Minimally invasive neurosurgery
’First, do no harm’ is the principle that lead medicine towards minimally invasive approaches. The extraordinary technological advancement of the last decades fastened the development of all medical fields. Endoscopes, the high power surgical microscopes, neuronavigation, the extraordinary anaesthetic procedures allow safer and more precise surgical interventions. Minimally invasive neurosurgery or keyhole neurosurgery offers the patients the possibility to have surgery with minimal neurologic, medical, infectious and aesthetic risk.
Neuronavigation allows choosing the optimum approach with minimal tissue destruction from skin to the brain. The approach is tailored as the exposure of the brain is the minimal possible without altering the main goal of the surgery. The fast rehabilitation, the decrease of the perioperative stress and emotions, the avoidance of the need to shave the head are important advantages of the keyhole neurosurgery.
Our team is involved not only into the surgery of the patient, but also in all the other aspects of the necessary treatment like radiotherapy, chemotherapy, interventional radiology, rehabilitation etc. The optimal results are obtained when multidisciplinary meetings take place and the patient gets a plan of the treatment from the beginning. Every patient is unique, consequently the treatment needs to be optimised accordingly.
Minimally invasive techniques require the use of state-of-the-art technology. Operator endoscopes of various types, dedicated operator microscope, neuronavigation, neuroelectrophysiology, advanced anesthesia techniques, awake patient surgery represent an armamentarium without which neurosurgery by “keyhole” would not be possible. Using the techniques above, we treat a broad spectrum of cranio-cerebral pathologies.
Glioblastoma
It is the most common primary cerebral tumor (which develops from cerebral tissue) in adults. It is classified by the World Health Organization as IV grade (the most aggressive type of tumor). Glioblastomas grow rapidly and infiltrate the neighboring brain tissue. Treatment involves a multidisciplinary approach including surgery, chemotherapy and radiotherapy.
It is the most common primary cerebral tumor (which develops from cerebral tissue) in adults. It is classified by the WHO (World Health Organization) as IVth grade (the most aggressive type of tumor). Glioblastomas grow rapidly and infiltrate neighboring brain tissue. They can occur at any age, but it is typically between 45 and 70 years old.
Signs and symptoms in order of frequency are:
• epileptic seizures
• Progressive headaches
• progressive loss of brain function such as speech, muscle strength, memory, ability to be careful, behavioral disorders, etc.
The causes are unknown, but there are plenty of ongoing studies to identify them.
There are no known risk factors.
You have most likely been seen by your family doctor. If your doctor suspected you had a brain tumor such as a glioblastoma, he probably sent you to a doctor who deals with brain diseases (neurologist or neurosurgeon). Here are some information that will help you prepare for the specialist consultation.
What can you do?
• Write any symptoms you have, including those that seem unrelated to the reason for your presentation
• Write any personal information, including any major stress or recent life changes
• Make a list of all the medicines you are taking, including vitamins, dietary supplements or alternative medication
• You are advised to come with a family member or a friend, if possible. Sometimes it is difficult to remember all the information that is given to you during a consultation. So, your family can help you remember the information you provided during the consultation.
• Write the questions you would like to ask your doctor during the consultation. Prepare a list of questions to help you make the most of your time in consultation with your doctor. For a glioblastoma, some questions that you can formulate include:
• Is glioblastoma a cancerous tumor?
• How serious is my illness?
• What are the advantages of treatment compared to its lack?
• What treatment do you recommend?
• How urgent is the treatment?
• What are the potential complications of a treatment?
• Are long-term complications that I should know about?
• Where can I find additional information about my illness?
Do not hesitate to ask any other questions. Diagnostic CT and MRI imaging with and without contrast, MRI perfusion and MR spectroscopy, make the presumptive diagnosis of glioblastoma. Diagnosis of certainty is done by an anatomopathological and immunohistochemical examination.
Diagnostic CT and MRI imaging with and without contrast, MRI perfusion and MR spectroscopy, make the presumptive diagnosis of glioblastoma. Diagnosis of certainty is done by an anatomopathological and immunohistochemical examination.
For a glioblastoma, patients require surgery to:
• retrieve bioptic material for the anatomopathological examination and establishing the diagnosis
• The most complete removal of tumor volume – this is possible in approximately 70 percent of cases, for the rest of 30% of cases, the risk of neurological deterioration impeding a total resection (total resection is defined as removal of the entire tumor contrast verified by the postoperative MRI exam)
Conformational radiotherapy – is usually recommended at 4 weeks – one month after diagnosis. Radiotherapy is usually 5 days a week for 6 weeks.
Chemotherapy – Temozolamide is used today, given daily during the six weeks of radiotherapy, and then as a single agent every 5 days a month for one year after surgery. The combination of chemotherapy and radiotherapy improves prognosis, especially in some patients with an inactivated gene (deletion). There are many studies that are currently underway and where new technologies are being tested for the treatment of glioblastomas, but to date there have been no advantages over classical treatment.
