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R.M. Gorgan, Angela Neacşu and A. Giovani

Abstract

Craniovertebral junction tumors represent a complex pathology carrying a high risk of injuring the vertebral artery and the lower cranial nerves. Dumbbell C1- C2 schannomas are very rare tumors in this location. We present a case of a 66 years old male accepted for left laterocervical localized pain, headache and vertigo, with a large C1 dumbbell schwannoma extending in lateral over the C1 arch and displacing the C3 segment of the vertebral artery superiorly and anteriorly. Complete removal of the tumor was achieved using a far lateral approach. The approach is discussed with focus on the vertebral artery anatomy as the approach should give enough space to gain control of the artery without creating instability. Safe removal of C1 nerve root schwanomas can be achieved even if they compress and displace the vertebral artery by entering a fibrous tissue plane between the tumor and the vertebral artery.

Open access

A. Giovani, F. Brehar and R.M. Gorgan

Abstract

Since 1985 when the EC-IC bypass study results were published and less procedures were performed for cerebral ischemia, the EC-IC bypass even high or low flow and the IC-IC bypass as flow replacement procedures gain acceptance for many neurosurgical pathologies, from extrinsic and intrinsic tumors requiring large vessels sacrifice to large giant and fusiform aneurysms. In recent years, after the results of Carotid Occlusion Surgery Study (COSS) and the Japanese EC-IC trial published their results the indications for extracranial-intracranial (EC-IC) by-pass expanded, including both extracranial carotid artery occlusive disease and intracranial atherosclerotic disease. The authors make a literature review of the indications for cerebral revascularization, with focus on the direct STA-MCA and indirect (EDAMS) revascularization techniques as a treatment for ischemic stroke. They present two cases of Moyamoya disease one treated with combined approaches and one with indirect approach and discuss the technical skills the surgeon should acquire in order to perform an anastomosis, focusing on the details of STA-MCA bypass, concluding that a combined approach gives better neurological results visible shortly after the surgery.

Open access

A. Giovani, Aurelia Sandu, Angela Neacsu and R.M. Gorgan

Abstract

Cavernous malformations (cavernomas) are congenital low flow angiographic occult vascular lesions with a high tencency to bleeding. The prevalence of cerebral cavernous vascular malformations is estimated to be 0.4% to 0.9%.2,7 CMs in deep locations, including the brainstem, thalamus, and basal ganglia, account for 9% to 35% of all malformations in the brain. We performed a retrospective 10 years study on 130 operated cerebral cavernomas and discussed the clinical status at presentation, the choice and timing of the surgical approach and the short and longterm follow up. The 130 operated cases were divided into a supratentorial 102 (78.46%) group and an infratantorial group 28 (21.53%). The average age at presentation was 43,62 years old (17-76) and there was no sex predominance, male/female = 1,44 (77/53). Only in 14 cases (10.76%) we could find multiple cavernomas which had relatives with multiple cavrnomas, but the familial inheritance was not studied, and only the symptomatic lesion was resected. We divided the outcome results reporting for agroup with superficial respectively profound lesions. The long term follow up for the patients in the profound lesions group showed that 31/37 (83,78%) of patients had a mRS between 0 and 2, and the rest had a poor long term outcome. After surgery there was no clinical deterioration in the superficial lesions group and 22 patients from those who presented in mRS 2 showed neurological improvement on long term follow up, meaning that 82,79% of patients had a 0 or 1 mRS. Microsurgery is the treatment of choice in symptomatic brain cavernomas, total resection being the only curative treatment, capable to prevent further bleeding and to offer an efficient control of seizures.

Open access

A. Giovani, Angela Neacsu, Ana Gheorghiu and R.M. Gorgan

Abstract

We report a case of complex large middle cerebral artery (MCA) bifurcation aneurysm that ruptured during dissection from the very adherent MCA branches but was successfully clipped and the MCA bifurcation reconstructed using 4 Yasargill clips. Through a right pterional craniotomy the sylvian fissure was largely opened as to allow enough workspace for clipping the aneurysm and placing a temporary clip on M1. The pacient recovered very well after surgery and was discharged after 1 week with no neurological deficit. Complex MCA bifurcation aneurysms can be safely reconstructed using regular clips, without the need of using fenestrated clips or complex by-pass procedures.

Open access

M.R. Gorgan, Narcisa Bucur, Catioara Cristescu and A. Giovani

Abstract

Spinal AVM are very rare vascular lesions and most o the studies give reports on only a few cases. Given their localization between the spinal tracts and the gray matter core of the medulla and their multiple feeders from posterior and anterior spinal arteries they are amongst the most difficult surgical pathology in the nervous sistem. We present the case of a 60 years old male with a glomus type T10-L2 spinal AVM that presented with motor deficit in the lower limbs and urinary incontinence. The partially thrombosed lesion was completely resected without previous embolisation, and the patient was walking with assistance at discharge. This is a rare case that presented with progressive neurological deterioration consistent with an ischemic rather than a hemorrhagic event. Microsurgery is a better option than conservative treatment in these rare cases of spontaneous occlusion of intramedullary arteriovenous malformations.

