Improvement of motoric and sensory functional after surgical resection craniovertebral junction meningioma: a case report

Background: Meningioma of the craniovertebral junction is a unique and rare case. The sensitivity of the region to surgical still debateable. Complete resection is the primary goal of surgery.

Aim: We report a unique and rare case of improvement motoric and sensory after surgical resection intramedullary craniovertebral junction meningioma.

Case report: 37 years old woman presented tetraplegia (0/0/0/0) and heavy breathing since six month. MRI showed mass on craniovertebral junction. Laminectomy C1, tumor excision, and suboccipital decompression should be done. One week post operation the patient showed an improvement in functional motoric (3/3/2/2) and sensory and improvement in clinical symptoms.

Conclusion: Complete resection is the primary goal to prevent sequel and recurrent craniovertebral junction meningioma.

Keywords: Craniovertebral junction meningioma, Laminectomy, Complete resection, Suboccipital decompression.

Metastasizing breast carcinoma to middle cranial fossa with extensive hyperostosis which occurred 8.5 years after the initial treatment

Introduction: Breast cancer is the second most common primary tumor with brain metastases. Breast cancer metastasizing to the neurocranium can include the skull, dura, or parenchyma of the brain. Skull metastases were most often found in the breast, typically presenting as osteolytic.

Case Presentation : A 53-year-old woman with a history of breast cancer surgery 8.5 years before she had a headache , nausea, and right visual disturbance. Neuroimaging studies have identified a large tumor in the anterior part of the right middle cranial fossa associated with severe hyperostosis of the underlying bones. Intraoperative exposure revealed that the primary tumor site was dura mater of the middle cranial fossa. The tumor has been histologically diagnosed as metastatic breast carcinoma with sphenoid bone invasion.  

Conclusion: Dural breast cancer metastasis may pose this uncommon characteristic of severe hyperostosis, which should be considered in primary skull tumor differential diagnosis.

Key words: Hyperostosis, Brain metastasis, Breast cancer, skull base tumor

The incidence of surgical site infections in neurosurgery procedure during January – December of 2017 in Kariadi General Hospital, Indonesia

Introduction: Surgical site infection (SSI) remains as substantial cause of morbidity, prolonged hospitalization and death. The most common types of inpatient surgical procedures include neurosurgery procedures. The aim of this study is to provide the incidence of surgical site infection in neurosurgical procedure and determine the most common etiological agent of surgical site infection in Kariadi General Hospital period January till December of 2017.

Methods: This was a descriptive-retrospective study. Data were collected from medical record of patient who underwent neurosurgical intervention in Kariadi General Hospital between 1 January – 31 December 2017. All respondent with neurosurgery procedure that meets the criteria of National Nosocomial Infections Surveillance (NNIS) of superficial incisions and Hulton criteria were included.

Results: A total of 196 patients underwent neurosurgery procedure during between 1 January – 31 December 2017. Of these, 15 cases (7.65%) experienced surgical site infections. There were 6 female cases and 9 male cases (2:3). The highest incidence rate was in old age group(45-65 yo). In microbiology study, we found some bacteria such as Acinetobacter baumannii 2 cases (13.3%), Escherichia coli 4 cases (26,6%), Enterococcus faecalis 1 case (6,6%), Proteus mirabilis 1 case (6,6%), no-bacteria 6 cases (40%) and 1 unidentified (6,6%).

Discussions: Surgical site infections are frequent and serious complications of surgical procedures and remain a major issue for patient safety. Several independent predictors of SSI is commonly in older people, including comorbid conditions, perioperative variables and socioeconomic factors. In an analysis of etiologic agents of infections in this study is Escherichia coli. According to the literature that the responsible pathogens in most SSIs are originate from the patient’s endogenous flora, in addition of exogenous resources. Its important to follow the evidence-based guidelines for the prevention of SSIs, from preoperative, perioperative and postoperative procedure.

Conclusion: We found 15 cases of surgical site infection in neurosurgery procedure in 1year period of time. Numerous patient-related and procedure-related factors influence the risk, and it requires a bundle approach to prevent the SSI incidence

Keywords: surgical site infection, neurosurgery, infection

“Unlocking the brain” - key concepts to accessing the anterolateral skull base made simple

Background: The close relationships of skull base structures make it crucial to approach it in a fashion that provides wider exposure with minimal retraction. The concept of brain unlocking adds to the axial and sagittal views allowing access to the optico-carotid window with much ease as compared to the only sylvian dissection in an oblique plane. Another concept introduced is a modification of the Dolenc approach that prevents the bleeding from the cavernous sinuses and also protects the spanning nerves from paresis while operating within the cavernous sinus.

Methods: Unlocking the frontal and temporal lobes in sagittal and axial planes involves drilling the sphenoid bone and sharply dissecting the orbito-meningeal band, respectively. The peeling of the temporal lobe from the cavernous sinus is carried out while keeping the true cavernous membrane intact. This is a modification of the Dolenc approach.

