Microsoft Word - 9.SelectedAbstracts.doc


 
 
 

Romanian Neurosurgery (2012) XIX 4: 309 – 355          309 

 
 
 

Selected abstracts 
The 8th International Congress of the Romanian Society of 
Neurosurgery 
 
26 - 29 September 2012, Bucharest 

 
 

CURRENT SURGICAL 
STRATEGIES IN 
INTRAMEDULLARY SPINAL CORD 
EPENDYMOMAS 
Prof. Jacques Brotchi, M.D., Ph.D. 
(Belgium) 

 
Introduction: It is well known that the 

gold standard treatment for low grade 
intramedullary spinal cord ependymomas 
(ISCE) is complete surgical removal. That 
should be the ultimate goal.  

Results: Our experience is based on 188 
ISCE among 480 operated intramedullary 
tumors.  

In all cases, the surgical approach was 
done through the posterior midline. 
Debulking with the CUSA and gently 
separation of the tumor from spinal cord 
under magnification were the rule.  

Complete removal has been achieved 
with success in 166 cases (89%) with only 
two recurrences. Subtotal or partial removal 
happened in 22 (11%), most of them being 
patients operating first elsewhere, 
sometimes with complementary radiation 
therapy which is a nonsense and coming to 
us with a recurrence. In those cases, we 
have been faced with a lack of a clear 
cleavage plane.  

Motor evoked potentials (MEPs) have 
been of great help to keep a good quality of 
life after surgery in patients where there 
was not a clear limit between the tumor and 

spinal cord. But when a clear plane was 
present between the ependymoma and 
spinal cord, we did not stop surgery even 
when MEPs were lost, without facing 
neurological motor deficit postoperatively. 
It means that MEPs are not an absolute 
criteria but an alarm to take in 
consideration.  

In partial removal, we had to operate 
again several years later, sometimes in 
succeeding to perform a complete removal 
(8 cases) but in 10 patients, we failed and 
they regularly have to be operated again. In 
two patients, the remaining bud stays stable 
on yearly follow-up MRIs. Two patients 
have been operated recently.  

Our follow-up runs from several 
months to 24 years. In 128 patients, we 
have a follow-up longer than 5 years. In all, 
we recommend a yearly MRI since in two 
cases, even after complete removal and 
clean MRI at 5 years, we observed a 
recurrence after 18 and 19 years 
respectively.  

Conclusion: We should keep in mind that 
even after complete removal, ISCE may 
recur many years after a successful surgery. 
MRI follow-up of those patients should 
never stop. In 89% ISCE have been totally 
removed. But in 11% no clear plane of 
delineation has tempered our surgical 
aggressivity to keep a good quality of life 
post-operatively. Surgery again in 
recommended when those tumors regrow. 



 
 
 
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There is no indication for radiation therapy 
either after surgery or in recurrent ISCE. 

SPINAL CORD 
HEMANGIOBLASTOMAS. 
CLASSIFICATION AND SURGICAL 
TREATMENT 
Prof. Jacques Brotchi, M.D., Ph.D. 
(Belgium) 

 
Complete removal of spinal cord 

hemangioblastomas (SCH) must be 
neurosurgeons’ ultimate goal. We have tried 
to draw up a simple topographic 
classification in order to achieve this goal 
with respect to patients’ post-operative 
neurological status. We have classified the 
lesions in three topographical categories 
based on our experience on 56 cases:  

- A. Pure intramedullary SCH (n=4)  
- B. Subpial posterior and postero-lateral 

SCH (n=40)  
- C. Small subpial lateral or anterior-

sided SCH (n=12--10 lateral and 2 
anterior)  

Different surgical approaches related to 
topographic classification were used:  

Class A. When the hemangioblastoma 
was not visible we opened the posterior 
sulcus along the midline using the same 
procedure as for any other intramedullary 
spinal cord tumor.  

Class B. Classical “en-bloc” resection 
with careful dissection of the lesion from 
spinal cord.  

Class C. In all the cases a tense 
syringomyelic cyst was present and 
aspirated with a 22G needle to deflate spinal 
cord and give an easy access to the solid 
nodular tumor after division of the dentate 
ligament and gentle rotation of spinal cord.  

