Romanian Neurosurgery 2021-03-09T21:29:11-05:00 Editor Open Journal Systems <p>Call for Papers - Vol. XXXV, No. 2 (June 2021)<br />Submission Deadline: May 1, 2021</p> On thin ice 2021-03-08T07:18:04-05:00 Ioan Alexandru Florian Teodora Larisa Timis Lehel Beni Larisa Serban Ioan Stefan Florian Adrian Bălașa Ioana Berindan-Neagoe <p><strong>Introduction</strong>. Brain vascular malformations (BVMs) are congenital lesions with evolutive properties that possess a considerable chance of causing intracranial haemorrhage. The most common types are arteriovenous malformations (AVMs), aberrant entanglements of deformed vessels that shunt blood from the arteries directly into the veins, and cavernous malformations (CMs), being mulberry-shaped sinusoid spaces filled with blood. The rate of hemorrhagic stroke varies between these two types of lesions, being the most common form of symptomatic presentation for AVMs, but a much rarer occurrence for CMs. The purpose of our pilot study was to test whether the incidence of intracranial haemorrhage from BVMs varies between seasons, as well as examining a possible causality for this event.</p> <p><strong>Material and methods</strong>. We performed a retrospective analysis on the cases of ruptured BVMs of the brain operated by the senior surgeon in our department between January 2008 and December 2019. We then divided the patients according to the type of lesion and gender, based on the month of the year when their pathologies caused the hemorrhagic stroke. We performed Pearson’s chi-square test to verify the&nbsp;relationship between season and rate of rupture of AVMs and CMs, individual month and rate of rupture, season and gender, and individual month and gender.</p> <p><strong>Results</strong>. There were 87 ruptured vascular malformations, out of which 71 were AVMs and 16 were CMs. There were 51 males (40 AVMs, 11 CMs) and 36 females (31 AVMs, 5 CMs). The majority of hemorrhagic strokes occurred in the months of July (10 AVVMs, 2 CMs) and December (10 AVMs, 1 CM). We obtained a statistically significant correlation between the summer season and presentation with ruptured cavernous malformation, as well as the male sex and presentation with a ruptured AVM in December, whereas the female sex presented a correlation with ruptured AVMs in the month of March. We also obtained a correlation between the male sex and presenting with a ruptured vascular malformation of any kind in December, as well as the female gender and hemorrhagic stroke from any vascular malformation in the months of January and August.</p> <p><strong>Conclusion</strong>. Despite promising statistical results, the relatively low number of cases may not be applicable to a larger patient population. It seems probable that meteorological conditions, especially extreme temperatures, might act as an additional risk factor for hemorrhagic stroke from vascular malformations, however, these findings should be corroborated with supplementary case series from other centres or a large prospective trial.</p> 2021-03-09T00:00:00-05:00 Copyright (c) 2021 Navigated transcranial magnetic stimulation mapping in patients with language-eloquent brain lesions 2021-03-08T06:00:13-05:00 George E. D. Petrescu Roxana Radu Andrei Giovani Cristina Gorgan Felix M. Brehar Radu M. Gorgan <p><strong>Introduction:</strong> The surgical resection of brain lesions located in language-eloquent areas harbours a great risk for determining new functional deficits. Navigated transcranial magnetic stimulation represents a novel non-invasive cortical mapping method that can be used preoperative to determine language-eloquent areas.</p> <p><strong>Materials and methods: </strong>We retrospectively reviewed a prospectively maintained database of patients that underwent preoperative cortical mapping using nTMS between March 2017 and June 2020. Patients older than 18 years old with brain lesions situated in a presumed language eloquent area, that underwent surgical resection of the brain lesion were included in the study. Various parameters such as error rate, number of language-negative sites were assessed.