Meningioma
Meningioma is a tumor that develops from the cerebral meninges (the membrane that surrounds the brain and spinal cord). Most meningiomas are benign (noncancerous) tumors, although rarely they can be malignant (cancerous). Some meningiomas do not necessarily require immediate treatment, so, depending on size, symptoms etc a meningioma can be followed up only.
Meningioma is a tumor that develops from the cerebral meninges (the membrane that surrounds the brain and the spinal cord). Most meningiomas are benign (noncancerous) tumors, although rarely they can be malignant (cancerous). Some meningiomas are called “atypical”, meaning they are neither malignant nor benign, but between the two. Most commonly, meningiomas occur in women over 50 years of age, but they can occur at any age in both women and men. Some meningiomas do not necessarily require immediate treatment, so a meningioma that does not produce symptoms can only be followed up over time.
Signs and symptoms of meningiomas are, at the beginning, often subtle. Depending on their location in relation to the brain, less commonly with the spinal cord, the signs and symptoms may include:
• headaches that worsen over time
• decrease in visual acuity, double vision
• hearing loss
• memory disorders
• loss of smell
• decreasing muscle strength in limbs
• paralysis of half the face, etc.
• epileptic seizures – suddenly occurring and life-threatening
Signs and symptoms of a meningioma develop slowly, but sometimes a meningioma requires urgent treatment. You must present yourself to the emergency room if you have:
• sudden onset of an epileptic seizure
• a sudden change in vision, memory, or consciousness
Ask for a doctor’s appointment if you have a persistent sign or symptom that worries you, such as a headache that is accentuated by the passage of time.
The exact causes of meningioma are unknown. It is known that some meningeal cells (the protective membrane that surrounds the brain and spinal cord) suffer changes that lead to the loss of control over their multiplication, resulting in the appearance of meningiomas. Factors related to inherited genes, the environment, hormones seem to be involved, but without knowing exactly how they act.
The risk factors known to occur in meningiomas are represented by:
• Cranio-cerebral radiotherapy – radiation treatment of the head may increase the risk of meningiomas
• Female hormones – meningiomas are more common in women, which means that hormone factors play a role in the development of these tumors
• Family-related diseases (genetics) – Example: Type 2 neurofibromatosis increases the risk of many brain tumors, including meningiomas.
A meningioma and its treatment, usually surgery and/or radiotherapy, can lead to long-term complications such as:
• Attention problems
• memory problems
• Personality changes
• epilepsy
Some of these complications can be treated, and others can provide specialist support to improve the quality of life.
You have most likely been seen by your family doctor. If your doctor suspects that you have a brain tumor, such as a meningioma, he probably sent you to a doctor who deals with brain diseases (neurologist or neurosurgeon). Here’s some information to help you prepare for a specialist consultation.
What can you do?
• Write any symptoms you have, including those that seem unrelated to the reason for your presentation
• Write any personal information, including any major stress or recent life changes
• Make a list of all the medicines you are taking, including vitamins, dietary supplements or alternative medication
• You are advised to come with a family member or a friend, if possible. Sometimes it is difficult to remember all the information that is given to you during a consultation. So, your attendant can help you remember the information you were provided during the consultation.
• Write the questions you would like to ask your doctor during the consultation. Prepare a list of questions to help you make the most of your time in consultation with your doctor.
For a meningioma, some questions that you can formulate include:
• Is my meningioma cancerous?
• How big is my meningioma?
• Does my meningioma grow? How fast?
• What treatment do you recommend?
• Is treatment necessary now, or is it better to observe treatment (“wait and see”)?
• What are the potential complications of a treatment?
• Are long-term complications that I should know about?
• Should I look for a “second opinion”? Can you recommend another doctor or other hospital that has experience in treating meningiomas?
• Where can I find additional information about my illness?
• Do I have to make a decision on the treatment quickly? How long can I wait? Do not hesitate to ask any other questions.
A meningioma can be detected by imaging tests, as follows:
• Cranio-cerebral or spinal CT (CT). The CT scan produces images of the examined area by X-ray technology. It is a method of choice for assessing bone anatomy, calcifications and bleeding. For further details, this review is less informative than MRI.
• Magnetic resonance imaging – MRI. Does not expose the body to radiation and provides fine details of the anatomy and functions of the area under examination. It is the examination of choice in the cranio-cerebral and spinal meningiomas.
• Digital Subtraction Arteriography (DSA) – rarely, angiographic evaluation of meningiomas is required to establish a therapeutic strategy.
The treatment that is offered for a meningioma depends on many factors, such as the size of the meningioma, its location, its aggressiveness, etc. Your doctor will take into consideration all these aspects before offering you an optimal treatment plan.