CUSA was never used, nor debulking of 
the tumor. Surgical technique started by 

cutting pia all around the tumor with 
coagulation and division of all vessels on 
the way in order to perform “en bloc” 
resection. Complete removal was achieved 
in all cases except in one previously 
operated upon twice and irradiated in 
another institution. Improvement was 
observed in 29, stabilization in 25 and 
worsening in 2 patients. The results were 
closely related to the pre-operative status. 
Patients with a good pre-operative 
neurological status or harboring a large 
cystic cavity had a better prognosis than 
others. Radiation therapy has no place in 
SCH. 

EVOLUTION OF 
TRANSSPHENOIDAL SURGERY 
FROM MICROSURGERY TO 
ENDOSCOPY; THE FOCH 
HOSPITAL EXPERIENCE  
Prof. Stephane GAILLARD, M.D., Ph.D. 
(France) 

 
There is an old tradition for pituitary 

and skull base surgery in our department, at 
first by microscopic approach and since few 
years by endoscopic endonasal approach.  

Since 2006, we have gone through a 
transition from microscope to endoscopic 
endonasal approach for pituitary disease and 
skull base tumor surgery. We submit some 
remarks on this transition from microscope 
to endoscope based on our experience 
about more than one thousand endoscopic 
endonasal procedures.  

From 2006 to 2011, more than 1000 
endoscopic endonasal approaches for 
pituitary disease and skull base tumors have 
been performed in our department by the 
same senior neurosurgeon (SG).  

We had used a simple transsellar 
approach for the majority of pituitary 



 
 
 

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adenomas, and an extended endonasal 
endoscopic approach for other tumors or 
skull base surgery (Craniopharyngiomas, 
Meningiomas, odontoid resection…..).  

The endonasal endoscopic approach for 
pituitary adenoma surgery decrease 
rhinologic complications, increase the 
patient’s comfort by avoiding post operative 
nasal packing, get a better view of the intra 
sellar and supra sellar aeras, reach the same 
endocrinological results, get a better control 
of the invasion of the cavernous sinus, and 
in some cases to allow their removal.  

We believe it is very important to 
separate the two various approaches: the 
endoscopic endonasal trans sellar approach 
and the endoscopic endonasal extended 
approaches, and to avoid at the needless 
extended approaches.  

For the lesions localized between 
tuberculum sellae and the odontoid, we 
found an important added value to the use 
of an endoscopic endonasal approach. But 
for the lesions localized in the front of the 
tuberculum sellae the added value of 
endoscopic endonasal approaches is not 
evident and must be evaluated in the future 
in comparison with mini invasive 
intracranial approaches. 

SURGICAL MANAGEMENT 
ANTERIOR SKULL BASE AND 
SELLAR MENINGIOMAS  
Prof. Madjid Samii, M.D., Ph.D. 
(Germany) 

 
The complex structure of the anterior 

skull base and the sellar region determine 
the risks, associated with surgery in those 
areas. Meningiomas are the most common 
tumors, involving these areas. The 
operative strategy and surgical approach 
chosen should be selected according to the 

precise location of the tumor and the 
neurological condition of the patient. The 
approach in itself should not be related to 
significant approach-related morbidity, but 
rather should increase the extent and safety 
of resection. We favour the frontolateral as 
the most suited approach to these region of 
the skull base. In the presentation we will 
present and discuss our experience with 
surgery of the anterior skull base and the 
sellar meningiomas and discuss our 
treatment strategy.  

SURGICAL STRATEGIES FOR 
CRANIOVERTEBRAL JUNCTION 
PATHOLOGY  
Prof. Madjid Samii, M.D., Ph.D. 
(Germany) 

 
The common pathological entities in the 

region of the craniocervical junction 
include congenital, developmental, 
inflammatory, and neoplastic abnormalities. 
In our series most frequent were the 
neoplastic lesions, both intra-and extraaxial. 
Surgery in the region of the craniovertebral 
junction is related to significant risk of 
morbidity and even mortality. Besides 
removal of the lesion and decompression of 
the lower brain stem and cervical spinal 
cord, surgery should avoid or treat any 
existing instability. All these issues will be 
discussed in our presentation based on our 
extensive experience. 

MANAGEMENT OF LESIONS IN 
THE BRAINSTEM  
Prof. Ladislau Steiner, M.D., Ph.D. 
(Germany) 

 
Background: The fact that the brainstem 

is packed with neural cell bodies and fiber 



 
 
 
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tracts, any trial to extirpate lesions at this 
level may result in significant deficits.  

