Search Results

You are looking at 1 - 10 of 12 items for

  • Author: Cristiana Moisescu x
Clear All Modify Search
Open access

Danil Adam, Dragos Iftimie and Cristiana Moisescu

Abstract

Background: Chronic subdural hematomas (CSDHs) are one of the most common intracranial lesions treated in a neurosurgical department. They associate significant morbidity and mortality that increase in the case of recurrences requiring reoperation. Despite extensive published literature, there is still significant debate regarding optimal management of CSDHs and their potential recurrence. Objective: Identify factors for recurrence requiring reoperation of CSDHs in order to adjust our management strategies. Methods: A retrospective review of 64 cases harbouring 71 CSDHs that were surgically treated in the Neurosurgery Department of “Saint Pantelimon” Clinical Emergency Hospital over a period of two years (January 2016 - December 2017). Two main surgical techniques were used: small trephine and large bone flap craniotomy, according to the operating surgeon’s preference. CT scans were performed at admission and 24 hours postoperatively. Postoperative management was similar in all cases. Results: Recurrence requiring reoperation (RrR) was encountered in 16 (25%) of the reviewed cases. Reoperation was found to be significantly more often encountered in particular preoperative CT characteristics: laminar type (RrR=38,10%, p=0.027) and maximal thickness above 22 mm (43,75%, p = 0,013). Surgical technique had a substantial impact on recurrence: in trephinated cases, reoperation was required in only 8 of 51 patients (RrR=15,69%, p = 0.007), while large bone flap craniotomy associated a RrR of 61,54% (p = 0.008), which increased when associated with inner membranectomy (RrR=87,5%, p = 0,007) or subdural drain placement (88,89%, p = 0.007). Reoperations not only doubled the neurosurgical hospital length of stay, but also associated higher perioperative mortality rates (18.75% versus 14,58%). Conclusions: In our series, surgical technique had a decisive impact on the rate of recurrence. CSDH surgery is another example of “in medio stat virtus”, where finding the right balance between the least and most aggressive technique has the potential of providing the best outcomes, and thus small trephination could be taken into consideration.

Open access

D. Adam, R. Cergan, D. Iftimie and Cristiana Moisescu

Abstract

Background: There is a significant variety of odontoid fracture classifications along with corresponding treatment strategies. There are though cases which cannot be framed within the existing classifications.

Clinical presentation: We report the case of a 91 years old female patient who suffered a cervical trauma secondary to a ground level fall. The cervical CT scan revealed a particular type of odontoid fracture, unframeable within existing classifications. The fracture line was at the base of the odontoid process and continued in an oblique trajectory through the right pedicle of the axis. As treatment strategy, we opted for external immobilization in a Minerva jacket and, after 3 months, the patient is symptom free, with partial bone fusion.

Conclusion: We named this rare case of odontoid fracture type II B for which external immobilization seems sufficient.

Open access

Danil Adam, Cristiana Moisescu, Dragos Iftimie and Gina Burdusa

Abstract

Background and importance: Paragangliomas are neuroendocrine tumors that occur most often within the adrenal glands. The most frequent extra-adrenal locations include the carotid body and the jugular bulb. Filum terminale paragangliomas are extremely rare, with just 33 cases reported to date. Imagistic appearance is similar with other types of intradural extramedullary tumors such as ependymomas and schwannomas. Histopathological examination is the only method of establishing a definitive diagnosis. They are classified as grade I WHO tumors with favorable prognosis in the case of total resection. Clinical presentation: A 46-year-old woman without any relevant medical history was admitted to our Neurosurgical Department, complaining of low back pain with bilateral sciatica. She presented no neurological deficits and routine blood tests, as well as heart rate and blood pressure, were within normal ranges. Lumbar spine MRI with gadolinium enhancement revealed an intradural tumor with irregular, well defined margins and intense homogeneous enhancement, located at the level of the L3 vertebra. It presented an unenhancing intradural cystic lesion that extended cranially up to the level of the L1 vertebra. The tumor and associated cyst were completely resected through L2-L4 laminectomy. The tumor-cyst complex was attached, yet nonadherent to the conus medullaris and nerve roots, which allowed safe total removal. Histopathological examination was suggestive for paraganglioma, a diagnosis confirmed by immunohistochemistry that classified it as moderately differentiated, non-secreting type. Serum metanephrines subsequently determined were within normal ranges. Also, additional imagistic tests consisting of cervical and abdominal ultrasound and contrast enhanced CT scans did not detect any additional tumors. Postoperatively, the patient was neurologically intact, with complete remission of presenting symptoms at 3 months follow-up. Conclusion: Filum terminale paraganglioma is a rare diagnosis which is frequently overlooked. However, gross total resection, a common goal for all spinal tumors, can be curative in these particular cases.