</p> <p><strong>Results: </strong>Fourteen patients were included in the study. There were 10 males and 4 females in total. Most of the tumours were in the temporal and frontal lobes (five and four cases, respectively). The histopathological diagnosis was glioblastoma in seven cases, in one case there was an anaplastic astrocytoma and there were two cases of low-grade gliomas. There were three cases of brain metastasis and one cavernoma. The median (range) tumor volume was 25.01 cm<sup>3 </sup>(0.89 – 86.55 cm<sup>3</sup>). Gross-total resection (GTR) was achieved in seven cases. The error rate was significantly higher in patients that continued to have an impaired language function after surgical resection (p = 0.016), while the perilesional error rate was higher in patients with preoperative aphasia (p = 0.019).</p> <p><strong>Conclusion: </strong>Our findings suggest that a lower tumour volume to perilesional negative stimuli ratio is associated with an extended surgical resection of brain tumours located in language-eloquent areas and that patients that presented with aphasia and have a high error rate have a worse functional prognosis. Through nTMS preoperative cortical mapping of language-eloquent areas, the neurosurgeon has more insight regarding the cortical function and can maximize the surgical resection, while avoiding the onset of new functional deficits.</p> 2021-03-09T00:00:00-05:00 Copyright (c) 2021 Romanian Neurosurgery Odontogen frontoparial epidural and subdural empyema complicated with frontal intracerebral abscess and Covid 2021-03-08T11:18:30-05:00 D. Balasa A. Tunas A.V. Stan <p><strong>Introduction: </strong>Cerebral infections (frontoparietal extradural and subdural empyema) following a dental abscess and multiple sinusitis is a rare and potentially devastating entity even in the era of modern diagnosis and treatment.</p> <p><strong>Case presentation: </strong>We present a patient with parietal epidural and subdural empyema and intracerebral frontal abscess, sinusitis and dental abscess, chronic consumer of alcohol and with neglected diabetes mellitus. He was initially diagnosed with encapsulated hematoma and sinusitis. The pus obtained at the intervention was certified by our laboratory as sterile with the consequent difficulty in antibiotic treatment and who induced a longer antibiotic treatment, a second surgical intervention for an encapsulated frontal abscess, a longer hospitalisation and favoured contamination with Covid 19. Despite these, the patient had a finally good evolution.</p> <p><strong>Conclusions: </strong>A frontoparietal extradural and subdural empyema and an intracerebral frontal abscess produced by a dental abscess and sinusitis is a rare and potentially lethal complication. The multidisciplinary approach between radiologist, neurosurgeon, otolaryngologist, dentist, microbiologists is mandatory for a proper diagnosis and treatment of these pathologies.</p> 2021-03-09T00:00:00-05:00 Copyright (c) 2021 Management of a double basilar tip aneurysm 2021-03-08T12:16:36-05:00 A. Chiriac N. Dobrin Georgiana Ion I. Poeata <p>Complex basilar tip aneurysms are still challenging to secure with coils or stent-assisted coiling. Double aneurysms at the basilar bifurcation and the basilar artery-superior cerebellar artery are a rare particular situation that usually requires more appropriate treatment. This case reports details of our experience with a double basilar tip aneurysm treated in two steps by coiling repair and stent-assisted coiling.</p> 2021-03-09T00:00:00-05:00 Copyright (c) 2021 The impact and causes of negative cortical mapping in primary motor area tumours 2021-03-08T17:51:49-05:00 Mihaela Coșman Bogdan Florin Iliescu Anca Sava Gabriela Florența Dumitrecu Ion Poeata <p><strong>Introduction:</strong> Intraoperative neurophysiological monitoring is the golden standard for lesions located in eloquent areas of the brain. On the one hand, positive mapping offers a view of the relationship between the anatomo-functional cortical organisation of the patient and the lesion, facilitating the choice of the cerebrotomy entry point and the resection until the functional borders are found. On the other hand, negative mapping does not offer certainty that the absence of the motor response, from the operative field, is the real feedback or is the result of the false-negative response. In such a situation, a differentiation between those two must be done.