Romanian Neurosurgery

Mediated cognitive rehabilitation after surgically treated intracerebral haemorrhage: a Feuerstein Instrumental Enrichment approach to executive recovery and return to work

Tue, 15 Sep 2026 00:00:00 +0000

Background. Intracerebral haemorrhage (ICH) accounts for more than a quarter of incident strokes worldwide and carries the highest burden of death and disability among stroke subtypes. In survivors, executive dysfunction rather than motor deficit is a principal barrier to return to work, yet it is rarely the focus of post-neurosurgical care. The Feuerstein Instrumental Enrichment (FIE) programme, based on the theory of Structural Cognitive Modifiability and Mediated Learning Experience, explicitly targets transfer of strategies to daily life but has seldom been reported in stroke.

Case presentation. A 57-year-old man with hypertension, type 2 diabetes mellitus and dyslipidaemia, previously employed in a technical-administrative role, presented with a right temporo-parietal intraparenchymal hematoma with mass effect and was treated neurosurgically. Postoperative neuropsychological assessment showed a predominant dysexecutive profile: impulsivity, execution without planning, anticipation errors and difficulty maintaining spatial constants, with preserved locomotor autonomy. He completed a 12-week mediated programme (2–3 sessions/week) using four sequential FIE instruments: Organisation of Dots, Comparisons, Orientation in Space and Analytic Perception.

Results. At 12 weeks, the patient showed reduced impulsivity, longer response latency, systematic anticipatory planning, greater decisional autonomy and resumed part-time organisational and administrative work.

Conclusion. Motor recovery does not guarantee occupational reintegration after ICH. Structured, mediated cognitive rehabilitation is a feasible, low-cost adjunct to neurosurgical care; controlled studies with standardised outcomes are warranted.

Giant right parasagittal and periventricular parietal meningioma in an 86-year-old female patient: a multidisciplinary challenge.

D. Balasa, I. Voicu, A.L. Tunas, E. Neagu, M. Banculescu, A. Timoftei, T. Scupra — Tue, 15 Sep 2026 00:00:00 +0000

Meningiomas are the most common intracranial tumours. Given the increase in life expectancy and the widespread access and use of brain imaging, the incidence in the elderly population (?65 years) is continuously increasing. Meningiomas in adults are mainly benign tumours that develop from the meninges. We present the case of an 86-year-old female patient admitted on an emergency basis to our department with severe left-sided hemiparesis (left brachial plegia, severe left crural paresis) of approximately 4 days duration, drowsy, GCS 14 points, Karnofsky score 70, headache of moderate intensity (VAS 5/10). Brain imaging (contrast-enhanced CT scan) revealed a giant cerebral meningioma (60 x 57 x 62 mm) located in the right parietal region, in a parasagittal and paraventricular position. The procedure was performed under magnification, with subtotal resection and a 2–3 mm residual fragment. The postoperative status was very good, with significant improvement of the motor deficit—allowing for effective mobilisation with a walker—and a Karnofsky score that reached 90. The headache disappeared.

Rapid complete spontaneous thrombosis in unruptured posterior cerebral artery aneurysm

A. Chiriac, N. Dobrin, Z. Faiyad — Tue, 15 Sep 2026 00:00:00 +0000

Posterior circulation aneurysms are rare in young patients but more common than in adults, tend to be larger and more complex, and often require endovascular treatment. However, in some cases, the aneurysm could occlude naturally, which was commonly defined as spontaneous thrombosis. We report the rapid spontaneous and complete thrombosis of an unruptured posterior cerebral artery aneurysm at the P1–P2 junction in a young patient who presented with blurred vision and consistent headaches. Complete spontaneous thrombosis cannot always be considered a permanent curative event. Its natural history may be associated with risks of recanalisation, rupture, and ischemic stroke. Conservative treatment of unruptured aneurysms with spontaneous thrombosis is a safe therapeutic option but requires periodic clinical and imaging follow-up.

Giant T1–T3 spinal meningioma in an elderly patient

D. Balasa, H.A. Tunas, M. Banculescu, L. Seicaru — Tue, 15 Sep 2026 00:00:00 +0000

We present the case of a 77-year-old female patient with complete paraplegia of two weeks duration, occurring on a background of slowly progressive bilateral lower-limb motor deficit spanning approximately three years. Imaging studies revealed a giant spinal intradural extramedullary (IDEM) meningioma at the T1–T3 level. The patient had a very good neurological postoperative outcome, and the associated complications also resolved.

