Romanian Neurosurgery

Cost-effective 3D reconstruction of skull defects

Mon, 15 Dec 2025 00:00:00 +0000

Cranial defects following decompressive craniectomy or tumour resection can result in major cosmetic, protective, and neurological deficits, including the “syndrome of the trephined”. While patient-specific PEEK and titanium implants offer excellent anatomical and functional results, their high-cost limits accessibility in many healthcare systems. This study describes a cost-effective cranioplasty technique that uses in-house 3D-printed skull models or templates to pre-contour standard titanium mesh implants. We report three representative cases of large cranial defects secondary to tumour resection, complex infection with decompressive craniectomy, and severe traumatic brain injury. In each case, preoperative CT data were used to generate a patient-specific 3D model, which guided precise shaping of the implant and restoration of the native cranial curvature. This workflow combines the affordability and availability of conventional materials with the accuracy of computer-aided planning, minimises intraoperative modelling time, and reduces the need for expensive industrial patient-specific implants. Our early experience suggests that 3D-assisted contouring of standard implants is a robust and accessible strategy for restoring cranial integrity and improving cosmetic outcomes in resource-constrained settings.

Incidence and severity of complications in postoperative spondylodiscitis after lumbar disc herniation surgery

A. Arsene, F. Urian, A.D. Corlatescu, G. Iacob, A.V. Ciurea — Mon, 15 Dec 2025 00:00:00 +0000

Background: Postoperative spondylodiscitis is a rare but serious complication after lumbar disc herniation surgery, with incidence varying between 0.2–4%. It is mainly related to intraoperative contamination and host-related risk factors. This study aimed to evaluate demographic variables, lifestyle-related factors, and clinical outcomes in patients diagnosed with postoperative spondylodiscitis.
Methods: We conducted a retrospective observational study on 85 patients treated between 2018 and 2024 in a tertiary care centre. Clinical and paraclinical data were collected, including demographic characteristics, residence, lifestyle-related risk factors, discectomy level, complications, treatment type, motor deficit, and hospitalisation duration. Statistical analyses were performed using ?² and Student’s t-tests, with significance set at p < 0.05.
Results: Complications were observed in 24 patients (28.2%), predominantly at the lumbar level. Age, sex, and residence showed no significant associations with complication status (p > 0.05). In contrast, lifestyle-related factors such as smoking, alcohol consumption, and poor hygiene were significantly correlated with complications (?² test, p < 0.05). Patients with complications had longer hospital stays (23.25 vs. 12.66 days, p < 0.05). Abscesses were the most frequent complication, followed by epiduritis. The presence of complications was significantly associated with motor deficits (p < 0.05).
Conclusion: While demographic factors did not influence outcomes, lifestyle-related risk factors and surgical treatment were associated with increased complications and prolonged hospitalisation. Early identification of high-risk patients and aggressive management of abscess formation remain essential to reduce morbidity.
Keywords: postoperative spondylodiscitis, lumbar disc herniation, spinal infection, complications, lifestyle risk factors, hospitalisation, motor deficit.
Abbreviations: N = number of patients; p = p-value; r = Pearson correlation factor; SD = standard deviation; t-test = Student’s t-test; ?² = Chi-square test.

Single vs multiple pathogens in brain abscesses

Mon, 15 Dec 2025 00:00:00 +0000

Brain abscesses represent life-threatening focal infections with diverse aetiologies. In the current era of escalating antimicrobial resistance, medical management is increasingly challenged and empiric regimens may be insufficient. We report two young immunocompetent male patients with brain abscesses due to distinct aetiologies: a monomicrobial subdural and epidural collection caused by Streptococcus constellatus and a polymicrobial post-traumatic orbitofrontal abscess associated with Enterococcus faecalis and Escherichia coli. Both patients underwent urgent surgical drainage combined with broad-spectrum intravenous antibiotics, later tailored to culture results. The first case illustrates the risk of suboptimal oral therapy and poor adherence, with subsequent relapse and development of antimicrobial resistance, whereas the second case highlights infectious complications following penetrating orbito-cranial trauma. These contrasting cases emphasise the need for timely neurosurgical intervention, prolonged targeted antimicrobial therapy, and strict avoidance of unsupervised antibiotic use in the management of brain abscesses.