Objective: In the present report the 
imaging and clinical outcome in low grade 
astrocytomas, metastatic tumors, as well 
AVMs following Gamma Surgery (GS) has 
been compared with the published results 
obtained after microsurgery or endovascular 
procedure.  

Methods: Retrospective analysis of 21 
astrocytomas, 53 metastatic lesions as well 
85 AVMs located in brainstem which has 
been treated with GS. Of 21 astrocytomas 
the tissue diagnosis was established only in 
10 cases before GS. The tumors had been 
located in midbrain in 16 patients, 4 were in 
the pons, and 1 in medulla oblongata. The 
mean tumor volume was 2.5 cm³ and the 
mean prescription dose was 15 Gy (range, 
10-18). The mean volume of the metastatic 
lesions was 2.8 cm³ (range, 0.5-21) and have 
been treated with a mean prescription dose 
of 17.6 Gy (range, 9-25). Mean volume was 
1.9 cm³ (range, 0.1- 8.9) in AVMs and the 
prescription dose was 19.9 Gy (range, 5-32). 
The mean follow up time with MRI was 
83.3 months (range, 24-252).  

Results: After treatment with GS, in 
patients with astrocytoma, tumor 
disappeared in 4 (20%), shrank in 12 (60%), 
and progressed in 4 (20%). In metastatic 
cases the lesion disappeared in 7 shrank in 
22, remained unchanged in 3, and grew in 
5. The angiographically obliteration in 
brainstem AVMs was achieved in 50 
patients (59%) and radiation induced 
changes were observed within 34 patients 
(40%).  

Conclusion: When the risks of surgery or 
embolization for lesions located in the 
brainstem are high or there are residuals 
left, GS can be a treatment option especially 
for nidi within the brainstem parenchyma. 

FUNCTIONAL PREOPERATIVE 
PLANNING FOR BRAIN TUMOR 
SURGERY IN CRITICAL AREAS  
Francesco Tomasello, MD  
Department of Neurosurgery, AOU Policlinico “G. 
Martino”, University of Messina, ITALY  

 
Preoperative cortical mapping is 

increasingly recognized as a fundamental 
procedure for better planning the surgical 
treatment of brain tumors in critical areas.  

Different technologies are currently 
available to perform a pre-operative 
identification of functional brain areas. 
Functional magnetic resonance imaging 
(fMRI) is probably the most commonly 
used technique. fMRI has a good spatial 
resolution, but a low temporal resolution 
and brain tumors may cause metabolic 
changes that may blur the identification of 
functional hypermetabolic areas.  

Transcranial magnetic stimulation 
(TMS) is an electrophysiological technique 
developed for the investigation of human 
cortical functions.  

Navigated brain stimulation (NBS) is a 
combination of TMS with 3-D MRI and 
computer analysis using a neuronavigation 
system, to provide feedback on the exact 
position of maximal stimulation. NBS 
offers different advantages for brain 
mapping over conventional technologies 
including the fact that it does not passively 
record brain activity during voluntary 
patient movements. Instead, NBS actively 
stimulates the patient’s motor cortex 
recording EMG changes.  

Few clinical studies have shown that 
preoperative NBS mapping of the motor 
cortex in brain tumor patients is more 
reliable than preoperative fMRI mapping 
and agreed well with the gold standard 
intraoperative direct cortical stimulation 



 
 
 

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(DCS). Here we reviewed our experience 
in pre-operative brain mapping using NBS 
and NBS combined with subcortical 
tractography and direct cortical and 
subcortical stimulation in patients with 
brain tumors including gliomas and 
metastases.  

Our preliminary data, based on surgical 
and clinical results in a consecutive series, 
showed that the NBS had a clear impact on 
the planning and surgery by changing the 
indications, the approach and the 
possibilities of tumor resection.  

NBS allowed a precise mapping of the 
motor cortex and the visualization of its 
spatial relationship with the tumor. Finally, 
comparison with DCS confirmed the 
spatial reliability of the pre-surgical brain 
mapping achieved by NBS. 

TELOVELAR MICROSURGICAL 
APPROACH TO FOURTH 
VENTRICLE TUMORS  
Francesco Tomasello, MD  
Department of Neurosurgery, AOU Policlinico “G. 
Martino”, University of Messina, Italy  

 
Fourth ventricle tumors are rare lesions 

and represent still today a neurosurgical 
challenge according to the relationships 
with vital neural structures and tumor 
histotype.  