Language impairment after spontaneous intracerebral haemorrhage

Cosmin-Nicodim Cindea, Iulia Cindea — Tue, 15 Sep 2026 00:00:00 +0000

Background and Objectives: Aphasia after spontaneous intracerebral haemorrhage (sICH) may result from cortical injury or disruption of subcortical language networks. This review summarises language phenotypes, recovery, prognostic factors, and evidence on hematoma evacuation.

Methods: Haemorrhage-specific studies reporting language outcomes were systematically reviewed, with mixed-stroke cohorts used for contextual recovery data. Language-specific surgical evidence was analysed separately from trials reporting global disability; owing to heterogeneity, findings were synthesised narratively.

Results: Putaminal and thalamic haemorrhages produced heterogeneous fluent and non-fluent aphasic syndromes. Longitudinal putaminal studies indicate that the largest gains usually occur within the first three months, while extensive corona-radiata/internal-capsule involvement and ventricular extension are associated with poorer recovery. One retrospective study reported better six-month language outcomes after endoscopic evacuation than craniotomy, but no conservative-treatment arm was included. Major randomised ICH surgery trials primarily measured global disability rather than aphasia. Bilingual haemorrhage reports showed parallel or differential impairment and recovery across languages.

Conclusions: Language outcome after sICH depends on lesion topography and network disruption. Recovery is greatest early, whereas a language-specific benefit from hematoma evacuation remains unproven.

Giant cranial metastasis of hepatocellular carcinoma

Tue, 15 Sep 2026 00:00:00 +0000

Brain metastases from hepatocellular carcinoma (HCC) are rare and usually occur in patients with advanced systemic disease. Cranial metastasis as the first manifestation of previously undiagnosed HCC is particularly uncommon.

We report a 70-year-old HCV-positive man with a rapidly growing cranial mass initially considered to be a lipoma. Within two months, the lesion reached an enormous size, with extensive cranial destruction and significant intracranial extension. Further diagnostic work-up revealed a previously unknown HCC without other detectable distant metastases. Complete surgical resection and cranioplasty were performed, and histopathology confirmed metastatic HCC. Five months after surgery, there was no evidence of local recurrence, although a new scapular lesion suspicious for metastatic disease subsequently developed and the patient declined further treatment.

Giant cranial metastasis may rarely represent the first manifestation of HCC. Surgical resection can provide effective local control, particularly in large symptomatic lesions with significant mass effect. Given the rarity of this condition and the absence of standardised treatment guidelines, an individualised multidisciplinary approach remains essential.

Lentiform appearance of acute SDH

Tue, 15 Sep 2026 00:00:00 +0000

Acute subdural hematoma (ASDH) is one of the most common clinical entities encountered in daily neurosurgical practice. The advent of computed tomography (CT) has made a major impact on the radiological diagnosis of ASDH. Although most of them appear as cresentic concavo convex hyderdense lesion in CT, sometimes they may present atypically. Here we report such a case where ASDH has presented as acute EDH causing a diagnostic dilemma.

Multiple brain carcinoma metastases treated surgically

Marcel Sincari, Filipa Ponte; Mark-Daniel Sincari — Tue, 15 Sep 2026 00:00:00 +0000

We present the case of a 47-year-old woman diagnosed with breast cancer who underwent surgery and, 35 months later, was diagnosed with multiple brain metastases. She was treated surgically, followed by Whole Brain Radiation Therapy and chemotherapy. Clinical and imaging follow-up revealed no tumour recurrence after more than 5 years.

Twig-like middle cerebral artery misdiagnosed as Moyamoya

Loucif Houari, Djida Ait Ali , Tanina Houari, Abdelhalim Morsli — Tue, 15 Sep 2026 00:00:00 +0000

Introduction: The twig-like middle cerebral artery (TL-MCA) constitutes an uncommon vascular anomaly characterized by the substitution of the M1 segment with a plexiform network of diminutive, delicate vessels. Due to its rarity and similarities in radiological features, it is frequently misdiagnosed as Moyamoya disease or arteriovenous malformation. This publication presents three cases of TL-MCA identified at a single center, providing detailed insights into the radiological and clinical findings, and discussing management strategies through illustrative cases.