</p> <p><strong>Materials and methods: </strong>We evaluated the results of direct cortical stimulation of lesion located in or near the primary motor area, which were diagnosticated with contrast-enhancement head MRI and admitted to the Third Department of Neurosurgery, "Prof. Dr N. Oblu” Emergency Clinical Hospital, Iasi, Romania, between January 2014 and July 2018. Special attention was given especially to the negative mapping cases, regarding the histological type, imagistic localisation, symptoms and neurological outcome immediate postoperative, at 6 months and one-year follow-up.</p> <p><strong>Results: </strong>From all 66 patients meeting the inclusion and exclusion criteria in 9,09% (6 cases) we did not obtain any motor response after direct cortical stimulation. The imagistic localisations of those cases were: 3 – Rolandic, 2 – pre-Rolandic and one retro-Rolandic. Tumors histological types were: glioblastoma, anaplastic astrocytoma, oligoastrocytoma and oligodendroglioma each one case and two cases of fibrillary astrocytoma. The intensity range was between 6 – 18mA, the mode – 12mA and the median – 10mA. Postoperatively the neurological condition of 3 patients worsened (4,54% from all the cases), while 3 had a favourable evolution with symptom remission. At 6monts and one-year follow-up in one case (1,51%), we observed no improvement in contrast with the other two, where dysfunction remission was highlighted.</p> <p><strong>Conclusion: </strong>The possible technical, surgical and anesthesiologic causes of false-negative motor response must be eliminated to be able to differentiate from the real absence of the functional area from the operative field. In the first scenario, the resection may be associated with permanent postoperative neurologic deficit and major life quality alteration while in the second one the patient presents no motor dysfunction after surgery and the resection may be extensive with multiple oncological benefits.</p> 2021-03-09T00:00:00-05:00 Copyright (c) 2021 Single-session treatment of bilateral, tandem, internal carotid artery aneurysms with pipeline flex with shield technology 2021-03-08T18:39:02-05:00 Rares Cristian Filep Lucian Marginean Andrei Florin Bloj Istvan Szikora <p>The treatment of intracranial aneurysms (IA) has been transformed by the development of flow-diversion (FD) devices. Initially, these revolutionary devices were conceived for giant and fusiform aneurysms located on the internal carotid artery (ICA). Technological improvements have expanded their indications. Distal middle cerebral, anterior cerebral artery aneurysms, or even posterior fossa aneurysms can now benefit from this technology. One other category of aneurysms that can be treated is multiple IA’s.</p> <p>Multiple IA’s are encountered in approximately one-quarter of patients presenting with subarachnoid haemorrhage. Endovascular management of such cases is complex, requiring different devices and treatment strategies to secure all lesions. FD’s can be successfully employed to reconstruct vessels, which harbour more than one aneurysm, especially multiple ICA lesions. Multiple aneurysms located on both ICA’s are generically known as tandem aneurysms.</p> <p>We present the case of a patient with tandem aneurysms located on both intracranial internal carotid arteries that we treated simultaneously with the Pipeline Flex with Shield Technology in one single session. To the best of our knowledge, this is the first case reported in the literature so far.</p> 2021-03-09T00:00:00-05:00 Copyright (c) 2021 The evolution of eloquent located low-grade gliomas surgical approaches, their natural history and molecular classification 2021-03-08T20:41:48-05:00 Mihaela Coșman Andrei Ionuț Cucu Alin Constantin Iordache Bogdan Florin Iliescu Gabriela Florența Dumitrecu Dana Mihaela Turliuc <p>Low-grade glioma is characterized by slow growth, infiltrative pattern through white matter tracts and progression to a malignant tumour type. The traditional classification is newly replaced by molecular stratification. This reorganisation gathers glioma with similar prognosis and treatment protocols. The preferential