Romanian Neurosurgery

Syringomyelia resulting from aneurysmal subarachnoid haemorrhage

Alexandru Ioan Bira, Horia Ples — Fri, 15 Mar 2024 00:00:00 -0400

Syringomyelia, characterized by cystic cavitation in the spinal cord, can be primary or secondary to various conditions.[1] This article focuses on syringomyelia resulting from subarachnoid haemorrhage (SAH). A case study of a 45-year-old female with SAH is presented. Despite successful aneurysm clipping, the patient developed post-SAH syringomyelia, a rare complication occurring in less than 1% of SAH cases. [2] The pathophysiology involves arachnoiditis disrupting cerebrospinal fluid dynamics, leading to spinal cord tethering. Multiple hypotheses, including inflammatory responses and disruptions in glymphatic flow, contribute to syrinx formation.[4] Surgical options, from arachnoid lysis to various shunting procedures, aim to address progressive symptoms. The choice remains case-specific, with debates on long-term shunt efficacy. Overall, syringomyelia post-SAH poses diagnostic and therapeutic challenges, emphasizing the need for further research in understanding and managing this rare complication.

Remember: 30 years since Constantin Arseni passed away

Alexandru Vlad Ciurea, Horia Ples, Aurel Mohan, Milena-Monica Ilie, Matei Serban — Sat, 15 Mar 2025 00:00:00 -0400

Professor Constantin Arseni (1912–1994) was a Romanian neurosurgeon whose pioneering contributions established the foundation for modern neurosurgery in Romania. Widely acknowledged as the founder of Romanian neurosurgery, his legacy reflects not only exceptional clinical expertise but also visionary leadership in the development of neurosurgical training programs, the establishment of scientific societies, and substantial contributions to international neurosurgical literature. Notably, in 1982, he founded the Romanian Society of Neurosurgery (RSN), a milestone that further cemented his influence in the field. His work and enduring legacy have profoundly shaped generations of neurosurgeons, both within Romania and internationally. Over the course of his illustrious career, Arseni authored an extensive body of scientific literature, spearheaded the establishment of one of Europe’s most advanced neurosurgical departments, and played a pivotal role in advancing neurosurgical techniques and technologies.

Gemistocytic astrocytoma mimicking hypertensive haemorrhage

Sat, 15 Mar 2025 00:00:00 -0400

Gemistocytic astrocytoma is a rare variant of diffuse astrocytoma, characterized by a high proportion of gemistocytic cells, which exhibit aggressive behaviour and an increased risk of malignant transformation. Its clinical and radiological presentation can be misleading, especially when it mimics other intracerebral pathologies, such as hypertensive intracerebral haemorrhage (ICH). Differentiating between a primary hemorrhagic event and a hemorrhagic tumour remains a significant diagnostic challenge.

We report the case of a 56-year-old male with no prior medical history who presented with sudden-onset right-sided hemiparesis and severe speech disturbances. Initial neuroimaging revealed a deep intraparenchymal hematoma in the left internal capsule, and lenticular nucleus, strongly suggestive of a hypertensive hemorrhagic stroke. Despite intensive medical management, the patient’s condition deteriorated, prompting further imaging studies, which raised suspicion of an underlying neoplastic process. Subsequent MRI findings indicated features atypical for a purely hemorrhagic lesion, necessitating neurosurgical intervention for definitive diagnosis.

The patient underwent a left fronto-temporo-parietal craniotomy, during which a tumour-like mass was encountered and completely resected. Histopathological analysis confirmed the diagnosis of gemistocytic astrocytoma. Postoperatively, the patient showed gradual neurological improvement, though residual deficits persisted.

This case highlights the complexity of differentiating a gemistocytic astrocytoma from a spontaneous hypertensive haemorrhage, particularly in patients without a prior oncological history. While intracerebral haemorrhage is commonly associated with chronic hypertension, intratumoral haemorrhage remains an important differential diagnosis, especially when imaging findings suggest a mass effect, perilesional oedema, or progressive neurological deterioration despite optimal medical therapy. MRI characteristics, such as hyperintense T2-weighted and FLAIR signals, can provide critical clues, but histopathological confirmation remains the gold standard.