Material and methods: We conducted a retrospective review of the records of patients referred for the management of Moyamoya disease. A total of 24 patients diagnosed with either Moyamoya disease or syndrome were included, with assessments encompassing clinical presentation, symptoms at the initial consultation, and findings from angiography and MRI.

Results: Between 2019 and 2022, a total of 24 patients referred for Moyamoya disease were evaluated. Of these, three patients exhibited the terminal segment of the middle cerebral artery (TL-MCA). The cohort included two females and one male, aged between 20 and 54 years, with a mean age of 41 years. Clinical presentations varied: two patients experienced only headaches, while one patient reported dysarthria and hemiparesis. Angiographic assessment revealed that the TL-MCA was on the left side in two patients and on the right side in one patient. In one patient, a distinguishable MCA trunk was observed, whereas in the other two patients, no trunk was identified; instead, a web-like plexiform structure was present in all cases.

Discussion: Moyamoya and TL MCA are two distinct entities that are frequently conflated owing to their comparable radiological characteristics. Since Moyamoya disease and TL-MCA both cause hypoperfusion of cerebral tissue, consideration should be given to direct extra-intracranial revascularization through bypass surgery, supplemented by indirect techniques.

Conclusion: LT-MCA and Moyamoya disease differ in their pathophysiology and radiological criteria. However, they share similarities in inducing cerebral hypoperfusion and clinical presentation. Consequently, decision-making and management strategies for Moyamoya are also applicable to LT-MCA, and bypass surgery is recommended in specific situations.

Median nerve giant schwannoma

Tue, 15 Sep 2026 00:00:00 +0000

Background: Schwannomas are benign peripheral nerve sheath tumors arising from Schwann cells, most commonly affecting the median nerve in the upper extremity. Although typically slow-growing and asymptomatic, they can present with pain, swelling, or neurologic symptoms due to nerve compression. Accurate diagnosis and appropriate management are crucial to ensure complete resection and preservation of nerve function.

Case Presentation: We report a case of a 30-year-old male presenting with a 3-year history of a painless, gradually enlarging swelling on the medial aspect of the distal left arm. On examination, a 6×6 cm, well-circumscribed, soft, and tender mass was noted, with mild motor weakness in thumb opposition and finger flexion. Magnetic resonance imaging (MRI) revealed a well-defined lesion within the muscular plane, arising from the median nerve, consistent with a benign peripheral nerve sheath tumor. The patient underwent complete surgical excision with preservation of the nerve fascicles, without the need for nerve grafting. Histopathological examination confirmed the diagnosis of schwannoma. Postoperatively, the patient experienced no new neurological deficits and showed clinical improvement.

Conclusion: This case highlights the importance of considering schwannomas in the differential diagnosis of soft tissue masses in the upper limb, particularly when associated with subtle neurological findings. Imaging modalities such as MRI and ultrasonography play a key role in preoperative assessment. Surgical enucleation remains the treatment of choice, offering excellent outcomes with low recurrence rates and preservation of nerve function. This report reinforces current literature on the clinical presentation, diagnostic approach, and successful management of median nerve schwannomas.

Olfactory nerve schwannoma

Hrushikesh Kharosekar, Skandeshwaran P., Vernon Velho — Tue, 15 Sep 2026 00:00:00 +0000

Schwannomas are common benign lesions but olfactory nerve schwannoma is rarely being reported in literature. these lesions can mimic esthesioneuroblastoma. If suspected early in workup these lesions can be excised completely with endoscopic approach as there is rarely intracranial extension.

Multiple meningiomas in a 55-year-old male

Tue, 15 Sep 2026 00:00:00 +0000

Multiple Meningiomas (MM) constitute a small but important subset of intracranial tumours, characterised by two or more independent dural-based lesions. Although more frequently reported in females, their occurrence in middle-aged males without neurocutaneous syndromes is uncommon. This report describes a 55-year-old Indian male presenting with symptomatic parasagittal, parietal, parieto-occipital, and sphenoid wing meningiomas. The paper outlines his clinical profile, radiological findings, surgical decision-making, and postoperative outcome, along with a concise review of Indian and global literature.