Observation – simple follow up
Immediate treatment is not necessary for all patients who have a meningioma. A small meningioma that grows slowly and does not cause signs or symptoms may not require treatment. If the “wait and see” method is considered the optimal plan, or you have chosen it, then it is recommended that you periodically do craniocerebral MRI exams to monitor growth and other signs of evolution (eg. Cerebral edema). If your doctor has determined that your meningioma grows and requires treatment, you have several therapeutic options.
Surgery
If your meningioma causes signs or symptoms or if it grows, your doctor may recommend surgery. The surgeon tries to make a full resection whenever possible. But because meningiomas can appear next to delicate structures, it is not always possible to remove the tumor entirely. The surgeon will remove as much as possible from the tumor.
The type of treatment you need after surgery (if one is needed) depends on a few factors:
• If there is no visible tumor – usually no treatment is needed. However, a periodic imaging follow-up (typically MRI) is required
• If the tumor is benign and only a small part of the tumor persists, your doctor may recommend only a periodic follow-up (usually MRI). In some cases, small tumoral debris can be treated with a form of radiation called stereotactic radiosurgery (Gamma Knife or LINAC – Cyber Knife, Novalis, etc.)
• If the tumor is atypical or malignant, you will probably need radiotherapy
Surgery can have risks, including infectious and haemorrhagic. The specific risk for your meningioma depends mainly on localization. For example, surgery for a meningioma that is around an optic nerve may lead to loss of vision. Ask your surgeon about the specific risks of your surgery.
Radiotherapy
Sometimes, due to location or risk factors for your other diseases, surgery is contraindicated. In these cases, radiotherapy is an alternative, with the aim of destroying the tumor cells so that tumor growth is stopped. Forms of modern radiotherapy are represented by: fractionated stereotactic radiotherapy, conformational radiotherapy (IMRT), etc.
Radiosurgery
Radiation surgery is a type of radiation therapy that provides a therapeutic dose only at the target volume, the rest of the tissues receiving a very low radiation dose, usually nontraumatic. Contrary to the name, radiosurgery does not require scalp incisions. As a rule, radiosurgery is performed in outpatients, requiring several hours in the clinic. Radiation surgery may be an option for meningioma that cannot be resected or for tumor regrowth. A limiting factor in the use of radiosurgery is the tumor volume (lesions have to have a diameter of under 3 cm).
Fractionate radiotherapy
For tumors too large for radiosurgery, or those that have structures in the vicinity that cannot tolerate high doses required by radiosurgery (the optic nerve), a possible option is the fractionation of radiation. This means administering small doses of repeated radiation several times. For example, a treatment may require a daytime radiation session for 30 days.
Chemotherapy
Chemotherapy is the last line of treatment when there is no response to surgery and radiotherapy. Unfortunately, there is no evidence of the efficacy of this treatment, but some medicines, such as hydroxyurea, are sometimes used.
Being diagnosed with a meningioma can be very stressful. Once you are diagnosed, your life can change radically, with visits to doctors and surgeons, to prepare a treatment plan. Learn everything you can about meningiomas:
• from the healthcare team
• credible online sources, usually recommended by specialists
• write the questions for the doctors you are going to consult – the more you know about your problem, the more prepared you will be to make the right decision about your treatment.
Build a support network
• family and friends support can be useful to manage your emotions
• A psychological consultation can help
• A conversation with a leader of the spiritual society you are part of can be useful (priest, rabbi, or other spiritual leader)
• there are support groups in your community or online
Try to stay healthy during treatment for meningioma, taking care of yourself. Eat a diet rich in fruits and vegetables and do moderate daily exercise if your doctor allows you. Sleep well enough to feel recreated. Reduce stress in life, focusing on what matters to you.
Vestibular schwannoma (acoustic neurinoma)
Vestibular schwannoma (acoustic neurinoma) is a rare, benign tumor that usually grows slowly and develops from the vestibular nerve (balance) near the acoustic and the facial nerves. Because of the pressure on these structures, signs and symptoms such as hearing loss often accompanied by constant and persistent sound in the affected ear, balance problems, and rarely facial paresis, are incipient signs of tumor progression.
Vestibular schwannoma (acoustic neurinoma) is a rare, benign tumor that usually grows slowly and develops from the vestibular nerve near the acoustic and facial nerves that link the brain to the inner ear. Because of the pressure on these structures, signs and symptoms such as hearing loss often accompanied by constant and persistent sound in the affected ear, balance problems, and rarely facial paresis, are signs of tumor progression. These tumors grow slowly, and although they are sometimes very small at the time of diagnosis, they require specialized treatment. The treatment may include surgery, radiosurgery and then follow-up imaging (MRI).
