Search

The aim of the study is to define radiological parameters which may indirectly indicate invasive expansion of a meningioma and thus forecast potential risks of postoperative neurological deficits. The study group includes 40 adult patients in comparable physical conditions (age 18-75, CRS 70-100, ASA 1-2) with meningiomas, affecting the brain tissue only. The results indicate that unfavorable parametres, predicting potential postoperative neurological deficits include: growth of a meningioma in eloquent regions and presence of a peritumoral oedema. Positive parametres, indicating that no neurological deficit would arise, include: dural supply, visible brain-tumor barrier, non-eloquent location of a meningioma and absence of a peritumoral oedema. The study results suggest that provided the two last parametres are present, a patient need not be exposed to risks of invasive selective angiography.

The authors present their own proposal for a standard diagnostic procedure algorithm in intracranial meningiomas, which they used in their prospective, non-randomized longitudinal study in a group of 30 subjects within a year. The following four criteria were assessed in each patient: age, physical condition according the ASA classification, location of the meningioma on the MRI (superficial, the scull base) and the growth invasivity using selective DSA (ACI+ACE) and MRI (the vascularization type, the oedema index and the change in the oedema signal intensity in 3.5 hours). The criteria helped to establish the optimum therapeutic procedure for each patient: embolisation without a follow-up surgery (2 subjects), observation (2 subjects), pre-operative embolisation (5 subjects) and surgery without preceeding embolisation (21 subjects). This study did not assess the intracranial meningiomas treatment outcome. It highlights significance of the diagnostic procedures standardization in order to establish their optimum therapeutic modality.

Currently there are three major surgical approaches into the sphenoid sinus during transsphenoidal microsurgery. The first approach is the sublabial incision with submucous resection along the nasal septum. It is particularly advantageous in patients with small nasal apertures, in pediatric patients, and for large tumors extending into the cavernous sinuses or into the clivus. The second approach, the transnasal submucous tunnel, is presently the most frequent technique used, although it provides the narrowest operation field. The third technique is the direct transnasal approach. This method is less destructive to structures in the nasal cavity and less time-consuming. In the period of 20 months the authors performed 81 transsphenoidal microsurgical operations in 44 women and 37 men. Visual field defect was the most frequent indication for surgery in 42 cases, followed by hormonal abnormality in 24 patients. The sublabial approach was used in 69 cases, the technique of transnasal submucous tunnel in 10 patients, and the direct transnasal approach in 2 cases. The authors encountered no short-term or long-term complications related to various surgical approaches to the sphenoid sinus.

Prolapse of an intervertebral disc and neurologically important spondylosis of the thoracic vertebrae are not a frequent finding--in the wide spectrum of surgical treatment of degenerative diseases of the spine the numbers of operations in the thoracic section account only for a few percent. The authors give an account of 12 patients treated surgically during the 5-year period 1997-2001 at the Neurosurgical Department of the First Medical Faculty Charles University and Institute for Postgraduate Training in Prague-Stresovice. They describe the establishment of the neurological finding from the differential diagnostic aspect, the algorithm of radiological examination and selected treatment. In the group of surgically treated patients were two with spinal and radicular symptoms, 8 patients had only spinal and 2 patients had only root symptoms. Laminectomy was performed in one female patient, in 9 patients discectomy was performed from a transpedicular approach and in two patients discectomy from costotransversectomy. Complete normalization of clinical complaints was recorded in 2 patients, in 8 the condition improved and 2 patients did not improve. In 2 patients a revision was made and extension of the approach on account of persisting clinical complaints, in one patient after revision complete normalization of the clinical finding occurred, the second patient did not improve after revision. Selection and results of the surgical approach--in all instances different types of posterior approach were involved--are discussed. In the discussion also a brief review, indications and illustrations of posterior approaches are given. The discussion deals also with the advantages and disadvantages of the method as compared with the anterior approach or endoscopic technique. The authors emphasize the advantages of the microsurgical technique--the open posterior approach still holds an irreplaceable place in the spectrum of surgical therapeutic methods despite the onset of endoscopic methods.

Subarachnoid hemorrhage still represents important medical problem, from both, ineffective prevention and high morbidity and mortality rate of the condition. On the other hand, majority of patients who survive initial hemorrhage and successful clipping of their aneurysm can live without major medical restrictions. Apart from surviving the initial attack the most important condition is properly clipped aneurysm. Doppler scanning control allows precise placement of the clip on the neck of an aneurysm. Since January 1997 through December 1999 the authors have surgically treated 204 aneurysms in 181 patient. In 40 surgeries the Doppler scanning was employed after the aneurysm complex was dissected free. Using 20 MHz PW Doppler probe the flow within the aneurysm and in the involved arteries was measured (usual depth 1.5 mm, range 1-2.5 mm). After the clipping the flow was evaluated again, to ensure proper exclusion of an aneurysm and good flow in involved arteries. The authors consider the Doppler scanning to be important technical aid in aneurysm surgery, especially in anatomically complex situations.

Traumatic pleuro-dural communication causing pneumocephalus needs rapid diagnostics and surgical treatment, so as to prevent the development of possible complications.

Based on a group of distal injuries of the median and ulnar nerve the authors evaluate the results of peripheral nerve regeneration. For evaluation of the results and comparison with other work they emphasize the necessity of adherence to objective criteria of a useful degree of reinnervation. In their opinion the most suitable criterium is evaluation of sensitive reinnervation respecting the discrimination test up to 12 mm in the entire autozone of the nerve. The results of suture depend on the technique, interval (injury-operation) and the patient's age. In acute operations 45% of the patients of all age groups achieved the useful grade of sensitive regeneration. In late operations, where the degree of useful regeneration was achieved only in 19% of patients, the authors draw attention to the fact that a successful outcome was achieved only in patients under 30 years. The main prerequisite of successful regeneration of peripheral nerves in according to the authors early diagnosis and treatment in the acute period. With regard to the declining regeneration potential with advancing age early treatment is much more important in patients older than 30 years. Microsurgical technique is a condition sine qua non.

The authors evaluate a group of 72 patients with the diagnosis of chronic subdural haematoma (cSDH). All subdural collections were confirmed on a computer tomograph. Sixty-nine patients were operated by trepanation and drainage into a closed system which was maintained for a maximum of five days. Three patients with a hyperdense CT finding were subjected to extended trepanation or craniectomy with membranectomy. The CT picture made on the 2nd-4th day after operation revealed a persisting subdural collection in 35% of the patients subjected to trephination. The authors were concerned with the problem whether this percentage makes trephination with drainage controversial as the only universal therapeutic method in cSDH. Nevertheless successful reinsertion of the drain (85%) is in favour of trephination although drainage from the first trephination in not always the definite solution. Conversely revision by craniotomy was a failure in 7 patients where the drainage method was not successful. Radical surgery proved useful only in the initial period in patients who despite a chronic course had on CT a hyperdense collection. The influence of the site, volume of collection, lateral overpressure and possibly a subsidiary CT finding could not be proved on a statistically significant scale, therefore the authors did not use these CT markers when selecting surgical intervention.