Psychiatric and neurobehavioral effects of posterior fossa surgery

Mon, 15 Dec 2025 00:00:00 +0000

The posterior fossa, housing the brainstem and cerebellum, has traditionally been viewed as exclusively responsible for motor functions. However, recent literature has highlighted the profound cognitive and psychiatric implications of lesions and surgery in this area. This literature review analyses case studies, clinical series, and systematic reviews regarding post-surgical neuropsychiatric sequelae in the posterior fossa. Relevant studies on cerebellar mutism, cerebellar cognitive affective syndrome, and emotional lability were included. Posterior fossa pathology is associated with a wide spectrum of disorders. Posterior Fossa Syndrome (PFS) is a common pediatric complication, characterised by mutism and irritability. In adults, although rarer, subtle personality changes, executive dysfunction, and severe emotional lability caused by brainstem compression can occur. Pathophysiological mechanisms involve the disruption of cerebello-cerebral circuits (diaschisis). Recognising postoperative psychiatric complications is essential. Neuropsychological assessment should be routine in posterior fossa surgery to optimise patient recovery and quality of life. This review may serve as a structured framework for future prospective and statistical studies that systematically evaluate psychiatric and cognitive outcomes after posterior fossa surgery.

Visual improvement following the treatment of internal carotid complex aneurysms through internal carotid ligation combined with STA-MCA bypass.

Loucif Houari, Djida Ait Ali , Tanina Houari, Abdelhalim Morsli — Mon, 15 Dec 2025 00:00:00 +0000

Objective: The combination of internal carotid artery (ICA) ligation with superficial temporal artery (STA) to middle cerebral artery (MCA) bypass has proven effective in the treatment of internal complex carotid aneurysms (ICCAs). Indirect exclusion through thrombosis is anticipated to alleviate the mass effect on adjacent neurovascular structures. However, visual impairment may occur secondary to thrombosis of the ICA and ophthalmic artery. The purpose of this study is to emphasise the paradoxical stabilisation and improvement of vision observed in certain cases.

Methods: A retrospective study was conducted from 2016 to 2020, analysing data from a cohort of patients with ICCAs, among whom nine patients underwent ICA ligation in combination with STA-MCA anastomosis. Preoperative and postoperative visual findings were analysed and compared.

Results: All patients underwent STA-MCA bypass in addition to complete ICA ligation. Postoperative clinical outcomes remained unchanged in 8 out of 9 patients. Complete aneurysm exclusion through thrombosis was achieved at 12 months. The STA-MCA anastomosis remained patent in 6 out of 9 patients, with no clinical deterioration observed, except in one case. Notably, irrespective of graft patency, this patient experienced a minor parietal stroke, from which full recovery was achieved after six months. Furthermore, an improvement in visual acuity was observed in two patients at three months.

Conclusion: The ICCA treatment, which involves ICA ligation combined with STA-MCA bypass, alleviates the mass effect on adjacent neurovascular structures. Despite the occurrence of ICA thrombosis, an enhancement in visual acuity has been documented, which can be attributed to the patency of the ophthalmic artery via the meningeal anastomotic circuits.

Hybrid embolization and radiosurgery for glossopharyngeal glomus tumour

Mon, 15 Dec 2025 00:00:00 +0000

Introduction: Tumours of the glossopharyngeal nerve are extremely rare, posing a challenge in diagnosis and treatment. These tumours can cause a variety of neurological symptoms, including sore throat, numbness of the tongue, decreased sensitivity, and changes in taste, difficulty swallowing, and dizziness. Due to their rarity, there is no standardised treatment protocol, and the approach is often tailored to the individual patient.

Aim: To present a rare case of glomus tumour of the glossopharyngeal nerve, and that the hybrid method of embolisation and radiosurgery proved to be a successful treatment.

