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  • Author: Dorin Nicolae Gherasim x
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Dorin Nicolae Gherasim, Gabriel Gyorki and Adrian Balasa

Abstract

Objective: This study presents the experience of one neurosurgical center in the treatment of 18 consecutive patients with distal anterior cerebral artery (DACA) aneurysms during a 10 years period. Our aim was to compare treatment outcomes of these lesions with intracranial aneurysms in general, and to present technical nuances in surgical treatment.

Methods: We analyzed the clinical and radiological data of 18 patients treated between 2005 and 2015. All patients were treated surgically using the microscope. No patients were lost to follow-up. We compared treatment and outcome of ruptured DACA aneurysms (n 18) with all consecutive ruptured aneurysms treated in our clinic during the same period (n 446).

Results: DACA aneurysms accounted for 4% of all intracranial aneurysms. They were smaller (median, 5,5 versus 9 mm) We found only one case with associated aneurysms (5,5%). DACA aneurysms presented more often with intracerebral hematomas (39% versus 26%) than ruptured aneurysms in general. Their microsurgical treatment showed the same complication rates (treatment morbidity, 15%) as for other ruptured aneurysms in literature. Their mortality rate was lower (11% versus 24%).

Conclusion: Despite their specific anatomic features, and particular surgical technique, with modern treatment methods, ruptured DACA aneurysms have the same favorable outcome and lower mortality as ruptured aneurysms in general.

Open access

Adrian Bălaşa and Dorin Nicolae Gherasim

Abstract

Introduction: There are four types of Chiari malformations described in the literature. Due to the fact that it is a common finding in the general population (true Chiari being present in 0,75% of the population), Chiari 1 malformation was also called Chiari anomaly.

Material and methods: In the last 5 years 17 patients with Chiari I malformation have been treated in our clinic. There were 12 women and 5 men. The mean age was 43 years (between 21 and 60 years). The symptoms were grouped in 6 syndromes: brain stem and bulbar palsy syndrome, cerebellar syndrome, central cord syndrome, paroxysmal intracranial hypertension, scoliosis, pyramidal syndrome.

Surgical treatment: According to recent literature patients respond best when operated within 2 years from the onset of symptoms. We recommend early surgery for symptomatic patients. Surgical treatment of Chiari I malformation should accomplish several golds. First of all, there is the obvious need to decompress the lower part of the cerebellum. Chiari I malformation being related to a small posterior fossa, the surgical treatment should realise enlargement of the total volume of the posterior fossa(7, 12). In the author’s opinion the key point in surgical treatment of Chiari 1 malformation should be to reestablish the CSF flow at the level of the foramen of Magendie and foramen magnum. Various approaches were used in the last five years in our clinic for the treatment of symptomatic patients: only osseous decompression in 2 patients; osseus decompression with dural grafting and intradural dissection of adhesions in 4 patients; osseous decompression with dural grafting, intradural dissection, and tonsillar coagulation in 11 patients

Results: The long-term (6 months postoperative) surgery-related result was considered excellent if symptoms resolved (7 patients). The result was considered good if the patient experienced significant improvement but also residual symptoms (8 patients). A poor result indicated no change in symptoms (2 patients). As for the surgical technique used, the vast majority of patients with good or excellent outcome at 6 months underwent osseous decompression with dural grafting, intradural dissection, and tonsillar coagulation

Conclusions: Regarding Chiari I malformations, the author considers that a proper patient selection is critical to prevent unnecessary procedures and maximize the outcome. In light of this study results and recent literature, the author considers that the surgical gold standard consists in three key steps: posterior fossa craniectomy followed by durotomy and subarachnoid decompression of CSF flow and last duroplasty.

Open access

Adrian Florian Bălașa, Rareș Chinezu and Dorin Nicolae Gherasim

Abstract

Introduction: Tuberculum sellae and planum sfenoidale meningiomas represent 5% to 10% of intracranial meningiomas and represent a subgroup of anterior skull base meningiomas. Approximately two thirds of patients complain of failing vision in one eye as the first symptom, and monocular blindness may be present in half of patients before surgery. Due to the constant antomical relationship of these tumors with the optic nerves there is a classic presentation of these tumors represented by the chiasmal syndrome.

Material and methods: In this study, we have retrospectively analyzed 18 cases consecutively operated between 2006 and 2012 at the Targu Mures Neurosurgery Department. Considering the length of the visual disturbances we have divided the study group in two categories: early decompression with visual distubances expressed within at most 12 months prior to surgery, and late decompression with visual disturbances of more than 1 year.

Surgical technique: Sugical approach has been performed on the side with the most visual deficit, and if visual deterioration was found to be approximative on both sides we chose the right side for surgical approach. In all the patients, we have performed a fronto-pterional craniotomy. In all the cases we chose a subfrontal approach. Tumor has been further resected using standard microsurgical techniques, total tumoral resection being the preoperative goal in all surgical interventions

Results: Out of the 18 cases operated, 13 cases were of tuberculum sellae meningiomas, while 5 cases were of planum sphenoidale meningiomas.

All patients in the early decompression group (9 cases) have presented visual improvement, whilst of the late decompression group 5 cases (55,5%) presented constant visual deficit, 2 cases (22,25%) presented visual improvement and 2 cases (22,25%) presented a decrease of the visual deficit.

The visual disturbances have improved in 11 cases (61.1%), in 5 cases (27,7%) the visual deficit has remained constant, and in 2 cases (11,2%) the visual deficit has worsened postoperatively. Conclusions: We consider that the optimal approach should be based on tumor anatomy and surgeon experience and from this point of view frontolateral and pterional approaches provide remarkable improvement compared to the bifrontal approach. Regardless of the selected surgical approach it is essential to avoid injury to the blood supply of the optic apparatus.Endoscopy will have a role in skull base surgery with