This presentation deals with a series of 
42 patients, 27 males and 15 females with 
mean age of 22.5 years (range 1- 66), 
harboring IV ventricle tumors both 
secondarily invading the ventricle and 
primarily growing into the cavity. In all 
these cases a telo-velar approach was used 
to enter the ventricle and to remove the 
tumor. The most frequent histotypes were 
gliomas and medulloblastomas.  

According to post-operative 
neuroradiological examination, the extent 
of removal was complete in 38 patients 
(90.5%) and subtotal in 4 (9.5%). One 
patient harboring a IV ventricle metastatic 
lesion died post-operatively. One patient 
developed post/operative transient VI c.n. 
palsy (completely recovered at 3 months 
follow-up). 2 patients (4.8%) had post-
operative CSF leakage requiring a 
permanent VP shunt. No significant 
damage of cerebellar tonsils and uvula was 
produced as demonstrated by intraoperative 
view and post-operative neuroradiological 
imaging. The approach allowed adequate 
control of lateral recesses and the rostral 
portion of the cavity up to the Sylvian 
acqueduct . Opening of the arachnoidal 
planes of the tela and inferior medullary 
velum and dissection of the tumor from the 
floor of the fourth ventricle are illustrated. 
Tips and tricks are suggested on the basis of 
the author personal experience. CSF 
pathway patency is a significant advantage 
of the telo-velar approach, as demonstrated 
by the low incidence of post-operative 
hydrocephalus requiring VP shunt or third 
ventriculostomy. Since few years after its 
original description, telo-velar approach 
represents the gold standard. This series 
suggests that the transvermian route has no 
further role in the surgical strategy for these 
tumors. 

SURGICAL STRATEGY FOR THE 
TREATMENT OF GIANT AND 
COMPLEX INTRACRANIAL 
ANEURYSM  
Yong-Kwang Tu, M.D., Ph.D  
Department of Neurosurgery, College of Medicine and 
Hospitals  
National Taiwan University, Taipei, Taiwan  

 



 
 
 
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Since the advent of many high-
technology devices in endovascular therapy 
for cerebrovascular diseases, the role of 
microsurgical clipping of intracranial 
aneurysm is gradually replaced by 
endovascular means. For instance, a wide 
neck aneurysm was considered as not to be 
a good candidate for coiling, however, now-
a-days the combination of coiling and 
stenting technique can easily solve this 
problem.  

However, due to the high occurrence 
rate of compaction phenomenon, 
microsurgical clipping is still the treatment 
of choice for giant aneurysm. In some giant 
aneurysm with the complexity of its 
configuration or its surrounding anatomy, 
neither clipping nor coiling modality can 
accomplish a satisfactory treatment, then 
various bypass procedure with trapping of 
the aneurysm may be needed as the 
ultimate method of treatment.  

In the past 12 years, a total of 63 EC-IC 
bypass operations were done for 61 patients. 
One patient with a stag horn shape 
aneurysm at the ICA bifurcation underwent 
two bypasses; one radial arterial graft bypass 
from the cervical ECA to the MCA and a 
side-to-side anastomosis of both ACAs at 
the A3 segments. Another patient has 
multiple aneurysms of the anterior and 
posterior circulation underwent two EC-IC 
bypasses to the MCA and PCA. Two more 
patients had their STA-MCA bypasses 
failed initially underwent the second 
operation for graft bypass.  

Of the 31 patients with cavernous ICA 
aneurysm all patient has a good patent of 
their graft bypass and one patient 
experience a transient ischemic attack after 
the bypass surgery. Of the 14 patients with 
their aneurysm at the supraclinoidal 
segment of the ICA, 10 patients underwent 

graft bypass and 4 underwent STA-MCA 
bypass. One patient with graft bypass has 
her graft occlude and two patients with 
STA-MCA bypass had their anastomosis 
occlude. A second graft bypass was 
performed on each of these two patients 
with occluded STA-MCA anastomosis. In 
this group of patients, there is no 
postoperative morbidity. For the patients 
with giant MCA aneurysm, two underwent 
interpositional short graft bypass for the 
main trunk of MCA, two underwent 
reimplantation of one of the major branch 
to the MCA main trunk, the other one had 
a graft bypass. One of the two patients with 
interpositional graft bypass developed major 
stroke after the surgery and eventually died 
at two months after the surgery. For the 
posterior circulation, one patient 
underwent STA-MCA bypass for VA an-
eurysm and the other patient underwent 
Occipital artery to PICA anastomosis had 
their anastomosis occluded. The later 
patient has his aneurysm trapped during the 
surgery developed lateral medullary 
syndrome after the surgery whereas the 
former did not have his main artery trapped 
had no postoperative neurological deficit 
and is waiting for the second surgery.  