They appear due to the effect of the compression on the nerve in which they develop (vestibular), or due to compression on adjacent vasculo-nervous structures. With tumor growth, signs and symptoms are more likely to occur, although tumor size is not always correlated with symptomatology. Thus, it is possible that a small tumor produces significant signs and symptoms.
You may experience the following signs and symptoms:
• hearing loss, unilaterally, usually gradual, although in some cases it occurs suddenly
• continuous sound in the ear (tinnitus, tingling) in the affected ear
• loss of balance
• vertigo (rotation of the room/space around the patient)
• decreased facial sensitivity
• very rare weakness of facial muscles
• exceptionally, when the tumors are very bulky, signs of hydrocephalus and brain stem compression may occur – small steps, memory disorders, urinary incontinence, consciousness alteration, hemicorporeal motor deficits, etc. These are life-threatening medical conditions.
Ask your doctor if you notice a loss of hearing, permanent earache, or an equilibrium disorder. An early diagnosis of a vestibular schwannoma can prevent its dangerous growth so as to cause serious consequences such as total loss of hearing or hydrocephalus that can threaten your life.
The causes of vestibular schwannoma are not known exactly, but seem to be due to genetic disorders in a gene that controls the growth of Schwann cells around the nerves. These defects are usually not inherited. This gene can be inherited in type 2 neurofibromatosis, a very rare disease, which usually causes bilateral vestibular schwannomas.
The only known risk factor is type 2 neurofibromatosis, but it is responsible for a very small part of the vestibular schwannomas. It is an autosomal dominant disease, meaning that the gene can be transmitted only from a single parent with the affection. Every child has a 50 percent risk of being affected.
A vestibular schwannoma can produce permanent complications such as:
• hearing loss
• altering the sensitivity of the face
• Affecting muscle strength at the facial level – facial paresis
• Issues of balance
• permanent earache – tinnitus
• dry eyes on the affected part, which may develop in extremis to corneal lesions.
• Large tumors can compress the brain stem, preventing normal drainage of the CSF (the normal fluid around the brain and spinal cord), resulting in excess accumulation of the CSF. In this case, obstructive hydrocephalus, which may be life-threatening, occurs.
You have most likely been seen by your family doctor. Your doctor can direct you to an ENT doctor (oto-rhino-laryngologist), or to a neurosurgeon.
Here’s some information to help you prepare for the consultation.
What can you do?
• Write any symptoms you have, including those that seem unrelated to the reason for your presentation
• Make a list of all the medicines you are taking, including vitamins, dietary supplements or alternative medication
• You are advised to come with a family member or a friend, if possible. Sometimes it is difficult to remember all the information that is given to you during a consultation. So, your attendant can help you remember the information you provided during the consultation.
• Write the questions you would like to ask your doctor during the consultation. Prepare a list of questions to help you make the most of your time spent in consultation with your doctor. For a vestibular schwannoma some questions that you can formulate include:
• What causes my symptoms?
• Are there other possible causes for my symptoms?
• What types of tests do I need?
• What treatment options do I have?
• What is the treatment recommendation?
• What is the probability of side effects for each treatment?
• What happens if I do nothing?
• Is treatment necessary now, or is it better to observe treatment (“wait and see”)?
• Are long-term complications that I should know about?
• Should I look for a “second opinion”? Can you recommend another doctor or hospital with experience in the treatment of vestibular schwannomas?
• Where can I find additional information about my illness?
Do not hesitate to ask any other questions.
Signs and symptoms caused by a vestibular schwannoma are often subtle and slowly progressive. This is why it is sometimes difficult to diagnose it in early stages of the disease.
After history taking and clinical examination, your doctor may ask for more exams, including:
• tonal and vocal audiogram – determines and classifies hearing deficiency. • ophthalmologic exam – Schirmer test (possibly accompanied by a biomicroscope exam) to determine the deficiency of tears on the affected part
• Medical imaging examinations – Cranio-cerebral CT – less commonly used, gives more accurate information about bone damage and does not have metric errors. Cranio-cerebral MRI – provides more detailed information on the anatomy and function of the area under examination.
Treatment is variable, depending on size and symptoms. Your doctor may recommend the following options:
• Wait and see: In the case of very small asymptomatic tumors, this strategy was used, which is now obsolete. In these cases, it is shown that there is a higher risk of hearing loss in untreated (followed-up) patients than in those treated with Gamma Knife radiosurgery. In other words, there is a loss of chance of keeping a functional hearing for the rest of life in patients who are just being watched. Thus, this option can only be recommended to patients who have very small tumors with complete hearing loss or inoperative hearing. Even a nonfunctional, but not absent, hearing has a role in locating the sound in space, so lack of treatment is questionable.
•Stereotactic Radiosurgery (Gamma Knife) Your doctor may recommend stereotactic radiosurgery when you have a relatively small tumor. The purpose of stereotactic radiosurgery is to stop tumor development, preserve facial function and possibly preserve hearing. Complications of radiosurgery are hearing loss (lower risk than surgery), tinnitus (permanent noise in the ear), facial hypoesthesia, balance problems, treatment failure (approximately 2%).
