G. Iacob and Angela Olarescu
Despite cavernous malformations of the CNS are pathologically similar, intramedullary cavernous malformations are very rare lesions, increasingly recognized after introduction of magnetic resonance image, generating gradual neurological decline, with severe deficits or acute loss of spinal function. We report our experience on six patients with intramedullary cavernomas defining the spectrum of presenting symptoms and signs analyzing the role of surgery as a treatment for these lesions. We present our experience with 2 cervical and 4 thoracal spinal intramedullary cavernoma from 2010 to 2014 searching history, onset of clinical manifestation, neurological status, radiological findings, operation, and clinical outcome. Among 6 patients male were 2 cases; female 4 cases; mean age was 42 years (range 25-72 years); mean duration of symptoms were 1,5 years (range 5 days and 2 years) with slowly progressive neurological decline. In two cases there was acute onset of neurological compromise. In all cases diagnosis was made on MRI and lesions were possible to be radically excised and gently extracted from the hemosiderin-stained bed inside of the spinal cord via a laminectomy and midline myelotomy with microsurgical techniques. The surgical outcome on a mean duration of follow up of 12 months were: for 4 cases - the patients neurological conditions remarkably improved 1 month later, for 2 cases no improvement were remarked. No recurrent hemorrhages were recorded. A follow-up MRI examination was made in all cases to confirm complete removal of the cavernous angioma. Spinal intramedullary cavernoma should be early recognized by MRI, can be positioned in a precarious position and generate significant neurologic deficits than cranial cavernomas. For symptomatic intramedullary cavernous malformations extended to the dorsal surface of the spinal cord, total resection with microsurgical techniques can offer good or excellent outcome, restoring neurological status and to stop chronic deterioration and acute rebleeding. To asymptomatic patients with deeper lesions which entail a higher operative risk, but also a surgically manageable cause of myelopathy a closed observation is mandatory.
G. Iacob and M. Craciun
Objective: Atypical meningioma are an intermediate group of meningiomas, exhibiting less favourable biological behavior than classic benign tumours, but a relatively more favourable biological behavior than definitive malignant meningiomas. Subject of controversy, atypia in meningioma still generate discordance between accurate criteria defining malignancy and biological behavior, prediction of recurrence.
Methods: This retrospective study intend to evaluate diagnosis on clinical and pathological data, treatment trends and early outcomes for 6 cases with atypical meningiomas occuring in 63 patients operated for benign meningioma in the last 5 years in our clinic between 2006-2011. All patients were explored CT, MRI, preoperative selective angiography and in all cases the WHO 2000 classification criteria were used to define atypical meningioma
Results: Between 2006-2011 we operated 6 atypical meningioma of 63 benign meningiomas (9,52%). Tumor sites in the patients were: parasagittal (3 cases), convexity (2 cases), spheno-cavernous (1 case). All patients were operated and dural graft was done to all cases. The extent of surgical resection was Simpson’s grade 1 in 2 cases and Simpson’s grade 2 in four cases, to which radiation was administered after the first surgery with a dose ranging from 52-62 Gy. Regrowth (enlargement of tumour after subtotal resection) was noticed in 2 irradiated cases: one case after 2 years after the first operation, the patient was again operated - pathological diagnosis was malignant meningioma; in another case after 3 years, at operation it was the atypical meningioma. No chemotherapy was used in our cases.
Conclusions: Atypical meningiomas are rare tumors, grow more rapidely, the diagnosis age ≥ 60 years, several histological criteria can define accurate identification to understand the biology of this group of tumors. Heterogenous contrast enhancement with marked peritumoral edema in neuroimaging are important; cerebral edema has prognostic value and should encourage fundamental and farmacologic research using anti VEGF and somatostatine analogs treatments. Surgery (Simpson grade 1) referring both tumor and dural implant area should be done de novo but also for recurrencies. Radiotherapy still are controversial without proven benefit and chemotherapy without statistic argues to improve quality of life.