Case description: We present the case of a 31-year-old female patient who came to the Emergency Centre due to excruciating headaches, vomiting and loss of taste and tingling in the tongue. After a detailed neurological examination and MRI diagnostics, a glossopharyngeal nerve tumour was discovered in the jugular foramen region. Due to the tumour's proximity to vital structures, surgical resection would have been high-risk. Therefore, it was decided to apply a hybrid approach, combining embolisation and radiosurgery. MRI scans showed a decrease in the size of the tumour. The patient was monitored regularly, and the results remained stable.

Conclusion: Hybrid treatment with embolisation and radiosurgery represents an effective option for the treatment of rare tumours of the glossopharyngeal nerve. This combination allows for the reduction of symptoms, reduction of tumour size, and improvement in patients' quality of life. Further research is needed to determine the optimal treatment protocols for these rare tumours.

Gross total resection of a rare epidermoid cyst in the supplementary motor area without postoperative SMA syndrome

Heng-zhou Xu, Peng Zhang, Jia Wei — Mon, 15 Dec 2025 00:00:00 +0000

Epidermoid cysts rarely occur in the supplementary motor area (SMA), where resection carries a particular risk of postoperative SMA syndrome. We present the case of a 25-year-old woman who developed persistent headache and intermittent dizziness. Preoperative MRI revealed a right medial frontal lesion with low T1, high T2, and restricted diffusion, consistent with an epidermoid cyst.
Microsurgical resection was performed via a right interhemispheric approach under neuronavigation. Internal decompression was followed by capsule dissection along the tumor–brain interface. Particular care was taken to preserve bridging veins, avoid fixed retractors, and minimise traction on the SMA cortex. A superficial cortical vein with focal wall irregularity was reinforced with hemostatic material instead of being sacrificed. Gross total removal was achieved with minimal blood loss.

The patient recovered without neurological deficits, was mobilised on the third postoperative day, and was discharged home. Histopathology confirmed the diagnosis. Follow-up MRI at six months showed no recurrence, and her modified Rankin Scale score was 0.

This case highlights that, although SMA epidermoid cysts are exceedingly rare, complete resection with full functional preservation is achievable. Careful surgical planning, venous preservation, and low-traction microsurgical techniques are crucial to avoid SMA syndrome in this eloquent cortical region.

Paediatric intradural cerebellopontine angle chordoma mimicking meningioma

Hrushikesh Kharosekar, Debabrata Patra, Mazarkhan Mulla, Vernon Velho — Mon, 15 Dec 2025 00:00:00 +0000

Chordomas are rare, notochord-derived neoplasms, most commonly affecting the sacrum and clivus, and exceedingly rare in the cerebellopontine angle (CPA), especially in children. This report describes a 10-year-old male presenting with hearing loss, giddiness, vomiting, and left-sided facial palsy, who was found to have a CPA chordoma that was SMARCB1-deficient, confirmed via histopathology. The clinical presentation and management are discussed, along with a review of the scant global literature.

Surgical strategy and predicator of insular glioma in a tertiary centre

Rajendra Shrestha — Mon, 12 Jan 2026 00:00:00 +0000

Introduction: The insular glioma is a rare condition in neurosurgical practice. The treatment of insular glioma lacks a distinct approach. This study aims to review the outcomes of insular glioma surgery and discuss strategies to minimise the risk in adults who have undergone initial or repeat resection of insular gliomas of all grades.

Methods: An observational study was done among 50 patients with insular gliomas who were admitted to the Department of Neurosurgery of a tertiary care centre during January 2015-August 2025. The treatment decisions and neurosurgical outcomes of the patients with insular glioma were analysed. All patients were assessed with either computed tomography, magnetic resonance imaging, or both.

Results: Among the admitted patients, the youngest patient was 25 years, and the oldest was 76 years, while there were 30 males and 20 females. Most of the patients, 42 (84%), presented with headache and 32 (64%) presented with seizures of sudden onset. Right-sided insular gliomas were observed in 27 (54%) patients, but 23 (46%) patients had left-sided tumours, and 27 (57%) patients were operated on with the Transylvanian approach and 20 (42%) patients with the transcortical approach. Extent of resection above 90% or above was achieved in 52% of cases, and EOR of 70-90% in 48% of cases.