•Surgical resection You may need a surgeon for the vestibular schwannoma resection. The purpose of surgery is to remove the tumor by preserving facial function and preserving hearing when possible. Surgery is performed under general anesthesia, usually using an incision of about 4 cm behind the ear. Sometimes it is not possible to completely remove the tumor due to its adherence to structures such as the brain stem or the facial nerve. In the case of residual tumor, patients are followed up and at the smallest sign of progression they are sent for radiosurgical treatment. Surgery may have complications, including worsening of symptoms, if some nerves or vasculo-nervous structures are damaged.
Complications may include:
• CSF leak
• hearing loss
• facial paresis
• decreasing facial sensitivity
• permanent earache
• tinnitus
• balance problems
• persistent headache
• meningitis
• Vascular lesions or intracranial hemorrhage
The stress you are undergoing knowing you can lose hearing and you can have a facial paralysis and decide which treatment is best for you is one that can be very important. Here are some suggestions that can help you manage this stress:
• The more you know about your affection, the better your choice of treatment
• a psychologist can help
• Ask other patients who have had the same problems
• family and friends can help you get over the stressful periods
Cerebral aneurysms
Cerebral aneurysms are abnormal dilations of cerebral arteries, usually saccular, but may also be fusiform. A cerebral aneurysm may rupture, leading to a bleeding in the brain and most often around it. A ruptured aneurysm is a surgical emergency. Frequently, aneurysms are discovered during investigations for other health problems. In these cases, treatment is usually needed to avoid a future rupture that is life-threatening.
Cerebral aneurysms are abnormal dilations of cerebral arteries, usually saccular, but they may also be fusiform. A cerebral aneurysm can rupture, leading to a bleeding into the brain and most often around it (subarachnoid hemorrhage – arachnoid being a fine membrane surrounding the cerebral vessels and the brain, part of the cerebral meninges). Frequently, aneurysms are found on investigations for other health issues, which are unruptured, that is, aneurysms that have not yet bled. In these cases, treatment is often needed to avoid a future rupture that may be life-threatening.
Ruptured aneurysms:
A sudden, intense headache, “the most important of one’s life” is the most common symptom of a ruptured aneurysm.
• extreme headaches
• nausea and vomiting
• meningeal signs – rigid neck, light sensitivity, etc
• visual disturbances, double vision
• epileptic seizures (rare)
• nerve palsy III (closure of an eyelid)
• loss of consciousness
• confusion, etc
Unruptured aneurysms
They often do not produce symptoms or signs. There are some aneurysms, usually large, that can produce symptoms through the “mass” effect they exert on the surrounding structures (pressure):
• pain
• third cranial nerve palsy – dilated pupil and / or fall of an eyelid
• visual disturbances
double vision
• motor and / or sensitive disorders.
A headache considered “the most important in one’s life”, which suddenly installs is an emergency and you need immediate medical care.
Aneurysms usually develop at the level of arterial bifurcations, most often at the base of the brain. The exact cause of this weakness in the vascular wall is not well understood. A small percentage are caused by genetic determinations, traumatic causes or infectious causes, usually mycotic.
Aneurysms are more common in adults than in children and more common in women than in men. We enumerate below some of the risk factors that are supposed to have an involvement in the occurrence of aneurysms:
• old age
• smoking
• hypertension
• arteriosclerosis
• drug abuse (cocaine)
• cranial trauma
• alcoholism
• systemic mycoses, etc
Inherited Causes • collagen diseases – Ex Ehlers Danlos • polycystic kidney disease • Aortic coarctation • Cerebral arterio-venous malformations • family history of aneurysms (brother, sister, father, mother)
When a cerebral aneurysm ruptures and the patient survives, bleeding usually takes seconds or minutes. There are injuries to nerve structures and sometimes vascular surroundings. There may also be an increase in intracranial pressure. If the pressure increases too much, the blood supply to the brain becomes inadequate, and the brain becomes hypofunctional or nonfunctional, leading to the onset of loss of consciousness, or even death. The most common complications after the rupture of an aneurysm are:
• death
• rebleeding – maximum risk (approximately 6%) within the first 24 hours after initial bleeding, then 1-2% for the next 30 days.
• Vasospasm – After an aneurysmal rupture, stenosis of the cerebral vessels may occur, which may be so important that blood flow to the brain is insufficient, which can lead to the death of the brain tissue. The risk of vasospasm is maximum between days 4 and 20 of the initial rupture.
• Hydrocephalus – Extravasated blood (which has drained out of the vessel) can obstruct the drainage and resorption pathways of the CSF, which may lead to excessive accumulation and increased intracranial pressure, which defines hydrocephalus. Hydrocephalus can lead to coma, and untreated, to death.
