^rd ventricular floor & 16 patients have no preoperative bowing. Among 16 patients without preoperative bowing of the floor of third ventricle, 6 (37.50%) had successful outcome, while 10 (62.50%) experienced failure. In contrast, among 16 patients with bowing of the floor of third ventricle, 13 (81.25%) were successful, whereas only 3 (18.75%) failed.

Conclusion: To conclude, the presence of pre-operative bowing of the third ventricle significantly increased the likelihood of ETV success.

Primary malignant transformation of an intradiploic epidermoid cyst to invasive squamous cell carcinoma

V. Tanwar — 2026-07-01

Malignant transformation of an intradiploic epidermoid cyst into an invasive squamous cell carcinoma (SCC) is an exceptionally rare and highly aggressive clinical entity. We present the case of a 72-year-old male with a three-year history of worsening headaches. Neuroimaging revealed an extra-axial cystic lesion arising from the right occipital diploic space, associated with a distinct calvarial bone defect and significant mass effect on the posterior fossa structures. The patient successfully underwent surgical resection under a tailored neuroanesthetic regimen. Histopathological examination confirmed a primary intradiploic epidermoid cyst with malignant transformation to invasive SCC. This report highlights the clinical presentation, complex intraoperative neuroanesthetic and surgical challenges, radiological markers of malignancy, and critical pathological findings of this rare condition.

Technical note on the supraorbital keyhole approach

Shoeb Khan — 2026-07-01

Background: The supraorbital keyhole approach represents a paradigm shift in the surgical management of anterior skull base lesions, combining the principles of minimal access surgery with targeted anatomical corridors. This technical note describes our institutional experience and operative nuances of this approach.

Methods: We describe our stepwise operative protocol for the supraorbital keyhole approach performed through an eyebrow skin incision. Positioning, craniotomy design, dural opening, intradural dissection, and closure are each outlined in detail. An illustrative case of an olfactory groove meningioma is presented to demonstrate key technical principles.

Conclusions: With meticulous preoperative planning, appropriate patient selection, and integration of endoscopy, the supraorbital keyhole approach affords adequate access to suprasellar and anterior skull base pathology while minimising approach-related morbidity.

Moyamoya disease in pediatric North African patients

Loucif Houari — 2026-07-01

Introduction: Moyamoya disease (MMD) is an uncommon cerebrovascular occlusive condition characterized by progressive narrowing and obstruction of the circle of Willis. Sporadic cases have been documented in the literature from North Africa.

This study presents the most comprehensive reported series of MMD cases in North Africa, emphasizing their characteristics compared with those of the largest series.

Method: We reported the clinical symptoms, imaging findings, and surgical outcomes of nine patients with Moyamoya disease using data collected from 2019 to 2022.

Results: In comparison with the Southern European population, females and pediatric patients were more frequently affected. The severity of symptom onset, neurological impairment, and vessel involvement diminished with increasing age. A review of the literature identified seven cases of Moyamoya disease (MMD) within the North African region, where authors often misdiagnosed Twig-like middle cerebral artery or Moyamoya syndrome as MMD.

Statistical analysis indicates the progression of the stenosis-occlusive phenomenon within the vessel. Anterior vessels, specifically the internal carotid arteries (ICAs), are involved significantly more frequently than posterior vessels, namely the posterior cerebral arteries (PCAs; p = 0.0009), thereby supporting the hypothesis of anteroposterior progression. This observation is further corroborated by a highly significant Chi-square test result (p = 0.0009). Right-to-left laterality is suggested, with a sequential progression in the following order: right ICA, left ICA, right PCA, and left PCA; however, this trend does not reach statistical significance (p = 0.0748).

Conclusion: Moyamoya disease is infrequent in North Africa and primarily impacts pediatric patients. Our series illustrates a distinctive anteroposterior pattern of vascular involvement and highlights the common diagnostic confusion with similar entities documented in the regional literature. These findings highlight the need for improved recognition and precise classification of MMD in this population.