Coccydynia, a rare presentation of invasive sacrococcygeal chordoma in a young adult patient

Shrijit Kumar, Hrushikesh Kharosekar, Reshma Pujara — Tue, 15 Sep 2026 00:00:00 +0000

Chordoma is a slow-growing malignant bone tumor that develops out of the embryonic notochordal residues and is rare. This is most frequently localized in sacrococcygeal joints, where the localized pain may go unnoticed or be mild in nature, and this may put off a diagnosis. Definitive diagnosis requires the use of histopathology with the assistance of immunohistochemistry. We describe a case of a 45-year-old male with progressive pain and swelling of the gluteal area since few months. Excision biopsy showed lobules of big polygonal physaliphorous cells in a myxoid stroma and had hemorrhage and necrosis. Mitotic activity was low. A chordoma provisional diagnosis was established based on the histomorphology. To prevent recurrence and achieve better outcomes, multidisciplinary management, which consists of surgical excision and long-term follow-up, is necessary.

Dual-level neonatal meningomyelocele in a resource-limited setting

Shivam Sharma, Avinash Sharma, Anand Sharma — Tue, 15 Sep 2026 00:00:00 +0000

Background: Multiple neural tube defects are rare congenital anomalies resulting from failure of neural tube closure at multiple sites. Double meningomyelocele is extremely uncommon, with very few cases reported worldwide.

Case presentation: An 11-day-old female neonate presented with two midline swellings over the dorsolumbar region since birth. MRI revealed dual meningomyeloceles at D12–L2 and L5–S1 levels with associated Chiari II malformation. The child underwent single-stage surgical repair with excision of both sacs, detethering, neurulation, and sectioning of filum terminale.

Management and outcome: Both lesions were successfully repaired in one sitting without intraoperative neuromonitoring. Postoperatively, the child had an uneventful recovery with no new neurological deficits.

Conclusion: Double meningomyelocele is an extremely rare entity. Careful radiological evaluation, meticulous surgical technique, and complete detethering are essential. Single-stage repair is safe and effective even in resource-limited settings.

Key message: Double meningomyelocele is exceedingly rare. Single-stage repair with meticulous neural placode detethering and filum terminale section—despite resource constraints—can yield excellent outcomes. Early recognition and comprehensive MRI evaluation are essential for surgical planning and parental counselling.

Brain abscess: pathophysiology, diagnosis, and management

Tue, 15 Sep 2026 00:00:00 +0000

Background: Brain abscess is a life-threatening intracranial infection, typically caused by contiguous spread (e.g., sinusitis) or hematogenous seeding (e.g., endocarditis), and is more common in males and in developing countries, with peak incidence in the first two decades of life. Symptoms include headache, fever, altered mental status, nausea/vomiting, seizures (25–34%), and focal neurological deficits. It progresses through four stages over 2–4 weeks, culminating in capsule formation. Diagnosis is best achieved with MRI (especially DWI and ¹H-MRS), which differentiates abscesses from tumors, while CT supports localization and monitoring. Treatment involves ?6 weeks of BBB-penetrating antibiotics and surgery—stereotactic aspiration for abscesses >2.5 cm, or excision for complex cases. Corticosteroids are used cautiously; anticonvulsants may be continued long-term. With prompt combined therapy, cure rates exceed 90%. Close imaging follow-up is essential to detect complications. This study highlights significant variability in presentation, pathology, management, and outcomes among surgical patients.

Methods: This prospective study analyzed 17 patients with brain abscess treated surgically at the Department of Neurosurgery, SVP Hospital and SMT. NHL Medical College, Ahmedabad, between January 2022 and August 2025. Inclusion required microbiological/histopathological confirmation of infection, characteristic MRI/CT findings, and lesion resolution with antibiotics; cases due to postoperative complications or meningioencephalitis were excluded. All patients underwent baseline and serial CT scans to evaluate abscess size, wall morphology, and perifocal edema. Abscesses ?2 cm were managed surgically—predominantly via craniotomy and excision—while those <2 cm received medical therapy alone. Empirical broad-spectrum intravenous antibiotics were initiated immediately, adjusted based on culture and sensitivity, and continued for six weeks. Adjunctive corticosteroids were given under antibiotic cover and tapered over four weeks. Postoperative CT was performed within 24 hours, followed by imaging at 1, 3, and 6 months. Clinical outcomes were assessed using the modified Rankin Scale. The study underscores a standardized, multimodal approach to brain abscess management with favorable outcomes.