location of that tumour in eloquent areas constituted, over time, a real challenge regarding the best surgical approach. Because of the high risk of postoperative neurological deficits initially a more conservative management was adopted. Once with the development of preoperative and intraoperative functional assessment techniques, a higher degree of resection was possible in the limits of cortico-subcortical eloquence, being well known that this is a statistically significant factor for survival. We present in this paper the natural evolution of low-grade glioma, their new molecular classification, prognostic factors and the various approach proposed for eloquent ones.</p> 2021-03-09T00:00:00-05:00 Copyright (c) 2021 Spontaneous intracerebral haemorrhage as an initial presentation of a choriocarcinoma 2021-03-08T21:33:44-05:00 Maher Khashea Mustafa Wamedh E. Matti Hussain J. Kadhum Zahraa A. Alsubaihawi Zahraa M. Kareem Zahraa F. Al-Sharshahi Samer S. Hoz <p><strong>Introduction:&nbsp;</strong>Choriocarcinoma is a rare gestational trophoblastic neoplasm with a high risk of pulmonary, hepatic, and, rarely, cerebral metastasis. We report a rare case of intracerebral haemorrhage as an initial manifestation of metastatic choriocarcinoma.&nbsp;</p> <p><strong>Case presentation:&nbsp;</strong>A 33-year-old female with a history of multiple abortions, ectopic pregnancy, and complete hydatidiform mole presented with a disturbed level of consciousness. Emergency brain computed tomography (CT) scan revealed an intraventricular haemorrhage (IVH) and a left frontoparietal, non-traumatic intracerebral haemorrhage (ICH) with a significant midline shift. The patient underwent emergency evacuation of the hematoma and histological evaluation revealed choriocarcinoma. Later investigations revealed evidence of systemic metastasis. The patient underwent chemoradiotherapy and recovered well.&nbsp;</p> <p><strong>Conclusion:&nbsp;</strong>Metastatic choriocarcinoma should always be in the differential of non-traumatic intracerebral haemorrhage in a female child-bearing age. Also, the pathological diagnosis should always be performed in cases of ICH of an unknown source.&nbsp; &nbsp; &nbsp; &nbsp; <strong>&nbsp;</strong></p> 2021-03-09T00:00:00-05:00 Copyright (c) 2021 rCBV and ADC based grading of gliomas with glimpse into radiogenomics 2021-03-09T05:00:45-05:00 Seema Rohilla Ambresh R. Deodurg Pritviraj S. Kanakavvanavar Ishwar Singh Veena Gupta Dhara B. Dhaulakhandi <p><strong>Purpose. </strong>The present study was carried out to study the role of relative cerebral blood volume (rCBV), apparent diffusion coefficient (ADC) and MR spectroscopy in grading gliomas to help the surgeon plan the approach and extent of surgery as well as judge the need for any adjuvant radio/chemotherapy.</p> <p><strong>Methods. </strong>65 patients with glioma were prospectively studied with MRI. Basic MR sequences (T1W, T2W, T2W/FLAIR) were followed by diffusion-weighted (DW) imaging with b value of 1000 (minimum ADC values used for analysis). Then the patients were administered Gadobenate Dimeglumine/ Meglumine Gadoterate in a dose of 0.1mmol/kg at a rate of 4ml/sec after which 20ml of saline was flushed at a rate of 4ml/sec and&nbsp; T2*W/FFE dynamic images were acquired; dynamics showing maximum fall in the intensity were used for creating rCBV and rCBF maps and calculating rCBV. Single voxel spectroscopy (SVC) was done using the PRESS sequence with intermediate TE of 144ms. NAA/Cr, Cho/Cr, Cho/NAA, Cho+Cr/NAA and NAA/Crn ratios (NAA from the tumour, Crn from the normal side) were calculated.</p> <p><strong>Results. </strong>Grade I gliomas showed minimum ADC&gt;0.84x10<sup>-3</sup>mm<sup>2</sup>/s and maximum rCBV&lt;1.9ml/100gm, grade II gliomas showed min ADC 0.75-0.84x10<sup>-3</sup>mm<sup>2</sup>/s and max rCBV of 1.9-2.6ml/100gm, grade III had min ADC of 0.70-0.75x10<sup>-3</sup>mm<sup>2</sup>/s and max rCBV of 2.7-3.0ml/100gm, while grade IV tumors showed min ADC&lt;0.70x10<sup>-3</sup>mm<sup>2</sup>/s and max rCBV&gt;3.0ml/100gm. rCBV values were better than ADC values in differentiating grade I from II and grade II from III. The ADC values were better than rCBV values in differentiating grade III from grade IV.