G. Iacob and C. Majer
G. Iacob and Andreea Marinescu
Idiopathic intracranial hypertension - IIH (synonymous old terms: benign intracranial hypertension - BIH, pseudotumor-cerebri - PTC) it’s a syndrome, related to elevated intracranial pressure, of unknown cause, sometimes cerebral emergency, occuring in all age groups, especially in children and young obese womans, in the absence of an underlying expansive intracranial lesion, despite extensive investigations. Although initial symptoms can resolve, IIH displays a high risk of recurrence several months or years later, even if initial symptoms resolved. Results: A 20-year-old male, obese since two years (body mass index 30, 9), was admitted for three months intense headache, vomiting, diplopia, progressive visual acuity loss. Neurologic examination confirmed diplopia by left abducens nerve palsy, papilledema right > left. At admission, cerebral CT scan and cerebral MRI with angio MRI 3DTOF and 2D venous TOF was normal. Despite treatment with acetazolamide (Diamox), corticosteroid, antidepressants (Amitriptyline), anticonvulsivants (Topiramate) three weeks later headache, diplopia persist and vision become worse, confirmed by visual field assessment, visual evoked potential (VEP). A cerebral arteriography demonstrate filling defect of the superior sagittal sinus in the 1/3 proximal part and very week filling of the transverse right sinus on venous time. Trombophylic profile has revealed a heterozygote V factor Leyden mutation, a homozygote MTHFR and PAI mutation justifying an anticoagulant treatment initiated to the patient. The MRI showed a superior sagittal sinus, right transverse and sigmoid sinus thrombosis, dilatation and buckling of the optic nerve sheaths with increased perineural fluid especially retrobulbar, discrete flattening of the posterior segment of the eyeballs, spinal MRI showed posterior epidural space with dilated venous branches, with mass effect on the spinal cord, that occurs pushed anterior on sagittal T1/T2 sequences cervical and thoracic. The opening pression of lumbar puncture, done with the patient in the lateral decubitus position, was 60 cm H2O, the cytochemical CSF study were normal. The patient was operated: a lombo-peritoneal with a variable pressure valve was inserted. Two months after the patient general condition improved: he was without headache, abducens palsy and the visual field assessment, ocular motility examination, ophthalmoscopy were normal. Conclusion: IHH is rare, variable in evolution, and in many cases it disappears on its own within 6 months without affecting life expectancy. Weight loss, fluid or salt restriction, in conjunction with medical treatment, angioplasty and venous stenting across the sinus stenosis under general anesthesia and surgical treatment (shunting, optic nerve sheath decompression and fenestration, gastric by-pass surgery) are treatment alternatives. Such disorder should be closed monitored because 10 to 25% of cases could be affected by recurrencies or by permanent vision loss to those patients with resistant papilledema despite treatment.
Background: to present personal experience in the surgical management of spinal meningiomas, also the literature results review too.
Methods: 32 patients (4 men and 28 women) harboring spinal meningiomas who had undergone microsurgical resection were treated between 2002 and 2012 in our department. Clinical presentation, diagnosis, histological examination, microsurgical resection, functional outcome were evaluated, defining potential prognosis factors associated with these lesions.
Results: tumors site was intradural, extramedullary with different topography: the most common the thoracic region, posterolateral and antero-lateral. In all cases neurologic improvement was noted after operation, without instability, despite the extent of preoperative deficits. Transient motor deficits were observed in 2 thoracal anterior placed tumors without mortality. In 2 cases with semimaligne meningioma (6,25%) recurrence was noted at one and two years after first operation, initial diagnosis was transitional type meningioma.
Conclusion: benign spinal meningiomas should have always early diagnosis and microsurgical total resection for a good outcome. For semimalignant or even malignant cases, radiotherapy should be considered.
G. Iacob, Silvia Tene, Mariana Iuga and G. Simion
Known as nerve sheath myxoma too, neurothekeoma are benign tumors, usually arise in the skin of the head, neck region and upper extremities, in young females. Cerebral neurothekeoma are very rare, a few cases were already described in the parasellar area, in the middle cranial and posterior fossa. We present a petro-clival neurotekoma. A 78-year-old male was admitted for two years left fronto-temporal headache completed in the last 6 months with left trigeminal V1 neuralgia, left facial hypoesthesia, diplopia, swallowing disorders for liquid foods, balance disorders. From his medical records we noticed: stage 2 chronic kidney disease, hypertension, prostate adenoma, dyslipidemia hypercholesterolemia. The MRI showed a macronodular petroclival mass in hiper T2, hipo T1, flair iso signal; normal cerebral angiography. The patient was operated on using a left retrosigmoid, retromastoidian approach. A 4/3/3 cm tumor, gray, encapsulated, soft consistency, partially cystic, less bleeding, attached to the dura, displacing the basilar artery and brain stem controlateral, encasing the trigeminal nerve. The tumor was totally removed with a good postop evolution. Six months follow up he had no more facial pain, but only persistant left facial hypoesthesia. Histologically the tumor had lobular appearance with spindle or stellate cells embedded in abundant myxoid background. The tumor cells were diffusely positive for S100, PGP9.5’, CD 34” positive in vessels, Ki67’positive in 5%. Cranial MRI performed one month after surgery did not show any residual tumor. Also known as nerve sheath myxomas, neurothekoma are rare benign tumors. For intracranial neurothekoma surgical indication is mandatory