Results: This prospective study analyzed 17 brain abscess patients (8 males, 9 females; median age 29 years) treated at SVP Hospital, Ahmedabad (Jan 2022–Aug 2025). Most common symptoms were fever/meningeal signs (11), seizures (5), headache (5), and neurological deficits (6). Temporo-parietal location predominated (11 cases); mean abscess size was 4.5 cm. Sixteen underwent craniotomy with excision; one had aspiration. All received 6 weeks of IV antibiotics (adjusted per culture) and a 4-week steroid taper. Causative organisms were identified in 10 cases (Staphylococcus spp., Streptococcus, M. tuberculosis, Aspergillus, hydatid cyst); 6 were culture-negative. Complications included ventriculitis with hydrocephalus (1), managed with ventriculostomy ± VP shunt. At 6 months, 88.23% had good outcomes (mRS 0–2); 2 patients died (one with congenital heart disease and altered sensorium, the other from meningitis/encephalitis). No recurrences occurred. Early diagnosis, surgical excision, and prompt antimicrobial therapy significantly predicted favorable outcomes (p < 0.001).

Conclusion: CNS infections remain life-threatening, demanding urgent multimodal care. Pyogenic brain abscesses >2 cm require emergent surgery—usually burr-hole aspiration; craniotomy is reserved for complex cases. Prolonged (?6 weeks) IV antibiotics prevent relapse. Despite challenges like diagnostic delays and antimicrobial resistance, outcomes have improved with advanced diagnostics, targeted therapy, and neurocritical care. Timely treatment yields excellent recovery. Reducing the global burden requires equitable access, innovation, and a holistic approach spanning prevention to rehabilitation.

Synchronous coexistence of low-grade and high-grade gliomas in a single patient

Tue, 15 Sep 2026 00:00:00 +0000

Background: The simultaneous occurrence of low-grade and high-grade gliomas in different brain regions of the same patient is exceedingly rare. This phenomenon may represent malignant progression of a pre-existing low-grade glioma, true synchronous gliomas, or multicentric gliomagenesis. Distinguishing among these entities has important diagnostic, prognostic, and therapeutic implications.

Case Description: A 53-year-old man with no significant neurological history had been followed for several years for a stable left thalamic lesion radiologically suggestive of a low-grade glioma. He presented with acute visual impairment and was diagnosed with a left occipital hemorrhagic lesion. Subsequent magnetic resonance imaging revealed a contrast-enhancing occipital mass with radiological characteristics suggestive of a high-grade glial neoplasm, while the thalamic lesion remained unchanged. Perfusion imaging demonstrated increased vascularity within the occipital lesion. The patient underwent gross total resection of the occipital tumour, and histopathological examination confirmed a high-grade glial neoplasm. Given the long-term radiological stability and deep location of the thalamic lesion, no surgical intervention was performed.

Conclusions: The synchronous coexistence of low-grade and high-grade gliomas in distinct cerebral locations is exceptionally uncommon. This case highlights the diagnostic challenges associated with multiple gliomas and emphasises the importance of integrating clinical, radiological, histopathological, and molecular findings to differentiate malignant progression from truly synchronous tumours. Further molecular characterisation is essential to improve our understanding of glioma pathogenesis and multicentric tumour development.