Open access

D. Adam, D. Iftimie, Cristiana Moisescu and Gina Burduşa

Abstract

Clinical presentation: We report the case of a 68-year-old patient that presented at our department 6 weeks after a mild traumatic brain injury with confusion and drowsiness. Emergency head CT scan revealed chronic bilateral subdural hematomas with no midline shift. His neurological status quickly deteriorated after admission (GCS of 9 points) and he was operated immediately. Although surgery was uneventful and his neurological status markedly improved, in the first postoperative day he developed blindness with visual anosognosia and visual confabulations, suggestive for Anton-Babinski syndrome. Emergency head MRI performed on the same day was normal but a repeat head MRI in the seventh postoperative day revealed bilateral occipital ischemia, thus explaining his symptoms. The patient became aware of his deficit two weeks after surgery, but was surprisingly ambivalent regarding it. Conclusion: Cortical blindness (sometimes presenting in the context of Anton-Babinski syndrome) is a rare complication of chronic bilateral subdural hematomas, a rather common neurosurgical pathology. Although it can be overlooked on the initial neurological examination, it should be taken into account, prompting emergency surgical treatment in order to prevent permanent visual deficits.

Open access

D. Adam, D. Iftimie, Gina Burduşa and Cristiana Moisescu

Abstract

Background and importance: Chronic subdural hematomas are a frequently encountered neurosurgical pathology, especially in the elderly. They often require surgical evacuation, but recent studies have shown good results with conservative treatment in selected cases.

Clinical presentation: We report the case of a 72-year old patient that developed large, non-traumatic, bilateral, acute-on-chronic subdural hematoma after repeated abdominal surgery for appendicular carcinoma. He presented an abdominal wound infection and good neurological status (GCS score of 14 points), factors that indicated the delay of surgical intervention. Subsequent clinical and radiological improvement forestalled the operation altogether and he presented complete spontaneous resolution of subdural hematomas at only 5 months after diagnosis.

Conclusion: Although surgical treatment is performed in the majority of chronic subdural hematomas, in clinically and radiologically selected cases, the operation can be avoided. The hematoma can present resolution, either spontaneously or with the help of conservative treatment.

Open access

D. Adam, D. Iftimie, Gina Burduşa and Cristiana Moisescu

Abstract

Background: Degenerative spinal disease surgery is frequently performed in most neurosurgical departments. Unplanned 30-day readmissions represent a significant economic burden and have been used in several studies as a tool to evaluate quality of patient care.

Objective: To review 30-day unplanned readmission rates after degenerative spinal disease surgery in our department, in order to identify their causes and determine strategies aimed at decreasing their frequency.

Methods: A retrospective analysis was performed on all patients operated in our department for spinal stenosis or disc herniation over a 3 year period (January 2014 – December 2016), evaluating the rate and causes of unplanned readmission in the first month after discharge. Complications were divided in medical and surgical.

Results: Out of the 1106 patients included, 33 (2,98%) presented a 30-day unplanned readmission. The percentage was higher after disc herniation surgery (3,40%), compared to spinal stenosis (1,92%). Pain management was the most common medical cause for readmission (45,45%), while in the surgical group, CSF leaks were the most frequent complication (18,18%).

Conclusions: The rate of 30-day readmissions was low in our series but, even so, they associate significant costs. They could be avoided by applying correct and aseptic surgical technique, proper availability of dural sealing agents and superior patient medical education.

Open access

Danil Adam1, Toma Papacocea, Ioana Hornea and Cristiana Moisescu

Abstract

Osteodiscitis represents a serious complication of lumbar disc herniation operations. The treatment of osteodiscitis is controversial and expensive to society. It extends over a period of several months from diagnosis. Reducing postoperative osteodiscitis by using simple measures may limit patient's suffering and reduce costs. The purpose of this study is to evaluate the early diagnosis of bacterial infections of the intervertebral disc by isolating germs located in the herniated disc fragment and topical Vancomycine powder application, along with the conventional anti-infective therapy. Medical files of patients who were operated on for lumbar disc herniations during 01.01.2013 - 30.06.2014 were reviewed. The diagnosis of lumbar disc herniation was established based on the clinical evaluation, confirmed by MRI results. The surgical intervention was performed by mini-open approach: fenestration and foraminotomy completed with removal of the herniated disc fragment and disc remnants from the intervertebral space. A group of 162 patients (group A) received conventional therapy for prevention of post-operative infections with 2 doses of cephalosporin. In the second group of 137 patients (group B), after the removal of the herniated disc fragments, 1g of Vancomycine powder was topically applied and the disc fragments were bacteriologically analyzed. They received the conventional treatment of preventing post-operative infections with cephalosprin - 2 doses. The two groups of patients were similar in terms of demographic characteristics: age, sex, operative level. Out of the 162 patients of group A, one patient developed postoperative osteodiscitis and was treated for 3 months with antibiotics. Regarding patients in group B, in four cases Staphylococcus was isolated from the disc fragments. Postoperative treatment for these patients with prolonged antibiotic therapy over the standard period avoided the developement of the clinical picture of osteodiscitis. Postoperative osteodiscitis requires prolonged antibiotherapy. By using simple measures, like topical Vancomycine powder application and early isolation of germs from the herniated intervertebral disc, followed by the immediate establishment of appropriate antibiotic treatment, this serious complication is avoided.