Gemistocytic astrocytomas, though rare, should be considered in cases of unexplained intracerebral haemorrhage, particularly when imaging findings or clinical progression are atypical. This case underscores the importance of a multidisciplinary approach involving neurology, neuroradiology, and neurosurgery to ensure timely diagnosis and appropriate management. A high index of suspicion is crucial to prevent delays in the recognition and treatment of hemorrhagic brain tumours, which can significantly impact patient outcomes.

Three decades of colloid cyst resection

William Mirfin-Boukouris , Mustafa Dashti, Ahmed Aly, Viswapathi Kandula — Sat, 15 Mar 2025 00:00:00 -0400

Purpose: To analyze 59 colloid cyst resections over 30 years at a single institution.

Methods: Retrospective review of electronic health records, including surgical approaches: transcortical (18), transcallosal (36), and endoscopic (5).

Results: Mean age at resection: 45.8 years. Cyst diameter: 4-27mm. Headache was the primary symptom (57.6%). Complications included memory deficits, infection, and neurological deficits; no mortality. Most cases were high-risk per Colloid Cyst Risk Score. Histology revealed pseudostratified epithelium (35%) and unique eosinophils. Craniotomy rate: 93%. Endoscopy had the highest reoperation rate; the transcallosal approach had more seizures and infections. Post-operative short-term memory issues: 40% (craniotomy), 50% (endoscopy).

Conclusions: Findings largely align with literature, with notable differences in headache prevalence, gender ratio, histology, and endoscopy outcomes.

This version reduces the word count by about 40% while retaining the essential information from each section. It maintains the structure and key points of the original abstract, allowing readers to quickly grasp the study's scope, methods, main findings, and conclusions.

Carpal Tunnel syndrome surgery

Sat, 15 Mar 2025 00:00:00 -0400

Carpal Tunnel Syndrome (CTS) is the most common peripheral nerve entrapment neuropathy, caused by compression of the median nerve at the wrist. It leads to hand pain, numbness, tingling, and weakness, often affecting the thumb, index, middle, and ring fingers. CTS frequently requires surgical treatment (carpal tunnel release) when symptoms are moderate to severe or unresponsive to conservative measures.

We analyzed a cohort of 442 CTS patients treated surgically over the last 10 years at the County Clinical Emergency Hospital of Sibiu (312 women, 130 men; 308 urban residents, 134 rural; average age 59 years) and compared the outcomes and characteristics with findings from the literature. This report examines risk factors and comorbidities associated with CTS, surgical outcome metrics (recurrence, failure, complications), bilateral involvement patterns, laterality, urban-rural differences, and occupational contributions, supported by recent studies.

A case report of a large gluteal schwannoma with pelvic extension

Sat, 15 Mar 2025 00:00:00 -0400

Benign schwannomas are slow-growing, painless tumours originating from Schwann cells, which form the sheaths of peripheral nerves. These tumours are relatively rare, with an incidence of 1-3 cases per 100,000 individuals annually. While they are most commonly found in the head, neck, and spine, schwannomas can also occur in the extremities, particularly in the upper limbs. Tumours in the pelvis and gluteal region are less frequent but are clinically significant due to their potential to compress adjacent structures.

We present a case of a 74-year-old male patient who underwent surgery for a large schwannoma in the gluteal region, extending into the pelvis at the level of the piriformis muscle and sciatic foramen. Initially misdiagnosed and treated as sciatica, this case highlights the importance of considering schwannomas in the differential diagnosis of patients presenting with neurological symptoms in unusual locations. Sciatic symptoms that do not respond to conservative treatment should be further investigated, and a thorough palpation of tender and painful points should always be performed to aid in the potential diagnosis of a local soft tissue tumour.

Brown spinal tumour secondary to primary hyperparathyroidism, a primary entity that we should not forget

Sat, 15 Mar 2025 00:00:00 -0400

Introduction: A thorough study of lytic lesions can guide us toward a more accurate aetiology in spinal column lesions. The use of imaging techniques and blood chemistry studies is useful when considering brown tumours as part of the differential diagnosis.