• Hyponatremia – due to alteration of the functioning of the hypothalamus, it can lead to cerebral edema and in extreme cases to death.
Frequently, aneurysms are detected after rupture, and you need immediate medical care. If you have been diagnosed with a cerebral aneurysm that has not ruptured, you will need to consult a neurosurgeon.
Prepare a list of questions to help you make the most of your time in consultation with your doctor. For an unruptured brain aneurysm, some questions that you can formulate include:
• What is the size and location of aneurysm and what impact do they have on the risk of bleeding?
• Are imagistic information (angiography, angioIRM, angioCT) important in determining the risk of bleeding?
• What treatment do you recommend at this time?
• If I do not treat the aneurysm, how often do I have to go into control and what tests do I have to do?
• What can I do to reduce the risk of an aneurysm to rupture?
Do not hesitate to ask any other questions.
Diagnostic
If you present yourself as an emergency, the usual tests are: Cranio-cerebral CT: it quickly identifies bleeding with great sensitivity and specificity, and if contrast is added, an AngioCT can be performed, which shows the cerebral aneurysm. Tests of the cerebrospinal fluid – by puncture on the lumbar spine – identify the bleeding and how old it is or it excludes an infectious meningitis. Cranio-cerebral MRI – can evaluate bleeding, vascular anatomy, brain damage caused by bleeding, ischemic lesions, hydrocephalus, etc. Digital subtraction angiography – involves the placement of a flexible catheter through which the contrast agent is injected into the cranio-cerebral arteries, thus providing detailed images of the cranial-cerebral vascular tree.
Screening for brain aneurysms
Screening is the assessment of the asymptomatic population in order to detect a potential aneurysm. Screening in the general population is not indicated. If there is more than one family member who has had bleeding from cerebral aneurysms, or a congenital illness that increases the risk of cerebral aneurysms (collagenosis, polycystic kidney, etc.) then a screening is required.
Surgical Clipping – Using microsurgical techniques, which can be minimally invasive, the aneurysm is excluded from the circulation by applying one or more clips to the aneurysm neck.
Endovascular Coiling is done usually through the waist of the thigh. Coils (specially constructed wire loops) are inserted through catheters, from inside the vessels, to occlude the aneurysm, excluding it from circulation. Both types of treatment have risks, especially brain bleeding and ischemia (loss of blood flow leading to the death of areas in the brain). Endovascular treatment is less invasive and can be initially safer, but it also has a higher risk of rebleeding over time and may require additional procedures. Your neurosurgeon will recommend you to one of the two possible treatments, depending on your age, location and form of the aneurysm, associated diseases, your option, etc.
Other treatments
• painkillers
• calcium channel blockers – reduce the risk of serious vasospasm
• antiepileptic – in patients with epileptic seizures
• Intra-arterial vasodilation – mechanical or endovascular drug therapy (necessary for patients with vasospasm resistant to medical treatment – triple H therapy)
• external ventricular drainage, followed, if necessary, by internal drainage (ventriculo-peritoneal, pleural, cardiac, etc.) – see hydrocephalus
• medical recovery – in case of neurological deficits, patients require medical recovery programs (kinesiotherapy, speech therapy, psychologist, etc.)
Surgical clipping.
Endovascular coiling.
In some cases, the risk of intervention may outweigh its benefit. The neurosurgeon can help you make the informed decision. In order to make the decision, factors such as size, location, your age, your health, family history, congenital illnesses that may increase the risk of bleeding will be taken into consideration. Controlling blood pressure is important, as does smoking cessation. Smoking has been shown to be a risk factor in the appearance, growth and rupture of aneurysms.
How do you change your lifestyle if you are diagnosed with an unruptured brain aneurysm?
• Do not smoke or use drugs
• Eat healthy and moderate daily exercise (blood pressure control)
• limit caffeine consumption as it may lead to transient increases in blood pressure, which may precipitate aneurysmal rupture
• Avoid lifting weights or making other efforts
Hydrocephalus
Hydrocephalus is a disease characterized by excessive accumulation of CSF inside the cranial cavity. The CSF is a fluid normally produced in organs within the brain and is mostly absorbed at the level of the meninges (a membrane that protects the brain and spinal cord) through its specialized organs. When there is an imbalance between production and resorption, hydrocephalus results.
Hydrocephalus is a disease characterized by excessive CSF accumulation inside the skull. The CSF is a fluid normally produced in organs within the brain and is mostly absorbed at the level of the meninges (the membranes that protects the brain and the spinal cord) through its specialized organs. When there is an imbalance between production and resorption, hydrocephalus results.