Simona Alexandra Iacob, Eugenia Panaitescu, Diana G. Iacob and Manole Cojocaru
Cathelicidin LL37 is an innate immunity antimicrobial peptide involved in the immune modulation of IFN-Abstract Cathelicidin LL37 is an innate immunity antimicrobial peptide involved in the immune modulation of IFN-γ, the key cytokine of T helper cell type 1 (Th1) response. The role of LL37 in viral hepatitis inflammation is unknown. We assessed the serum variations of LL37 and the Th1 response in hepatitis C virus (HCV), hepatitis B virus (HBV) and hepatitis D virus (HDV) infections. The LL37 level (Elisa detection) and Th1 response (defined by IFN-γ level, CD4+ and CD8+ T cell count) were analyzed in 87 patients: 65 hepatitis patients (34 HCV, 18 HBV, 13 HDV) and 22 healthy controls. The subjects, 33 males/ 54 women aged 20-64 years, were selected at "Matei Bals" Institut, Bucharest, Romania. Hepatitis patients were classified according to viral etiology and viral replication as active cases (detectable viremia) versus negative cases (undetectable viremia). Student T test and Mann Whitney analysis were applied. High levels of LL37 (138.09±88.45ng/ml, p=0.045) and IFN-γ (69.82 pg/ml, p=0.005) were detected in the whole group of hepatitis. Active HCV hepatitis presented a significant increase in LL37 level (155.15±78.84ng/ml, p=0.014) and Th1 response by comparison with inactive HCV hepatitis. Conversely active HBV patients displayed low LL37 levels (76.75ng/ml, p=0.009) and no Th1 dominant response by comparison with inactive B hepatitis. High levels of LL37 up to 171.01±72.08 ng/ml and a moderate Th1 response defined HDV patients. Our results highlights increased levels of the cathelicidin LL37 in all viral hepatitis correlated with a strong and concordant immune response in active HCV hepatitis. , the key cytokine of T helper cell type 1 (Th1) response. The role of LL37 in viral hepatitis inflammation is unknown. We assessed the serum variations of LL37 and the Th1 response in hepatitis C virus (HCV), hepatitis B virus (HBV) and hepatitis D virus (HDV) infections. The LL37 level (Elisa detection) and Th1 response (defined by IFN-γ level, CD4+ and CD8+ T cell count) were analyzed in 87 patients: 65 hepatitis patients (34 HCV, 18 HBV, 13 HDV) and 22 healthy controls. The subjects, 33 males/ 54 women aged 20-64 years, were selected at "Matei Bals" Institut, Bucharest, Romania. Hepatitis patients were classified according to viral etiology and viral replication as active cases (detectable viremia) versus negative cases (undetectable viremia). Student T test and Mann Whitney analysis were applied. High levels of LL37 (138.09±88.45ng/ml, p=0.045) and IFN-γ (69.82 pg/ml, p=0.005) were detected in the whole group of hepatitis. Active HCV hepatitis presented a significant increase in LL37 level (155.15±78.84ng/ml, p=0.014) and Th1 response by comparison with inactive HCV hepatitis. Conversely active HBV patients displayed low LL37 levels (76.75ng/ml, p=0.009) and no Th1 dominant response by comparison with inactive B hepatitis. High levels of LL37 up to 171.01±72.08 ng/ml and a moderate Th1 response defined HDV patients. Our results highlights increased levels of the cathelicidin LL37 in all viral hepatitis correlated with a strong and concordant immune response in active HCV hepatitis.
G. Iacob, M. Crăciun, Liliana Parascan and Maria Sajin
A rare case of giant intra and parasellar chordoma, mimicking a pituitary prolactinoma is presented. The tumor involving pituitary fossa and surrounding structures was removed via a bifrontal approach. The pathology exhibited the typical histological patterns of a chordoma. The authors present a rare case of a giant sellar and parasellar chordoma and review the literature on that.
G. Iacob, B. Rotund, A. Iancu, A. Madalan, Andreea Marinescu and G. Simion
A very rare, purely intradural, spinal, extramedullary cavernous hemangioma was fortunately discovered in a 56 years old woman, presenting with bilateral brachial paresthesia. Using conventional spin-echo T1 proton density, T2-weighted magnetic resonance and gadolinium images an intradural spinal T4-T5, an extramedullary cavernous hemangioma was discovered. The patient underwent surgery, with laminectomy and microsurgical resection followed by an uneventful postoperative clinical course. Similar as in cerebral locations a mixed signal intensity in all sequences on magnetic resonance images might be indicative of cavernous hemangioma, rendering a presumptive preoperative diagnosis of the lesion and surgical planning for a good microsurgical resection.