Clinical Case: A 43-year-old woman with multiple comorbidities presented with lumbar pain. A lytic lesion in the body of S2 was documented, and thoracoabdominal lesions were initially ruled out. However, during her stay, a malignant thyroid lesion was documented.

Discussion: Hyperparathyroidism, whether primary (adenomas, hyperplasia, or carcinoma) or secondary (vitamin D deficiency or chronic kidney disease), causes skeletal alterations in approximately 16% of cases. Among its manifestations are parathyroid tumours, which primarily affect the pelvis, rib arches, facial bones, and long bones, with less frequency in the spine. Clinically, these present progressive pain and neurological deficits. Diagnosis requires paraclinical tests and imaging studies. Treatment should address the underlying cause of hyperparathyroidism, with options ranging from medical therapies to surgical interventions.

Conclusion: Thyroid carcinoma as a manifestation of a brown tumour at the sacral level is a rare presentation. We consider it pertinent to perform extension studies when evaluating patients with multiple comorbidities and a single lytic lesion.

Symptomatic relief of pain following percutaneous vertebroplasty compared to conservative management in patients with osteoporotic vertebral compression fractures

Pradhumna Kumar Yadav, Ahtesham Khizar, Bushra Tariq Ali , Hammad Mehtab — Sat, 15 Mar 2025 00:00:00 -0400

Objectives: To determine the efficacy of percutaneous vertebroplasty in pain management over conservative management in patients with osteoporotic vertebral compression fractures.

Materials and Methods: A prospective cohort study was conducted from 13^th December 2018 to 12^th December 2019 at PIMS/SZABMU, Islamabad, Pakistan. A total of 76 patients (Aged: 35-75 years) of both genders having osteoporotic vertebral compression fractures involving a maximum of two vertebrae were enrolled. Patients were divided equally into two groups. One group was managed surgically through vertebroplasty (Group A) and the other group was managed conservatively (Group B). All the patients were asked about the intensity of pain, assessed by Visual Analogue Scale (VAS) score at the presentation and after 24 hours, 3^rd and 6^th week of given treatment and compared using independent sample t-test in both groups. Complications were also assessed and compared in both groups.

Results: In group A, dorsal vertebrae were involved in 23.7%, lumbar vertebrae in 68.4% and dorsal/lumbar vertebrae in 7.9% of cases. In group B, dorsal vertebrae were involved in 21.1%, lumbar vertebrae in 60.5% and dorsal/lumbar vertebrae in 18.4% of cases. At baseline, mean VAS was 8.01 ± 0.99 in group A and it was 8.35 ± 0.75 in group B. At 24 hours after the intervention, mean VAS was 4.37 ± 0.79 in group A and it was 7.29 ± 1.21 in group B. At 3 weeks after the intervention, mean VAS was 4.03 ± 0.85 in group A and it was 6.37 ± 0.91 in group B and at 6 weeks after the intervention, mean VAS was 3.87 ± 1.09 in group A and it was 5.37 ± 0.97 in group B. The overall complication rate was 10.5% at 24 hours in group A and it was 5.3% in group B. At 3 weeks, the complication rate was 5.3% in group A and it was 28.9% in group B. At 6 weeks, the complication rate was 21.1% in group A and it was 55.3% in group B patients.

Conclusion: Mean VAS score was found to be significantly lower in patients who underwent vertebroplasty as compared to those managed conservatively. Overall complication rate was similar in both groups at 24 hours, however, it was significantly lower at 3^rd and 6^th weeks in patients who underwent vertebroplasty as compared to those managed conservatively.

Outcome of endovascular treatment of giant aneurysm

Rahul Singh, Surendra Jain, Ashok Gandhi, Suresh Kumar Choudhary, Hariom Meena — Sat, 15 Mar 2025 00:00:00 -0400

Introduction: Very large and giant aneurysms are among the most challenging cerebrovascular pathologies in neurosurgery. The risk of aneurysmal rupture compounds with an increase in the size of the aneurysm thus warranting appropriate intervention.

Objective: To analyze the outcome of endovascular treatment of giant aneurysm.