</p> <p><strong>Conclusions. </strong>Both minimum ADC and maximum rCBV within the tumour were significant but these parameters within peritumoral oedema were not significant in grading gliomas. Though lipid and lactate (especially lipid) peaks were found more frequently in higher-grade tumours, various spectroscopy parameters were not significant in grading gliomas. Preoperative grading of gliomas with the help of advanced MR parameters like ADC and rCBV can help the surgeon plan the approach and extent of surgery as well as judge the need for any adjuvant radio/chemotherapy. Advancing radio-genomic and radiomic technologies can supplement the current radiologic methods of diagnosis and prognosis.&nbsp;&nbsp;</p> 2021-03-09T00:00:00-05:00 Copyright (c) 2021 Volumetric threshold of pituitary macroadenoma as a predictor to visual impairment 2021-03-09T11:54:51-05:00 Mohamed Elsherbini Mahmoud Saad Mohamed Deniwar <p><strong>Purpose</strong>: In this study, we aimed at correlating the curve of visual impairment against pituitary macroadenoma size.</p> <p><strong>Method</strong>: In this study, we retrospectively analyzed the visual correlation between the volume and dimensions of pituitary adenoma and the degree of visual impairment on patients’ examination. 35 patients with no history of eye or refraction disorder were included in the study. Spearman correlation test was used to validate the correlation.</p> <p><strong>Results</strong>: 57 % of pituitary macroadenoma patients suffer from visual impairment, even if not the primary presentation. Macroadenomas greater than 5 cm³ in volume and/or 2 cm height are more likely to cause various degrees of visual impairment, this correlation is not linear beyond these values.</p> <p><strong>Conclusion</strong>: Visual impairment due to pituitary adenomas is more frequent than the presentation, the threshold volume is 5 cm³ and height is 2 cm, bigger adenomas behaviour is more multifactorial than the only size.</p> 2021-03-09T00:00:00-05:00 Copyright (c) 2021 Primary multiple cerebral hydatid disease in a young patient with surgically-treated intracerebral haemorrhage 2021-03-09T12:32:44-05:00 Anwar N. Hafedh Awfa A. Aktham Zahraa F. Al-Sharshahi Ahmed Ibrahim Al-Jorani Sama Albairamani Zahraa A. Alsubaihawi Aktham O. Al-Khafaji Samer S. Hoz <p><strong>Introduction</strong>:&nbsp;&nbsp;Cerebral hydatid disease (CHD) is rare and the multiple-cystic variety is even rarer. In this paper, we report a case of multiple CHD and explore a possible link with a preceding spontaneous intracerebral haemorrhage (ICH).&nbsp;&nbsp;</p> <p><strong>Case presentation</strong>: A 27-year old gentleman with a history of surgically-evacuated, spontaneous ICH presented with severe headache, left-sided weakness - Medical Research Council (MRC) grade II - and recurrent tonic-clonic seizures, while on a full dose of anti-epileptic medication. Brain magnetic resonance imaging (MRI) scans showed multiple intra-axial cystic lesions in the right hemisphere. The cysts were removed intact using Dowling’s technique through a large temporoparietal craniotomy. The surgery went uneventful and the patient recovered as expected. Post-operatively, a prophylactic course of albendazole (200 mg) was prescribed. On his one-year follow-up visit, the patient was symptom-free and his weakness had improved (left upper limb: MRC grade IV and full power of the left lower limb). The computed tomography (CT) scan showed no new findings.&nbsp;&nbsp;</p> <p><strong>Conclusion</strong>:&nbsp;Primary cerebral hydatid disease is rare and the multiple-cyst variety is even rare. In this case, a peculiar association with a surgically-treated ICH was explored with possible theories to suggest future research directions.</p> 2021-03-09T00:00:00-05:00 Copyright (c) 2021 Radiological features of the intracranial extra-skeletal mesenchymal chondrosarcoma 2021-03-09T13:04:09-05:00 Anas Abdallah İrfan Çınar <p><strong>Background:</strong>&nbsp;Mesenchymal chondrosarcomas are the most malignant form of chondrosarcomas. They have mostly affected bones. Rarely, these tumors can be intracranial extraskeletal (IEMC) that originates from the meninges or parenchyma.