Approximately 34 cases of intracranial tuberculomas with paradoxical response to antituberculous chemotherapy have been documented worldwide. In most of the previously reported cases an associated tuberculous meningitis was reported. The majority of these patients were children or young adults, who had inoperable intracranial tuberculomas located in high risk regions that developed a few weeks or months after the start of an appropriate chemotherapy. Fifty-three percent of the patients recovered completely, 37% improved with mild neurological defects and 10% died. It is interesting that these intracranial tuberculomas developed or enlarged at a stage when systemic tuberculosis was being treated successfully. A recent experience with these potentially curable tumors of the central nervous system is reported. The literature is reviewed, and diagnostic and therapeutic considerations are discussed. The possible immunological mechanisms of this phenomenon are analyzed. In conclusion, patients who are suspected to have a CNS-tuberculosis should receive a prolonged (12-30 months) course of effective antituberculous therapy. The evidence of new intracranial tuberculomas or the expansion of older existing lesions does not indicate the need to change the antituberculous drug program. In such cases systemic dexamethasone as adjuvant therapy for 4 to 8 weeks is worthwhile and effective. Surgical intervention may be necessary in situations with acute complications of CNS tuberculosis, such as shunting procedures for the treatment of hydrocephalus. When the diagnosis is not ensured and there is no response to therapy within 8 weeks, a stereotactic biopsy on a suspected tuberculoma could be performed. If the largest lesion is not located in high risk deep regions of the brain, it could be totally removed surgically. With this combined management, a satisfactory outcome can be obtained in the majority of cases.
Approximately 34 cases of intracranial tuberculomas with paradoxical response to antituberculous chemotherapy have been documented worldwide. In most of the previously reported cases of this entity an associated tuberculous meningitis has been reported. The majority of these patients were children or young adults, who had inoperably located intracranial tuberculomas in high risk regions developing a few weeks or months after the start of appropriate chemotherapy. 53% of them recovered completely, 37% improved with mild neurological deficits and 10% died. It is interesting that these intracranial tuberculomas developed or enlarged at a stage when systemic tuberculosis was being treated successfully. We report our recent experience with these potentially curable tumours of the central nervous system. The literature is reviewed and diagnostic and therapeutic considerations are discussed. The possible immunological mechanisms of this phenomenon are analysed. In conclusion, patients, who are suspected to be suffering from CNS-tuberculosis should receive a prolonged (12-30 months) course of effective antituberculous therapy. Evidence of new intracranial tuberculomas or the expansion of older existing lesions require no change in the antituberculous drug programme. In such cases systemic dexamethasone as adjuvant therapy for 4 to 8 weeks is worthwhile and effective. Surgical intervention may be necessary in situations with acute complications of CNS tuberculosis such as shunting procedures for the treatment of hydrocephalus. When the diagnosis is not firm and there is no response to therapy within 8 weeks, a stereotactic biopsy of a suspected tuberculoma should be performed. If the largest lesion is not located in high risk deep regions of the brain, it should be total removed surgically. With this combined management, a satisfactory outcome can be obtained in the majority of cases.
the unilateral decompressive craniectomy has an advantage over non-surgical treatment of children with severe brain injury and should be considered in their management.
A retrospective study was conducted on 67 patients undergoing posterior cervical foraminotomy (PCF) for unilateral intraforaminal soft and hard disc disease. Neurologic impairment, employment, and severity of associated signs were assessed preoperatively and at a 3.1-year average follow-up (range, 1.5-7 years). Diminution or complete disappearance of radicular symptoms was observed in 62 cases (93%), 3 months to 3 years after surgery. Minimal neurologic deficits persisted in 5 cases (7%). Neck pain improved in 62 cases, remained unchanged in three, and progressed in two cases with severe preoperative deficits. Fifty-three patients (79%) returned to their previous occupation; only seven (10%) retired prematurely on the basis of disc disease alone. Based on Prolo's functional economic outcome rating scale, 60 patients (90%) showed excellent economic outcome. Posterior cervical foraminotomy is an efficient means of decompressing lateral spinal roots compromised by soft disk herniations or osteophytic spurs, without the risk of an anterior approach with or without fusion. Careful patient selection and microsurgical technique are essential in obtaining consistent, excellent results. Additionally, the recent trend toward minimally invasive techniques and key-hole operations in neurosurgery and other specialisations favours the posterior approach.