Materials and Methods: A retrospective study was conducted at the Department of Neurosurgery. 35 cases were selected from the database with radiological diagnoses of giant aneurysm referred to our departments from 2016 to 2023.

Results: The patients mainly belonged to >60 years age group (37.14%) and had a mean age of 49 years, with a slight female preponderance (57.14%). Aneurysms were mainly located in patients who had left internal carotid artery (ICA) supraclinoid aneurysms (14.29%) and right middle carotid artery (MCA) bifurcation aneurysms (14.29%). The patients predominantly underwent simple coiling (45.7%) and stent-assisted coiling (42.8%). Of 35 patients, 2 (5.7%) died. The recurrence was higher in posterior circulation aneurysms with, 75% in basilar top aneurysms (3 out of 4 cases), 50% in posterior communicating artery aneurysms (one out of 2 cases), 37.9% in remaining cases (11 out of 29 patients).

Conclusion: Giant aneurysm is associated with reasonably high morbidity and mortality. The aneurysms are found most often in the anterior circulation, while the recurrence is mainly observed in the posterior circulation have more chances of recurrence. However, favourable outcome was frequently observed (94.3%).

Spontaneous extradural hematoma in sickle cell anaemia-a stroke mimic

Sat, 15 Mar 2025 00:00:00 -0400

In the absence of trauma, extradural hematoma is rarely considered a cause of hemiplegia in a sickle cell disease patient, rather a cerebrovascular accident, as this occurs in about a quarter of sickle cell disease patients. We report two sickle cell anaemia patients who were initially diagnosed as cases of stroke having presented with hemiplegia/hemiparesis without a prior history of trauma to the head. Cranial computed tomographic scans however revealed extradural hematomas and both of them underwent surgical evacuation of the hematomas with subsequent neurologic recovery.

Sagittal alignment in lumbar spinal canal stenosis

Sat, 15 Mar 2025 00:00:00 -0400

Objective: To evaluate the impact of lumbar canal stenosis on the sagittal balance of patients by studying the parameters of sagittal alignment.

Methods: This single-centre prospective study, conducted from January 2020 to January 2022, included 47 patients presenting with lumbar canal stenosis confirmed by MRI and documented spinal balance assessed by full spine X-ray in standing profile. Patients with lumbo-radicular pain post-lumbar arthrodesis surgery were also included. The sagittal alignment parameters assessed were pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), L4-S1 lordosis (LL4-S1), PI-LL mismatch, thoracic kyphosis (TK), sagittal vertical axis (SVA), and TPA.

Results: The mean pelvic incidence (PI) was 60.97° (SD 13.93°), with Class IV incidence in 36.2% of cases. Pelvic tilt (PT) averaged 18.65° (SD 10.91°), with values <10° in 19%, 10-25° in 53%, and >25° in 28% of patients. Sacral slope (SS) was 42.87° (SD 8.49°), with 53.2% in the 35-45° range. The measured lumbar lordosis (LL) was 46.10° (SD 17.84°), significantly lower than the theoretical LL (p=0.001). L4-S1 lordosis averaged 38.85° (SD 15.34°), also less than the theoretical value (p=0.017). PI-LL mismatch >10° was present in 60% of cases. Thoracic kyphosis (TK) averaged 14.57° (SD 11.29°), and sagittal vertical axis (SVA) was >5 cm in 81% of patients. T1 pelvic angle (TPA) was <20° in 57.4%.

Conclusion: The analysis revealed that lumbar canal stenosis significantly affected spinal architecture, primarily through the loss of lumbar lordosis, and had a notable impact on thoracic kyphosis. Therapeutic approaches should not only focus on root decompression but also on restoring lumbar lordosis, with careful consideration of the arthrodesis level.

Carcinoma metastasis mimicking meningioma

Marcel Sincari, Margarida Conceição, Mark-Daniel Sincari — Sat, 15 Mar 2025 00:00:00 -0400

The scientific approach to dural metastases mimicking meningiomas holds significant relevance, as these cases pose considerable challenges to clinicians in routine practice. Differentiating between these two distinct pathologies is critical, particularly when conservative management is considered for patients diagnosed with non-surgical meningiomas. Misdiagnosis in such scenarios can lead to detrimental outcomes for the patient, underscoring the need for vigilant follow-up in cases exhibiting suspicious imaging patterns.