Conclusion: The surgical approach for insular gliomas requires technical mastery of intraoperative technologies to minimise postoperative morbidity.

A poignant odyssey of migrating distal end of ventriculoperitoneal shunt from inguinal canal to anal canal

Ritu Gaur, Abhishek Shah, Kapil Pareek, Dinesh Sodhi — Mon, 15 Dec 2025 00:00:00 +0000

Ventriculoperitoneal (VP) shunt procedure is the most commonly performed and widely accepted treatment method for hydrocephalus of any aetiology. Unfortunately VP shunt is associated with varying complications beginning right from its ventricular end to the peritoneal end [1]. Here we present a challenging case of migrating distal end of VP shunt with its extrusion through the inguinal region, followed by per anal protrusion in the same patient. Scarcity of literature on sequential dual protrusion of the distal end of VP shunt in the same patient makes it a very uncommon case attracting our attention.

Descending spinal vascular axis in contact with the artery of Adamkiewicz

Mon, 15 Dec 2025 00:00:00 +0000

Objective: This study aims to determine whether the descending vascular axis distal to the Adamkiewicz loop is a continuation of the AKA or the ASA, using both morphological and statistical analyses.

Method: A cadaveric study was conducted on 15 adult male specimens. Following posterior access and removal of the spinal cord en bloc, low-pressure injections were performed into the ASA to visualize spinal vasculature. In several cases, the AKA was identifiable without injection due to its prominent calibre. Using digital callipers, morphometric measurements were obtained for the ascending branch, arch, and descending segment of the AKA, as well as the ASA segment proximal to the AKA loop.

Results: The mean diameter of the ASA was 1.0 mm (range: 0.5–1.86 mm), with 80% of specimens exhibiting a calibre under 1 mm. The ASA occupied less than 10% of the spinal cord’s ventral surface. The AKA had a mean diameter of 1.14 mm, while the descending vascular axis measured 1.69 mm on average (range: 0.8–2.1 mm). In all specimens, the AKA presented as a continuous single trunk with ascending, arching, and descending components. The descending vascular axis showed greater morphological similarity in calibre to the AKA than to the ASA.

Conclusion: Morphometric evidence suggests that the descending spinal axis beyond the AKA loop more closely resembles a continuation of the Adamkiewicz artery rather than the anterior spinal artery.

Mass lesion in cases of cerebral arteriovenous malformations post gamma knife radiosurgery or embolization

Darpan Gupta, Chinmaya Srivastava, Sudhanshu Agrawal — Mon, 15 Dec 2025 00:00:00 +0000

Background: Cerebral Arteriovenous Malformations (AVM) have been conventionally treated with surgery, embolisation and/or Gamma Knife Radiosurgery (GKRS). This article is to present a rare complication after Embolisation/ Gamma Knife Radio Surgery for Cerebral AVMs.

Method: 05 patients with cerebral AVMs presenting with an unusual complication of a mass lesion at the site of the treated lesion were treated. Two modes of index treatment were used: endovascular embolisation and/or GKRS. These patients developed new-onset neurological deficits at varying intervals after index treatment. They were investigated radiologically, revealing a mass lesion at the site of the treated AVM. The pathophysiology of this complication, along with the management algorithm, has been studied and is presented.

Results: All the patients in the series responded well to surgery. The histopathological examination revealed vascular elements in all cases without any evidence of neoplasm.

Conclusion: Delayed presentation as a mass lesion of a treated AVM is unusual. The mass lesion in cerebral arteriovenous malformations with suspicion of malignant transformation or with unresponsive raised intracranial pressure may mandate craniotomy and excision.

Neurofibromatosis type 1 associated with multiple internal and external anterior abdominal wall defects

Mon, 15 Dec 2025 00:00:00 +0000

Neurofibromatosis type 1 is a relatively common autosomal dominantly inherited genetic disorder. It is characterised by variable clinical manifestations, including café-au-lait spots, axillary or inguinal freckling, cutaneous neurofibromas, plexiform neurofibroma, bony lesions, optic glioma, and iris Lisch nodules, which constitute the clinical diagnostic criteria. In addition, a wide range of systemic abnormalities, including skeletal deformities, cardiovascular anomalies, neurocognitive deficits, as well as nervous system and non-nervous system tumours, have been described in patients with NF1. We present a previously unreported systemic association in NF 1 in an adolescent male: the presence of bilateral congenital hydrocele, divarication of rectus abdominis muscles and umbilical hernia, all external and internal defects of the anterior abdominal wall.