Results: The outcomes of these maneuvers is clearly depicted in the cadaver and surgical dissections performed for skull base approaches. The immediate effects of brain unlocking can be seen as the brain flattens out completely at the fronto-temporal junction. This, followed by a modified Dolenc maintaining a pericavernous plane helps reduce the bleeding considerably. 

Conclusion: The use of brain unlocking maneuvers can be essential in providing a wider surgical corridor to approach deep structures in the middle fossa. Maintaining a pericavernous plane while peeling the temporal dura can help reduce cavernous bleeding and prevent nerve paresis in the region.

Keywords: anterolateral skull base; sphenoid; orbito-meningeal band; Dolenc; cavernous sinus; anterior clinoid; petrosectomy

Fahr’s disease: incidentally diagnosed and treated in a case of RTA with SDH

Introduction- Fahr's disease is a rare clinical entity characterised by bilaterally symmetric calcification of the basal ganglia, cerebellar dentate nuclei and bilateral cerebral white matter. Most of the patients present with extrapyramidal symptoms, but the natural history, progression and treatment is still a mystery.

Case presentation - We report a case of Fahr’s disease incidentally diagnosed in a case of RTA with SDH and treated in our department. In our knowledge, it is the first case of Fahr’s disease reported in case of RTA with SDH. We are reporting this case in order to create awareness amongst neurosurgeons about the disease and its management.

Conclusion- A neurosurgeon should be aware of the clinical features of Fahr’s disease which is a rare clinical entity but may be found incidentally in patients who present to us due to some other reasons. Thorough clinical examination and knowledge about the disease along with typical findings in CT Brain help one to come to a proper diagnosis. Multidisciplinary approach along with neurology and neuropsychiatry consultation is helpful in managing the patients.

Key-words: Basal ganglia Calcification, Fahr’s disease, SDH, RTA

The Effect of ACTH4-10Pro8-Gly9-Pro10 on Spinal Cord’s IL-1, TNF-α and NF-κB Expression in Sprague-Dawley Rat on Acute Spinal Cord Injury

Background: Acute spinal cord injury (ASCI) is one of the causes of morbidity that is severe enough to cause vascular damage. This vascular damage will cause necrosis or apoptosis. ACTH_4-10Pro⁸-Gly⁹-Pro¹⁰ is one of the peptide groups that can affect peripheral nerve regeneration and rehabilitation.

Objective: This study was aimed to test the effect of ACTH_4-10Pro⁸-Gly⁹-Pro¹⁰ on spinal cord’s IL-1, TNF-α and NF-κB expression in sprague-dawley rat on ASCI.

Methods: This research is a true experimental laboratory research with completely randomized design (factorial pattern). The subjects were Sprague Dawley rats with light and heavy compression of the spinal cord was performed respectively.

Results: : In rats with mild ASCI given ACTH_4-10Pro⁸-Gly⁹-Pro¹⁰, IL-1, TNF-α, NF-kB expression results were 5.14 ± 1.95, 4 ± 1.73, 6.43 ± 1.61 and 10.71 ± 3.14, 6.29 ± 1.70, 11.14 ± 1.77 after 3 and 6 hours period of time respectively. In rats with severe ASCI given ACTH_4-10Pro⁸-Gly⁹-Pro¹⁰ given ACTH_4-10Pro⁸-Gly⁹-Pro¹⁰, IL-1, TNF-α, NF-kB results were 9.57 ± 1.81, 9.43 ± 1.81, 8, 71 ± 1.25 and 14.14 ± 2.11, 14.29 ± 2.28, 13.57 ± 1.81 after 3- and 6-hours period of time respectively. The administration of ACTH_4-10Pro⁸-Gly⁹-Pro¹⁰ showed the results of IL-1, TNF-α, NF-kB expression were able to reduce IL-1, TNF-α and NF-kB expression when compared to NaCl 0.9% treatment group.

Conclusion: The administration of ACTH_4-10Pro⁸-Gly⁹-Pro¹⁰ can reduce the expression of IL-1, TNF-α and NF-kB at 3 hours and 6 hours after mild and severe ASCI in Sprague Dawley rats. Future researches are recommended.

Keywords: ACTH_4-10Pro⁸-Gly⁹-Pro¹⁰, Acute spinal cord injury, IL-1, NF-kB, TNF-α

Remote patient monitoring in neurosurgery: looking for new technologies in healthcare

Patient monitoring outside of clinical settings is a new concept in clinical practice. The possibility of continuing the follow-up of our patients opens a world of possibilities and especially in neurosurgery. The advantages of using remote monitoring focus on improving the quality and efficiency of care.The remote monitoring of a patient in the clinical context is called telemonitoring. In this way, the evolution of patients can be monitored, mainly by checking basic physiological parameters. The aging of the world population and the scarcity of health personnel will force new remote monitoring technologies to be incorporated into our practice in the next few years.