While biopsy could provide definitive diagnosis in uncertain cases, it is often avoided due to its inherent risks, especially in elderly patients and in cases where the meningiomas are located in surgically challenging regions. Consequently, most conservatively managed cases are presumed to be typical meningiomas, and invasive diagnostic measures are typically not pursued unless absolutely necessary [1].

However, carcinomas from various primary sites including the breast, prostate, gallbladder, larynx, and less commonly, Ewing’s sarcoma or melanoma can rarely present as dural metastases, especially in the parasagittal convexity [2,3,4]. These metastases can closely mimic meningiomas both clinically and radiologically. A study of 1,000 meningioma cases diagnosed between 2004 and 2010 revealed that 20 (2%) were ultimately found to mimic, with histological diagnoses including gliosarcoma, Rosai-Dorfman disease, hemangiopericytoma, osteosarcoma, medulloblastoma, adenocarcinoma, and nonseminomatous germ cell tumours [5].

Among these, adenocarcinomas are the most common metastatic tumours mimicking meningiomas. These lesions, like meningiomas, exhibit attachment to the dura, a dural tail, and contrast enhancement [6]. Such imaging characteristics can make distinguishing metastatic tumors from meningiomas exceedingly difficult using standard neuroimaging techniques [7,8]. Even intraoperatively, dural metastases can appear identical to meningiomas, complicating diagnosis further [4]. Both conditions may share features such as a solid structure, limited diffusion of water molecules, extensive peritumoral edema, and similar contrast enhancement patterns [9].

The pathways for metastatic spread include arterial and venous routes, particularly via Batson’s venous plexus [10]. Cases of cerebrospinal fluid (CSF) dissemination have not been described.

This report describes three cases of dural metastases mimicking meningiomas, with locations including the temporal region, the cavernous sinus, and the cervicothoracic dura.

Sellar space-occupying lesion: not always a pituitary tumour!

Sharad Pandey, Monica N, Nirupma P. Khan, Anurag Anand — Sat, 15 Mar 2025 00:00:00 -0400

Background and objective: Hypophysitis is an inflammatory disease of the pituitary gland that is clinically and radiologically similar to pituitary tumours. We are reporting a case of xanthogranulomatous hypophysitis which was confused as a pituitary neoplasm preoperatively.

Materials and methods: A 56-year-old woman presented with extreme tiredness and visual disturbances for 4 months and had visited multiple doctors for the same. NCCT head and CEMRI done preoperatively were suggestive of sellar SOL. The patient was optimised preoperatively and underwent trans-nasal transsphenoidal surgery was performed. Histologic examination of the tissue was s/o xanthogranulomatous hypophisitis

Conclusion: We have described an unusual inflammatory lesion of the pituitary in the sellar region that was mimicking neoplasm. A high level of clinical suspicion and knowledge regarding the differential diagnosis of the sellar region is necessary for correct diagnosis and management.

Key message: All the sellar space occupying lesions are not always pituitary adenomas. Rare entities like xa thogranulomatous hypophisitis should be thought of when we encounter patients with hypocortisolism.

A rare case of cerebral astroblastoma

Binoy Singh, Tamajyoti Ghosh, Biswajit Dey — Sat, 15 Mar 2025 00:00:00 -0400

Cerebral Astroblastomas are rare central nervous system tumours constituting 0.45-2.8% of neuroglial tumours Recent 2021 WHO classification of Brain tumours has described Astroblastoma as “other neuroepithelial tumours” with MN1 rearrangement. Because of its rare entity and indistinctive radiological and pathological features diagnosis and further management continue to remain a challenge. Ependymoma and angiocentric glioma are the most important differential diagnoses of Astroblastoma and at times pre-operative differentiation is challenging. Here we discuss the case of a 22-year-old female with features of headache and vomiting. Histopathological examination revealed Cerebral Astroblastoma MN1 altered. Post-operative imaging suggested gross total resection of the tumour and the patient was subjected to radiotherapy of 54Gy in the tumour bed. 1-year followup of the patient showed no recurrence

Cranioplasty: autologous bone graft vs. titanium mesh

Binit Kedia, Kritesh Goel, Krishna Govind Lodha, Gaurav Jaiswal — Sat, 15 Mar 2025 00:00:00 -0400

Background: Cranioplasty (CP) is a neurosurgical procedure performed after decompressive craniectomy using autologous bone graft or various artificial materials.