</p> <p><strong>Methods and Materials:</strong>&nbsp;We presented two IEMC patients who were treated at our institutions and followed up for the long-term. To understand the radiological features of IEMC, we conducted a systematic literature review for previously reported series and cases of IEMCs.</p> <p><strong>Results:</strong>&nbsp;We surgically treated two young males with IEMC initially diagnosed at their age of 18 and 20 years. The patients initially treated with gross total resection (GTR) and GTR followed by radiotherapy, and followed-up for 218 and 73 months, respectively. With both patients, we obtained 83 reported IEMC patients from the literature. Among them, only 30 cases were reported with their radiological MRI details. The mean age of the reported cases was 24.5±16.0 years (2 months–71 years). Female predominance was 54.2%. The mean progression-free and overall survivals were 27.9 and 39.0 months, respectively. Most IEMCs showed a partially calcified mass on roentgenography and a highly vascular mass on angiography. On T1WIs, IEMCs almost show hypo- to isointensity and intense heterogeneous enhancement after administering a contrast substance. On T2WIs, IEMCs show iso- to hyperintensity.</p> <p><strong>Conclusions: </strong>IEMCs usually show dural attachment without a net dural tail sign and a well-identified brimmed vascular nodule on TOF-MRA. This nodule appears as a prominent blooming on SWI. TOF-MRA and SWI images can help in the radiological diagnosis of IEMCs.</p> 2021-03-09T00:00:00-05:00 Copyright (c) 2021 Outcomes of surgical treatment for pituitary metastasis 2021-03-09T14:09:40-05:00 Dmytro S. Teslenko Mykola O. Guk Olga Yu. Chuvashova <p>We analyzed the outcomes of surgical treatment for pituitary metastasis (PM) based on 35 observations. We registered the best estimates of resection radicalism in patients with minor PM, its inconsiderable spread ascending and descending from the diaphragm of the sella turcica, slightly bleeding metastasis, and no invading to the cavernous sinus. Positive changes in the PM patients’ quality of life are chiefly associated with regressed visual impairment, local pain syndrome, and, to a lesser degree, oculomotor disorders. No post-operative regress or intensifying of hormonal impairments, such as diabetes insipidus and hypopituitarism, were seen. The age of patients, the time interval between the cancer diagnosis and the PM occurrence, control of the underlying disease, size of the tumour are the factors determining the life expectancy in PM patients.</p> 2021-03-09T00:00:00-05:00 Copyright (c) 2021 Intracranial hydatid disease 2021-03-09T14:30:51-05:00 S.N. Gautam Jigmisha Acharya Banesh Jain Piyush Kumar Panchariya <p><strong>Background</strong>: Echinococcosis also known as hydatid disease is an endemic zoonotic disease with growing public health concern with an estimated financial burden of US Dollars 193,539,740 annually. Its definitive host being carnivores and man being an accidental intermediate host. The most common organ affected is the liver, the brain is involved in about 2% of cases. Intracranial hydatid carries high morbidity owing to pressure effect and a slow-growing hence the diagnosis is often delayed. Surgery is the mainstay of treatment, medical management being reserved for selected cases.</p> <p><strong>Materials and method</strong><em>: </em>A retrospective analysis of all the cases of intracranial hydatid disease managed at our department was done from 2013 to 2020 and data were analysed<em>. </em></p> <p><strong>Results</strong><em>: </em>A total of 6 cases were found with an incidence of 1.33% of all intracranial space-occupying lesions during the study period with male to female ratio of 5:1, mean age at presentation 21.2 years, 4 out of 6 patient in the pediatric age group, cyst localised mainly in middle cerebral artery territory, mostly solitary but multiple in one case, all cases managed surgically with preoperative rupture in one case, recurrence noted in another one, Albendazole was given to cases only with rupture or recurrence.