Calcified chronic subdural hematoma with subacute presentation

Kaushal Nayak, Shubhamitra Chaudhuri — Mon, 15 Dec 2025 00:00:00 +0000

Chronic subdural hematomas are a very common disease occurring spontaneously, following trauma, ventriculoperitoneal shunt and postcranial surgeries, with an incidence of 1.72-20.6 per 100,000 persons per year. But sometimes calcification may occur over the outer layer of membrane or within the collection, which may occur from 6 months to many years [1]. The exact aetiology and pathogenesis of calcification remains unknown; it was first reported by a Bohemian pathologist carl von Rokitansky, in 1884[2]. Due to its appearance sometimes, it’s calledan armoured brain [3] or matryoshka head after Russian nesting dolls [4]. Though limited cases have been reported majority of cases are asymptomatic, and surgical management is advocated for those having mass effect or neurological deficit. Inan article published in 2020 by Turgut et al total of 114 cases have been reported [5]. The total incidence of calcification in chronic subdural hematoma is about 02-2.7% [6]. We report a case that presented with a neurological deficit and was treated surgically with craniectomy and complete excision.

Retained knife fragment in thoracic spine following stab injury

Kushal Goyal, Sushil Acharya, Gograj Garhwal — Mon, 15 Dec 2025 00:00:00 +0000

This case report presents a rare instance of a retained knife fragment within the thoracic spine following a stab injury in a 24-year-old male. The patient presented with stable vitals and no neurological deficit despite the knife penetrating near the spinal cord at the T9–T10 level. Prompt imaging, surgical intervention, and multidisciplinary coordination resulted in complete recovery without a lasting neurological deficit. This case highlights the importance of rapid assessment and careful surgical management in preventing secondary injury.

Management of Moyamoya disease

Mon, 15 Dec 2025 00:00:00 +0000

Background: Moyamoya disease (MDD), defined by a chronic, progressive stenosis of the terminal portion of the internal carotid arteries (ICA) on both sides, carries the anomalous vascular information network, which functions as a collateral pathway to the brain. The aim is to understand the management of moyamoya disease (MMD) in terms of the approaches and different types of arterial revascularisations (direct, indirect, and combined), regardless of the pathological mechanism of origin to be investigated.

Materials and methods: A review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The review focused on moyamoya disease, outcomes before and after revascularisation, and related treatment modalities (STA-MCA) in various databases, including ScienceDirect and PubMed/MEDLINE, using the PRISMA guidelines, R, and Excel. Only studies published in English up to August 2025 were included.

Results: Our systematic review included 4800 patients, comprising (N=2866, 60%), patients, (N=2024,42%), surgical interventions, and (N=2112,44%,), revascularisations. See Table 1. (N=1199, 25%), patients included (N=977, 20%), surgical approaches (N=615, 13%), and revascularisations.

Conclusion: This study has shown that moyamoya disease (MMD) is a vascular concern that, regardless of ethnicity, is very rare; cases have been reported in Europe and the United States, as well as in the Hispanic population, but none have been reported in African regions. Therefore, encountering this pathology cannot be ruled out, and one should be up-to-date on the types of revascularisations, whether STA-MCA, ACA-PCA.

Lumbar spinal stenosis associated with alkaptonuria

Tahir Yıldırım, Bilal Ertuğrul, Muhammet Çalık, Metin Kaplan — Mon, 15 Dec 2025 00:00:00 +0000

Alkaptonuria is a rare autosomal recessive metabolic disorder caused by a deficiency of the homogentisic acid oxidase enzyme. In this disease, degenerative changes occur in the intervertebral discs and connective tissue due to pigment accumulation. This report presents a 45-year-old female patient who developed multi-level lumbar spinal stenosis due to alkaptonuria and underwent surgical treatment. Clinical findings, radiological imaging, and characteristic pigment accumulation observed during surgery were discussed. In this patient with severe spinal stenosis unresponsive to conservative treatment, surgical decompression provided significant improvement in symptoms, while intraoperative black disc material and pigmented ligamentum flavum provided important clues for diagnosis. As spinal degeneration associated with alkaptonuria can be aggressive, these cases should be followed up regularly over the long term.