Open access

D. Adam, D. Iftimie, Gina Burduşa and Cristiana Moisescu

Abstract

Background and importance: “Fish vertebra” is an uncommon anomaly of vertebral body shape, consisting of central depression of the superior and inferior vertebral surfaces. It has been associated with various conditions: osteoporosis, osteomalacia, hyperparathyroidism, Paget disease, sickle cell disease, multiple myeloma and systemic lupus erythematosus.

Clinical presentation: A 29-year-old male patient, previously treated for ankylosing spondylitis (with NSAIDs and TNFα inhibitor), without any clinical improvement, was admitted to our Neurosurgical Department. He complained of difficult gait, possible only with the aid of a cane, low back pain and bilateral hip pain, but without leg pain. He denied any history of recent trauma. Neurological examination was normal. Plain thoracic and lumbar spine X-rays revealed multilevel “fish vertebrae”. Lumbar spine MRI and contrast thoraco-abdominal CT scan showed fractures of multiple structures: left L4 pedicle, right L4 lamina and pars interarticularis, right II-VII costal arches, left I-V costal arches and bilateral sacral alae. We performed extensive laboratory tests that detected low seric phosphorous and PTH levels, with increased alkaline phosphatase, indicating a possible endocrinological cause for this condition. Subsequently, we decided to transfer the patient to an Endocrinological Department. A diagnosis of hypophosphatemic osteomalacia was established and increased FGF23 levels, later determined, suggested it was tumor-induced osteomalacia. Whole-body MRI was unable to locate the tumor, but Gallium-68 DOTATATE PET/CT revealed a small (15 mm in diameter), hyperfixating mass in the head of the right femur. The patient was treated with oral calcitriol and phosphate, with alleviation of symptoms. Surgical excision of the tumor was recommended, but the patient decided to postopone the operation.

Conclusion: Modern medical imaging and biochemical testing have made the leap from merely observing vertebral biconcavities to diagnosing their cause and, consequently, the possibility to adequately treat uncommon causes of “fish vertebra”, such as neuroendocrine tumor-induced osteomalacia.

Open access

Danil Adam, Toma Papacocea, Ioana Hornea and Cristiana Moisescu

Abstract

Meningioma is in most cases a benign tumor of the central nervous system with two growth patterns: en masse and en plaque. Hyperostosis is associated in 13 - 49 % of the cases with en plaque meningioma. We describe the case of a 47 years old woman with meningotelial sphenoid ridge meningioma which was totally removed. At the first admission she presented with no neurological deficits, seizures and a mild right exophthalmos. This had an indolent growth. After 10 years, the patient was readmitted for headache, blurred vision and right exophthalmos. Skull X-rays and brain MRI revealed an important thickening of the right superior orbit wall and sphenoid ridge. She underwent a new surgery. There was no intradural tumor found. Instead, bones of the superior and lateral right orbit walls were very hiperostotic. A hole of 3/2 cm in the right superior orbital wall was drilled and the orbital cavity was decompressed. In the postoperative period, the symptoms were remitted and the exophthalmos reduced. We discuss the causes and management of hyperostosis associated with meningiomas.

Open access

Danil Adam, Ioana Hornea, Cristiana Moisescu, Dragos Iftimie and Toma Papacocea

Abstract

Microcystic meningioma is a particular morphopathological form of benign meningiomas, with different imaging characteristics compared to other forms of meningiomas. It is presented the case of an 80 year old woman with repeated head injuries, initially operated for a right fronto-temporo-parietal pericerebral fluid collection. After four years, the patient returned with headache, confusional status, somnolence, symptoms wich appeared after a new head injury. Cerebral CT scan revealed a hypodense lesion in the right sylvian fissure of 5.7/3.5 cm, without perilesional edema, which was interpreted as an arachnoid cyst. Intraoperative, a soft, gelatinfibrous tumor mass was identified, partially adherent to the dura mater and the underlying cortex, which was completely resected. The morphopathological diagnosis was microcystic meningioma. It is discussed the imaging aspect of the presented case compared to the literature data regarding the microcystic meningiomas and the relationship between head traumas and the occurrence of meningiomas.