</p> <p><strong>Conclusions</strong>:&nbsp; Intracranial hydatid disease should be suspected in all non-enhancing cystic brain lesions especially in endemic regions and all patients should have preferably surgical excision using the “Dowling technique” with medical management reserved for inaccessible lesions, patients unfit for surgery, rupture and recurrent cases. Its high time when public health strategies should also be focussed on prevention and control of disease with appropriate measure at the community level.</p> 2021-03-09T00:00:00-05:00 Copyright (c) 2021 Retrospective study on early outcomes of carotid stenting 2020-11-27T17:03:48-05:00 Saurabh Sharma Prashant Raj Singh Ram Kumar Goyal Raghavendra Kumar Sharma Yashuhiro Yamada Yoko Kato <p><strong>Objective</strong>: This study is conducted to evaluate the early events after Carotid artery stenting (CAS) among our patients in a single institute.</p> <p><strong>Methods</strong>: This study was conducted on 40 patients. These patients underwent stenting of extracranial carotid arteries. Stenting was performed on symptomatic patients with carotid artery stenosis of more than 50 per cent of asymptomatic patients with more than 70 per cent carotid artery stenosis on Doppler ultrasonography. Follow up period for this study was of one month. </p> <p><strong>Results</strong>: 40 patients who underwent CAS between August 2018 and June 2019 were included in the study. Self-expandable hybrid stents were implanted in all patients and pre or poststent-dilatation was performed if required after implantation. None of the patients suffered from a stroke, myocardial infarction or death due to CAS during their hospital stay. Only one patient had a minor stroke during follow up, which was managed conservatively. No transient ischemic attack (TIA), myocardial infarction or death during the follow-up period. Re-stenosis was not observed in the follow-up carotid Doppler ultrasonography; flow rates were within normal limits.</p> <p><strong>Conclusions</strong>: Carotid stenting is a safe alternative to CEA (carotid endarterectomy) in the treatment of carotid stenosis regardless of age. CAS with cerebral protection can be performed safely in patients who are at high surgical risk, with low perioperative morbidity and mortality. The durability of the procedure must be determined with a longer follow-up. Further high-quality RCTs are required to address other shortcomings and controversies.</p> 2021-03-09T00:00:00-05:00 Copyright (c) 2021 Romanian Neurosurgery The effect of long-term subgaleal drain retention (for 14 days) in preventing Cerebro-Spinal Fluid (CSF) fistula development in cases with an insufficiently closed dural defect after craniotomy or craniectomy 2021-03-09T16:12:15-05:00 Umit Kocaman Hakan Yilmaz <p><strong>Purpose:</strong> Our aim was to determine the effectiveness of long-term subgaleal drain retention&nbsp;in preventing CSF fistula development that may occur in the wound site when the dura cannot&nbsp;be completely closed after craniotomy or craniectomy.</p> <p><strong>Material and method:</strong> This study was planned to include the cases of craniotomy and craniectomy performed at Bak?rcay University Cigli Training and Research Hospital during 2017-2021. The study has been made in a retrospective manner to include a subgaleal drain group and a control group. Both groups were selected from Bak?rcay University Cigli Training and Research Hospital. A subgaleal drain was placed in 18 cases with a large or multiple defect after craniotomy or craniectomy where the defect could not be completely closed with grafts. It was planned to be kept in place for 14days with free drainage. Patients were administered antibiotics for three days after the surgery. Patients were monitored for CSF fistula and infection development. On the other hand, 12 patients having large dural defect were included in the control group. Patients in the control group were determined by a random selection method. Patients were followed for 2 days under subgaleal drainage. The Control group was also monitored for CSF fistula and infection development. Both groups statistically were compared with each other in terms of CSF fistula and infection development.