Clinical and radiological assessment of diffuse axonal injury in traumatic brain injury patients

Mon, 15 Dec 2025 00:00:00 +0000

Background: Diffuse Axonal Injury (DAI) is a severe form of traumatic brain injury (TBI), characterised by widespread damage to white matter tracts due to shearing forces. It is often associated with high morbidity and mortality, especially when diagnosis and management are delayed.

Objective: This study aims to evaluate the clinical, demographic, and radiological features of DAI patients and assess their treatment outcomes. Additionally, it investigates the correlation between MRI-based Adams Grading and prognosis using the Glasgow Outcome Scale (GOS).

Methods: A retrospective analysis was conducted on 30 patients diagnosed with DAI and admitted to the Department of Neurosurgery, SVP Hospital, Ahmedabad, from June 2022 to June 2024. Data collected included age, gender, mechanism of injury, initial Glasgow Coma Scale (GCS) score, MRI findings (Adams Grade), treatment modalities, and GOS scores at discharge or follow-up.

Results: DAI was most commonly observed in young adults aged 11–30 years, with road traffic accidents being the leading cause. MRI demonstrated superior diagnostic accuracy compared to CT. Adams Grading showed a strong correlation with clinical outcomes: higher grades (II and III) were associated with poorer GOS scores (1–3), while lower grades (I) had better outcomes (4–5). Early neurocritical care and timely imaging significantly influenced recovery.

Conclusion: DAI predominantly affects young individuals, primarily due to preventable trauma. MRI plays a crucial role in early diagnosis and prognostication. A multidisciplinary approach, including prompt neuro-intensive care and rehabilitation, is essential for improving outcomes in DAI patients.

Impact of coagulopathy on the management and outcome of chronic subdural hematoma

Mon, 15 Dec 2025 00:00:00 +0000

Background: Chronic subdural hematoma (CSDH) is one of the commonest conditions encountered in neurosurgical practice. It is a disease more commonly seen in the elderly, and its incidence is expected to rise as the population of persons above 65 years increases. With improving survival and an increasing ageing population, the use of antithrombotic medications to prevent and treat cardiovascular diseases appears to be on the rise. Though trauma is the leading cause of CSDH, these pharmacologic agents alter coagulation and have been associated with the rising recurrence of CSDH. There appears to be a complex relationship between CSDH and coagulopathy, which can lead to rebleeding or recurrence after surgical evacuation of the hematoma.

Aim/Objectives: To determine the relationship between the presence of coagulopathy and outcome in patients who underwent burr hole drainage of CSDH.

Methodology: This was a retrospective cohort study on all patients who underwent drainage of CSDH at the University of Benin Teaching Hospital over a 19-year period from June 2006 to May 2025. Clinical data were obtained from a computerised log of patients' records and analysed using STATA software version 12.

Results: One hundred and forty patients were studied. The male-to-female ratio was 4:1, and most patients were above 60 years (55.5%). Fifty-one per cent (51%) had coagulopathy - 10.07% were on antiplatelet medications and 0.71% were on warfarin. Seventy-two per cent (72%) of patients with coagulopathy had a history of trauma. Bilateral CSDH was found in thirty-six per cent (36%) of patients with coagulopathy. The patients who had coagulopathy had lower mean hematoma volumes, longer hospital stay, and accounted for all the patients (4) who required ICU admission. The presence of coagulopathy did not alter the rate of recurrence, reoperation, and GOS at discharge.

Conclusion: There is a high incidence of coagulopathy in patients who have CSDH, and most of them would require prompt evacuation irrespective of haematoma volume. Pre- and post-operative substitution of coagulation factors is associated with very good outcomes despite poor neurological status at presentation.