In general, there are two types of hydrocephalus, depending on the level of obstruction. If there is an obstacle (eg a morphological abnormality, a tumor) in the normal drainage pathways of the CSF, then it is called obstructive hydrocephalus. If the resorption is deficient due to a malfunction of the resorption organs (frequently, in the elderly, an atrophy of the resorption organs occurs), then it is called a communicating hydrocephalus. Frequently there is mixed hydrocephalus in which there is both a resorptive and an obstructive problem (infections, intracranial bleeding, etc.).
Hydrocephalus treatment is surgical and aims to drain the excess CSF. When hydrocephalus is obstructive, we can frequently proceed with an endoscopic, minimally invasive treatment (Ex VCS – ventriculo-cisterno-stoma), or, if possible, remove the cause of the obstruction (tumor, hematoma, etc.). These two treatments provide the patient with the chance to avoid introducing into the body a mechanical drainage device that has significant risks (up to 40% of cases per year – infection, obstruction, tearing, etc.). When the cause of hydrocephalus is a resorptive one, the surgeon may be required to proceed with the implantation of a mechanical drainage devices. The surplus of fluid is drained into natural body cavities such as peritoneum, heart, chest, etc.
Sometimes there are transient hydrocephalus causes (eg bleeding) that are initially treated with external drainage (outside the body) that can be left attached by the patient for up to a few weeks until hydrocephalus resolves.
Signs and symptoms of hydrocephalus are due to increased intracranial pressure and possibly dilation of cerebral ventricles (cavities filled with CSF within the brain). If fluid accumulation is slow, allowing for some adaptability of brain tissue, the patient may stay for long periods without clear signs or symptoms. The rapid increase in intracranial pressure (or reaching a threshold) and possibly the size of the ventricles leads to the rapid appearance of the symptoms. Headache is an important symptom. It may vary in intensity, may be continuous or intermittent, is usually more intense in the morning and may be associated with nausea and vomiting. Patients often experience personality and behavioral disorders such as:
– irritability
– indifference
– losing interest in everything that surrounds them
– aggressiveness and impulsivity
– memory disorders
Hydrocephalus patients may also have difficulty walking (walking slowly, with small, unsteady steps, with legs more distant than normal), urinary incontinence, and cognitive impairment. When hydrocephalus progresses, it affects consciousness. Initially the patient is lethargic, asleep, and in extreme stages the patient is in a coma. The succession of these signs can be fast in a few hours, or it can take years, depending on the trigger cause.
All the signs and symptoms above lead to the patient’s presentation to the doctor. Once the suspicion of hydrocephalus is raised, a medical imaging examination (CT or MRI) is required, which in most cases can make the diagnosis of hydrocephalus. Sometimes, diagnosis can not be confirmed by imaging, and additional tests are required that are usually done in a neurology clinic (neuropsychological testing, lumbar puncture, CSF pressure measurement). If the tests are positive and after a discussion with the neurosurgeon you may require a CSF drainage treatment.
The patient diagnosed with hydrocephalus is oriented to the neurosurgeon. Depending on the type and severity of hydrocephalus, the optimal treatment will be evaluated. Thus, a treatment may be proposed for the removal of the obstructive pathology (ex tumor), an external drainage, a ventriculo-cisterno-stoma, or a ventriculo-peritoneal drainage.
The patient can reach the surgeon in a critical condition (in a coma or with major consciousness disorders), this situation requiring urgent surgical treatment. If the symptoms are not so important, the treatment should be done so that the timing for surgery is optimal. Hydrocephalus is a serious problem, so the patient does not have to waste time before attending a neurosurgeon.
1. Removal of the obstruction – which can mean removal of the obstruction – The excellent technical platform at Provita Hospital includes an operating microscope, endoscopes, an ultrasonic aspirator (removes tumors without manipulating surrounding normal tissues), electrophysiological monitoring (potentially evoked sensory and / cranial and / or peripheral, cortical stimulator, etc.).
2. External ventricular drainage (CSF drainage via a tube mounted inside the head connected with a special bag, located near the patient’s bed). This is a short intervention, which takes about 10 minutes. It requires an 1 cm incision behind the hair insertion line, perforating the skull with a special high-speed bur and inserting the drain tube into the ventricles and then attaching it to the drainage bag outside the patient’s body.
3. Ventriculocisternostoma – It is an endoscopic intervention, it takes about 30 minutes. It requires an 1 cm incision behind the hair insertion line, perforating the skull with a high speed bur, and inserting an endoscope (<3 mm diameter) into the lateral ventricle, then into the third ventricle (the ventricles are cavities inside the brain). A hole is going to be done in the floor of the third ventricle with different instruments. Once the communication is created, the endoscope is withdrawn and the skin is closed with resorbable sutures, which do not require removal (falling alone under the shower).
4. Internal ventricular drainage (ventriculo-peritoneal, atrial, pleural, etc.). They are short interventions, that take about 30 minutes. The intervention requires two small incisions, a cranial one behind the right ear and an abdominal one, and the implantation of a catheter from the ventricles to the peritoneum. The catheter incorporates an opening pressure valve.