</p> <p><strong>Results:</strong> There were 18 cases where the dura was closed insufficiently, long-term subgaleal drainage was performed. The mean age was 66.6 (34-82) years. The surgery performed was craniotomy/craniectomy for cerebellar hematoma drainage in 3 cases, acute subdural hematoma drainage in 5 cases, supratentorial tumour resection in 5 cases, large depression fracture in 4 cases and debridement of cerebral tissue damaged by firearm injury in 1 case. The drain was withdrawn at the end of the 14th day in all patients. A CSF fistula did not occur in any of 18 patients (%0) included in the study. In all patients (%100), the wounds were healed without any problems and no signs of local or systemic infection were found. In the control group, the mean age is 62.2 (48-88) years. CSF fistula developed in 4 (%33.3) of 12 patients in the control group. We had to apply lumbal external drainage in 2(%50) of 4 patients with CSF fistula. Central nervous system infection developed in one (% 8.33) patient.</p> <p><strong>Conclusion:</strong> Long-term subgaleal drainage can be used as an alternative to lumbar external&nbsp;drainage.</p> 2021-03-09T00:00:00-05:00 Copyright (c) 2021 Safety of surgical management of accessory sinus pericranii in infants 2021-03-09T16:41:04-05:00 Mohamed M. Elsherbini Hatem Badr Amr Farid Khalil <p><strong>Purpose</strong>: to better understand the pathological process of sinus pericranii and the safety of the surgical intervention.</p> <p><strong>Methods</strong>: patients’ archive review of patients who underwent surgical management for sinus pericranii with a confirmed diagnosis and with follow up period greater than 6 months.</p> <p><strong>Results</strong>: 6 infants were included; all underwent disconnection surgically with good outcome in all cases.</p> <p><strong>Conclusion</strong>: disconnection surgery for sinus pericranii is a safe procedure with a good prognosis.</p> 2021-03-09T00:00:00-05:00 Copyright (c) 2021 Endoscopic lumbar discectomy using side viewing conical working tube 2021-03-09T18:05:36-05:00 Mohammad Kaif Kuldeep Yadav Rakesh Kumar Deepak Kumar Singh <p><strong>Objective</strong>: The paradigm of surgical therapy for spinal disease especially for lumbar disc herniation has gradually shifted from traditional open surgeries to minimally invasive spinal surgeries. Endoscopic discectomy has been performed widely using various devices and techniques. In this study, we present our experience of endoscopic discectomy using a unique device with separate side viewing channel.</p> <p><strong>Methods</strong>: 26 patients of lumbar disc herniation treated between March 2015 to April 2018 using the unique conical working tube with separate side-viewing endoscopic channel have been retrospectively analysed. Their preoperative and postoperative Oswestry Disability Index (ODI) and Macnab scores were used to evaluate the outcome with a mean follow up of 37.04 months.</p> <p><strong>Results</strong>: There were 18 males and 08 females with age ranging from 19-72 years (mean-38.4 years). The follow up ranged from 25 months to 60 months with a mean of 37.04 months. The mean preoperative ODI score was 72.4 which decreased to a mean of 7.6 and the outcome evaluated by Macnab criteria was 65.3% excellent, 19.2 % good, 11.5% fair, 3.8% poor. 1 patient underwent a second surgery. None of the patients had to change their occupation postoperatively. Complications occurred were dural tear in 1 patient and transient foot paresis in 1 which improved spontaneously.</p> <p><strong>Conclusion</strong>: Endoscopic discectomy using conical working tube is a safe and effective technique for lumbar disc prolapse. The long term results are comparable to conventional techniques.</p> 2021-03-09T00:00:00-05:00 Copyright (c) 2021 Ossified longitudinal ligament causing same level cord contusion in a case of Klippel-Feil syndrome 2020-12-29T06:04:48-05:00 Amit Agrawal <p>Klippel-Feil syndrome (KFS) is a congenital fusion of two or more cervical vertebrae due to faulty segmentation of the vertebral axis during gestation. (1-5) These patients present with a constellation of manifes­tations and are typically prone to cervical cord injury after a minor fall or a major traumatic episode. (2, 5-8) 34 years old gentlemen, a plumber by profession presented with a history of slipped and fall about two stairs height while he was working. </p> 2021-03-09T00:00:00-05:00 Copyright (c) 2021 Romanian Neurosurgery