Objective: To determine differences in complications between patients who underwent CP using an autologous bone flap versus titanium mesh and to identify significant risk factors for post-CP complications.

Study design: Comparative cross-sectional study.

Methods: A total of 38 patients, 29 males (76.4%) and 9 females (23.6%), were included in this study. All patients underwent cranioplasty with titanium mesh or autologous bone graft.

Results: The results were compared between autografts and titanium implants. Autologous bone graft was used in 76.3% of the patients and titanium implant was used in 23.7%. Different complications occurred in 5.26% of the patients in both groups, 2.63% in the autologous group and 2.63% in the titanium mesh group respectively. Infection occurred in the surgical site in 5.26% of the patients in both groups (similar). Cranioplasty infection occurred in 2.63% of the patients who underwent autologous transplantation. One patient developed a hematoma in both groups. One patient underwent autologous bone graft removal, and one patient underwent mesh removal.

Practical implication: Titanium mesh cranioplasty is an essential procedure for junior neurosurgeons to learn and achieve good results, shorten hospital stays, and save hospital resources.

Conclusion: Titanium mesh cranioplasty has similar complications to autologous bone cranioplasty.

Management of intracranial lesions during pregnancy

Reeka Pradhan , Rajendra Shrestha — Sat, 15 Mar 2025 00:00:00 -0400

Introduction. Intracranial lesions during pregnancy are very rare conditions in obstetrical and neurosurgical practice. There is no precise protocol for the management of intracranial lesions during pregnancy yet. The aim of this study was to elaborate on pregnant patients with intracranial pathology in order to achieve better outcomes in the future.

Methods. This is a descriptive cross-sectional study conducted among patients presented with intracranial lesions at the Department of Neurosurgery at the National Academy of Medical Science, Bir Hospital. The data was collected. retrospectively from hospital data thirty patients with intracranial lesions during pregnancy from 2015 to 2024. We analyzed the treatment decisions and obstetrical and neurosurgical outcomes. All patients were evaluated with either computed tomography, magnetic resonance imaging, or both.

Results. Among the admitted patients, the youngest patient was 20 years and the oldest was 42 years, of which 2, 13 and 15 patients were diagnosed in the first, second and third trimesters, respectively. The distribution of neurosurgical problems was as follows: subarachnoid haemorrhage (SAH) n=6, cerebral venous thrombosis (CVT) n=6, brain tumour n=5, trauma n=6, Intracranial haemorrhage (ICH) n=2, VP shunt n=2, tuberculoma n=1, neurocysticercosis n=1, and pituitary adenoma n=1. Fifteen patients (50%) underwent brain operation, eleven patients (36%) had conservative therapy, one patient died and four patients were terminated during pregnancy.

Conclusion. Multidisciplinary teams are not only required to successfully diagnose and treat intracranial lesions but also to safeguard both the mother and child.

Giant sacral schwannoma mimicking teratoma

Sat, 15 Mar 2025 00:00:00 -0400

Background: Sacral schwannomas are uncommon, constituting 1-5% of schwannomas. They present with vague symptoms. Schwannomas occurring in sacral and presacral regions present with enormous dimensions and are difficult to manage.

Case summary: We present a case of schwannoma occurring in the sacral region extending into the presacral region in a 45-year-old female which was diagnosed as teratoma on imageology. The lesion was excised and on histopathological examination, diagnosis of schwannoma was considered

Conclusion: Sacral schwannoma with cystic degeneration should be considered as a differential diagnosis for solid and cystic lesions of the sacral region. MRI and CT scanning will be helpful in diagnosis.