Early postoperative vasospasm and cerebral infarction after endoscopic endonasal approach for pituitary macroadenoma resection

Tue, 15 Sep 2026 00:00:00 +0000

Cerebral vasospasm leading to delayed cerebral ischemia is an uncommon but life-threatening complication of the endoscopic endonasal approach (EEA), which could cause devastating neurological sequelae. Herein, we report the case of a 59-year-old female with a medical history of poorly controlled type 2 diabetes mellitus, high blood pressure, dyslipidemia, and allergy to penicillin, who presented with left eye amaurosis and right temporal hemianopsia, for which a magnetic resonance imaging (MRI) was requested, revealing a pituitary macroadenoma of approximately 3.39 x 3.43 x 3.15 cm. Surgical management was indicated for resection of the tumoral lesion by endoscopic endonasal approach. A postoperative MRI and computed tomography (CT) were performed due to severe deterioration of visual acuity and disorientation in time and place, showing supratentorial subarachnoid hemorrhage in addition to vasogenic edema in the perioperative frontal region. A subsequent magnetic resonance angiography (MRA) revealed acute fronto-cingulate ischemia in the territory of both anterior cerebral arteries (ACA). Management with nimodipine and triple H therapy was initiated, in addition to strict neurological follow-up. The patient also required follow-up and management by endocrinology due to the development of diabetes insipidus. Subsequent imaging confirmed reperfusion of both ACAs; however, the patient was discharged 40 days after surgery with persistent impairment in higher mental functions, including temporal disorientation, bradyphrenia, and operative and episodic amnesia. This is a rare complication, but strict postoperative follow-up aids in timely suspicion to provide indicated treatment, reducing sequelae and improving neurological outcomes.

Left frontal WHO grade 4 gliosarcoma with glial and sarcomatous component in a young adult female

Namit Singhal, Vinay Agarwal, Mayank Agarwal, Ankur Agarwal — Tue, 15 Sep 2026 00:00:00 +0000

Gliosarcoma (GS) is a rare and aggressive variant of glioblastoma (GBM), accounting for 2–8% of all GBM cases. It is characterized by biphasic histology comprising glial and sarcomatous components and carries a dismal prognosis. A 32-year-old female presented with progressive headache, vomiting, seizures, and right-sided weakness for two months. Magnetic resonance imaging revealed heterogeneously enhancing left frontal lesion with mass effect, for which patient underwent near-total surgical excision. Histopathological examination demonstrated biphasic morphology with glial and sarcomatous components, mitotic activity, giant tumor cells, and extensive necrosis. Immunohistochemistry revealed GFAP positivity in the glial component and vimentin, SMA, and weak GFAP positivity in the sarcomatous component. ATRX was retained, IDH-1 was negative, and Ki-67 index was 50%, confirming WHO grade 4 GS with smooth muscle differentiation. Despite aggressive multimodal therapy including surgery, radiotherapy, and temozolomide-based chemotherapy, the patient succumbed after three cycles, reflecting the poor prognosis associated with GS.

Large falcotentorial meningioma mimicking a pineal region tumor

Shikhar Chohan, Sana Ahuja, Sufian Zaheer, Vishesh Guglani, Anant Sharma — Tue, 15 Sep 2026 00:00:00 +0000

Background: Pineal region tumors are uncommon and encompass a histologically diverse group of lesions. Meningiomas arising from the falcotentorial region and presenting as pineal masses are rare, accounting for a small proportion of intracranial meningiomas. Their deep-seated location and close relationship with critical neurovascular structures pose significant surgical challenges. We report a large falcotentorial meningioma of the pineal region highlighting operative considerations and clinical outcome.

Case presentation: A 50-year-old female presented with progressive headache, vomiting, visual disturbances, and features of Parinaud’s syndrome. Magnetic resonance imaging demonstrated a well-defined, homogeneously enhancing pineal region mass measuring 5.3 × 4.5 × 4.2 cm, causing obstructive hydrocephalus and displacement of deep venous structures. Serum and cerebrospinal fluid tumor markers were negative. Following ventriculoperitoneal shunt placement, the patient underwent gross total excision via an interhemispheric approach. Intraoperatively, the tumor was soft, vascular, and attached to the falx cerebri and tentorium cerebelli. Postoperative imaging demonstrated satisfactory decompression without definite residual enhancing lesion. Histopathological examination confirmed a World Health Organization Grade I transitional meningioma. The postoperative course was uneventful, and the patient remained neurologically stable on follow-up.

Conclusions: Large falcotentorial meningiomas presenting as pineal region masses are uncommon and technically demanding due to their anatomical proximity to the quadrigeminal plate and deep venous system. Careful preoperative evaluation and meticulous microsurgical technique enable safe resection with favorable outcomes.