Open access

F. Brehar, A. Giovani, L. Munteanu and R.M. Gorgan

Abstract

Young age is associated with better outcome in patients with severe traumatic brain injury (TBI). Still the reported mortality rate in patients that present in profound coma Glasgow Coma Scale (GCS) -3 pts is very high, even approaching 100% in the presence of fixed and dilated pupils in some series. We report a case of a 25 years old patient with a severe TBI in a car crush and presented in severe coma with a bilateral frontal and right temporal brain laceration with extended posttraumatic subarachnoid hemorrhage and a complex cominutive right frontal, maxillary and zygomatic fracture corresponding to Le Fort III fracture. After a difficult postoperative course with complications of tracheostomy like candidosis and bronchopneumony, then after a slowly progressive recovery, the patient was hemiparetic and with a persistent right 3rd nerve paresis at 6 weeks after the traumatic event, but was able to speak and to ambulate with assistance. Given the large bony defect that remained, a frontal and facial bony reconstruction was made by an interdisciplinary team using titanium plates and screws. Considering the excellent results in this case we advocate that young patients who suffered severe TBI even if they present in a very bad neurological shape should be given access to the best treatment.

Open access

M.R. Gorgan, A. Giovani and F.M. Brehar

Abstract

Vagus nerve stimulation (VNS) represents one of the main surgical options for the treatment of the refractory epilepsy in pediatric and adult patients. There are several mechanism involved in vagal nerve stimulation which could influence the pathophysiology of seizures like neuromodulation of the thalamic and subthalamic nuclei involved in seizure initiation and the modulation of the neurotransmitters pattern norepinefrin, GABA, and serotonin. The VNS system is composed of the implanted components (the generator, the lead with the electrodes attached) and the programming system components (programming wand and handheld computer). The authors present their experience with 81 patients diagnosed with refractory epilepsy, investigated, selected and implanted with vagal neurostimulators between December 2012 and January 2015 in Neurosurgery Clinic, "Bagdasar-Arseni" Emergency Hospital. The surgical technique and the potential pitfalls are described in detail. There were 20 children (24,7%) and 61 (75,3%) adults in this series. There was no death in this series and no intraoperative incidence. One patient presented dysphagia postoperatively which completely remitted after two months of follow-up. The outcome in term of seizure frequency and severity was better for patients under 30 years compared with patients older than 30 years. VNS represents now a safe, quick and efficient surgical procedure with a minimum period of hospitalization and a short recovery period. The good results on long term improve the quality of life of the patients and facilitate the social and professional reinsertion

Open access

D. Martin, A. Giovani, Narcisa Bucur and R.M. Gorgan

Abstract

Training in a specialty like cerebrovascular neurosurgery becomes more and more difficult as the access to training is limited by the increasing number of neurosurgical departments and the lack of expert centers for specific pathology. This is why an increased investment in experimental training is encountered in many centers worldwide. The best models for training the clipping technique are ex Vivo on cadaveric heads aneurysm models, animal models or augmented reality models. We present a few ex Vivo models of aneurysms mimicking ACOA, ACM bifurcation and basil are tip aneurysms using a pulsed continuous perfusion system. Clipping training on aneurysm models is an invaluable tool both for the residents and for the specialists with a special interest in cerebrovascular surgery.

Open access

G. Popescu, A. Giovani, N. Bucur, A. Neacsu, A. Gheorghiu, S. Mara and R.M. Gorgan

Abstract

Introduction: Intracranial epidermoid and dermoid cysts are the result of an embryogenesis dysfunction leading to an abnormal migration of ectodermal cells characterised by a slow and benign rate of growth which is associated with minimal neurological symptoms in large or giant tumors.

Materials and methods: We retrospectively reviewed the case files of 17 patients with epidermoid and dermoid cysts operated using the operative microscope and neuronavigation in our department between January 2011 and December 2015.

Results: Reviewing the case files we selected fourteen patients with epidermoid cysts and 3 patients with dermoid cysts who underwent surgical resection. Most of the cysts were located infratentorial (64%) with a propensity for the CP angle (81%). Total resection was attempted in all cases but was possible in only 13 cases. All cases with subtotal resection were infratentorially located in close relation to the brainstem or cranial nerves.

Conclusion: When the tumor extension reaches beyond the limits of the surgical approach used, the tumor remnant should be addressed in a second surgery. Using the cysternal anatomy and the vessels dissection technique the risks aseptic meningitis and of injuring the cranial nerves are diminished.

Open access

Aurelia Mihaela Sandu, A. Giovani and M.R. Gorgan

Abstract

Introduction: Brain arteriovenous malformations (AVMs) represent a serious health problem all around the world. Experimental models help to better understand the pathophysiology of these lesions. Experiment: We performed an experimental model of AVM using biological grafts, arteries and veins harvested from chicken wings at the elbow joint. We used 14 vessels and we performed 20 end-to-end anastomoses to create a nidus with a single feeding artery and a single draining vein. The system was irrigated with colored solution. The experiment was done according with law in force regarding experimental research activity. Conclusions: Experimental models allow us to understand the hemodynamics and predict the outcome of brain AVMs in humans. This experimental model is a useful tool in understanding the hemodynamic properties of brain AVMs. It is very useful in vascular anastomosis training