Complications characteristic for any neurosurgical intervention are:
– anesthetic – the patient must be put to sleep and awaken – with the technology and specialization of the anesthetic team these risks are very low
– thromboembolic risks – minimized by preoperative evaluation and by preoperative, peroperative and postoperative active measures
– infectious risk – about 1% for operations that do not require the insertion of a mechanical drainage device;
– surgical risks: interventions for obstructive lesions (tumors, hematomas, etc.) have site-specific risks. These will be explained to the patient at the time of the neurosurgical consultation.
External ventricular drainage has a primary risk of infection (5% on average and increases with time). If the CSF resorption does not return to normal, further surgical treatment is required.
Internal ventricular drainage (ventriculo-peritoneal, ventriculo-cardiac, etc.) has a higher than other surgeries infectious risk, with the best series of literature being 3-4%. In addition, mechanical complications may occur: obstruction, tearing of tubes, etc., so that the complications of this treatment in the literature are also reported at 40% per year. In our experience, the infectious risk is about 3% and the mechanical complications do not exceed 5-10% (these results are due to the improvement of the asepsis and antisepsis conditions as well as the implanted materials).
Ventriculo-cisterno-stoma, when indicated, has specific complications<1% (endocrine and / or hypothalamic problems, haemorrhages) and a mortality of less than 0.2%. Sometimes VCS is not sufficient for the treatment of hydrocephalus (mixed hydrocephalus), thus requiring the use of other internal drainage methods (ventriculo-peritoneal, ventriculo-atrial, etc.). In our clinic you will be advised, whenever possible and even when there is only a few chances of success, ventriculo-cisterno-stoma as the first treatment, given the small risks it implies when compared to other drainage methods.
Prognosis depends on the cause of hydrocephalus, and there is a spectrum ranging from excellent (very good quality of life without loss of life expectancy) to an extremely bad one (malignant tumors that cause hydrocephalus).
The patient must understand that each case is unique and that our team is doing everything possible to provide the best treatment available.
Cavernomas
Cavernomas are vascular malformations that can form anywhere in the body. In the brain and spinal cord they can cause problems due to their hemorrhagic and epileptogenic potential. As their name says (cavernous malformations), these lesions are not tumors in the true sense of the word, but vascular abnormalities that usually develop in intrauterine life. Bleeding is usually unpredictable. There are never-bleeding lesions or lesions that bleed frequently, thus increasing the risk of major neurological deficits.
Cavernomas represent vascular malformations that can form anywhere in the body. In the brain and spinal cord they can cause problems due to their hemorrhagic and epileptogenic potential. As their name says (cavernous malformations), these lesions do not represent tumors in the true sense of the word, but vascular abnormalities that usually develop in intrauterine life. Depending on localization, the growth and bleeding of these cavernous lesions may lead to neurological deficits such as muscle weakness, sensitive deficits, speech problems, memory problems, epileptic seizures, visual problems, etc. Bleeding is usually unpredictable. There are lesions that never bleed, lesions that bleed once, and lesions that bleed very frequently, thus increasing the risk of major neurological deficits. Those injuries that become symptomatic and risk to leave neurological sequelae or aggravate the existing ones, require treatment, which is usually surgical. Most cavernomas appear sporadically, but there are cases where they are hereditary.
Diagnosis is performed using mainly a cranio-cerebral and / or spinal MRI examination, as appropriate. This investigation usually makes the diagnosis, there are signs that are specific to this condition. Cerebral and / or spinal CT may highlight recent bleeding, brain edema caused by it and the lesion itself, but without being able to put the diagnosis of certainty, as MRI can do in most cases.
If you were diagnosed with a cerebral cavernoma you probably were sent to a neurosurgeon for specialist advice. Depending on the location of the lesion, the age of the patient, the associated disease, the number of bleedings and their frequency, and the neurological impact, the neurosurgeon will propose a therapeutic plan or a simple periodic follow-up. To get the most out of your consultation with the neurosurgeon, make a list of questions you want to ask. Possible questions can be:
• Where is my cavern located?
• What important neurological structures are in the vicinity and what importance does this have?
• Do I need to operate?
• Are there other therapeutic alternatives?
• What could be the long-term complications if I do not operate?
• What could be the complications of surgery?
• How long do I have to operate?
• Can I ask for a second opinion?
• How can I find out more about my problem?
Feel free to address any other questions you want.
Cerebral metastases
Cerebral metastases – are malignant tumors originating from another neoplasia of the organism. Their treatment is often a combination of surgery, radiotherapy and chemotherapy. Treatment needs to be adapted to each patient, the multidisciplinary meetings held in our clinic being the ideal approach for such a pathology.