True intramedullary teratoma is an extremely rare tumor, with only seven cases reported in the literature. The authors present two personal cases of spinal intramedullary cystic teratoma of the conus medullaris with exophytic growth and some unusual aspects. Their cases are unusual not only because they were diagnosed by MRI but also because the monitored microsurgical removal of the tumor was apparently total, with excellent results, in clinical and neuroradiologic terms. We recommend early radical surgery whenever possible, when the patient's neurological status is still good. To prevent traumatizing adjacent spinal cord for cases in which the teratoma tightly adheres to the functional neurological tissue of the spinal cord with no cleavage plane, we do not recommend an aggressive surgical attempt. Because of the mostly benign nature of this disease, the symptomatic recurrence of such incompletely resected mature teratomas is slow and may eventually require a second surgical procedure. The relevant literature is also reviewed.
Frameless neuronavigation has been increasingly used in intracranial and spinal neurosurgery. However, the application of neuronavigation in orbital surgery has not yet been reported. The purpose of this study was to evaluate whether frameless navigation in the orbit provides sufficient clinical application accuracy and thus a useful tool in orbital surgery. A frameless infrared-based neuronavigation system (VectorVision, BrainLAB, Heimstetten, Germany) was used in the microsurgical removal of 11 orbital tumors (five cavernomas, three lymphomas, two dermoid tumors, and one rhabdomyosarcoma). The transconjunctival approach was performed in seven cases, lateral orbitotomy in three cases, and the extradural pterional approach was performed in one case. The surgery was successful and without any complications in all cases. The registration accuracy of the neuronavigation was between 1.8 and 2.2 mm, with a mean of 1.9 mm. Subtotal tumor debulking was performed in one case with lymphoma. One patient was only biopsied due to suspected systemic lymphoma disease. Total removal of the tumor could be accomplished in the other nine patients. Image guidance during orbital surgery offered excellent three-dimensional guidance on the surface of the intraorbital lesions, allowing a safer, more controlled surgery. The surgical targets in the orbit are fixed structures, thus no shifting occurs and continuous high intraoperative navigation accuracy can be achieved. The use of the navigation clearly reduces the operative risk and increases the effectiveness of microsurgical orbital procedures.
We collected data to provide evidence that orbital cavernous malformations (CMs) are histopathologically, neuroradiologically, and clinically different from cerebral CMs and may represent a distinct entity. In this study, the main clinical, histopathological and radiological characteristics of 19 patients (11 females and eight males, mean age 49.1 years) with orbital CMs out of a series of 376 orbital tumors are analyzed and compared with 107 cases with cerebral CMs treated in the same period. Decrease of visual acuity and painless progressive proptosis were the main clinical signs observed in 17 patients (89%). Complete microsurgical excision of lesions via individualized approaches was obtained in all cases. Follow-up examinations were obtained after a mean of 3.1 years (11 months to 7 years) and yielded complete recovery in 14 patients, while five remained clinically unchanged. Based on clinicopathological and neuroradiological studies of these 19 patients with orbital and 107 patients with cerebral CMs treated in the same period, we found evidence that orbital CMs have specific features to distinguish them from cerebral CMs. Orbital CMs, in contrast to the cerebral CMs, showed non-degenerated well-developed vessel walls and were covered by a hard and compact capsule. Clinical symptoms are characterized by the growth of orbital CMs due to intraluminal thrombosis and subsequent recanalization of cavernous vessels; there were no signs of hemorrhage. We found evidence to suggest that orbital CMs represent a distinct clinicopathologic and neuroradiologic entity.
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