In this series of patients, the overall 
bypass patent rate is 93%. There is no 
mortality and four mordibity (5.1%) after 
the bypass surgery and trapping of the 
aneurysm..  

In conclusion, we still need to train 
neurosurgeons for mastering various 
clipping technique in microsurgical 
treatment of complex aneurysm. However, 
with the decreasing patient volume for 
microsurgery, the training of a good 
microvascular neurosurgeon will be a 
dilemma. On the other hand microvascular 
anastomosis technique as neglected by the 



 
 
 

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majority of neurosurgeons will be a 
pertinent skill for microvascular 
neurosurgeons in the future. 

SURGICAL TREATMENT OF THE 
THIRD VENTRICLE TUMORS  
Grigore Zapuhlih, Serghei Borodin,  
Radu Safta  

 
Objective: Tumors of the third ventricle 

are among the lesions that are most difficult 
to treat. They pose great technical 
challenges, given their intimate 
relationships with the neural and vascular 
structures of the base of the brain, as well as 
with the hypothalamo-pituitary axis. We are 
going to share our experience with the 
treatment of this particular type of tumors.  

Design: We report the technique, 
outcome and complications seen in 63 cases 
of third ventricle tumors operated by our 
neurosurgical team, in the Institute of 
Neurology and Neurosurgery, from 
Chisinau, Moldova.  

Patients/Materials and Methods: Sixty-three 
patients with third ventricle tumors, 
including 47 tumors of the anterior third 
ventricle and 16 tumors of the posterior 
third ventricle, were operated in our 
institution during the period from April 
2006 to May 2011. The most common 
types were craniopharyngiomas (21 cases), 
colloid cysts (16 cases) and gliomas (8 
cases). For the anterior third ventricle the 
most usually used routes were the 
interhemispheric transcallosal 
transforaminal approach, pterional or 
fronto-lateral approach, and the lamina 
terminalis approach. Most of the colloid 
cysts (11 cases) were removed using the 
fully endoscopic technique. The tumors of 
the posterior third ventricle, represented by 
the tumors of the pineal region, were 

approached by infratentorial supracerebellar 
route in 13 cases, combined supra-
infratentorial approach in 2 cases, and 
through the third ventricle, fully 
endoscopically, in 1 case.  

Results: Good and excellent results were 
obtained in the majority of the colloid cyst 
cases. A zero mortality rate was obtained in 
this group of patients. In 14 cases the 
colloid content and the cyst walls were 
completely removed. The results were 
totally different in the craniopharyngioma 
series, where a high mortality (4 cases) and 
morbidity rate was observed. Total excision 
was obtained in 12 cases of 
craniopharyngioma, subtotal in 7 cases and 
partial removal in 2 cases. All the patients 
received post-resection radiation therapy. 
Five patients where reoperated because of 
tumor recurrence. The most devastating 
complications included acute 
hypothalamic-pituitary dysfunction, 
diabetes insipidus and formation of a 
hematoma into the tumor bed.  

Conclusions: The tumors of the third 
ventricle are often histologically benign and 
the main goal of the surgery is safe and total 
removal. Knowledge of the surgical 
anatomy of the third ventricle, high quality 
image diagnostic techniques, use of 
microsurgical techniques and 
neuronavigation favors the treatment of this 
type of tumors with good results. 

FIRST EXPERIENCE OF USING 
ULTRASOUND INTEGRATED 
NEURONAVIGATION IN 
MOLDOVA  
Grigore Zapuhlih, Andrei Peciul, Constanta 
Dogaru-Peciul  
State Medical and Pharmaceutical University “N. 
Testemitanu”, Neurosurgery Department  

 



 
 
 
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Objective: Reliable intraoperative 
orientation in neurosurgery remains 
paramount. Anatomical topographic 
landmarks, frame based and frameless 
neuronavigation, intraoperative ultrasound 
(iUS) allow the neurosurgeon to localize 
the lesion and surrounding structures, to 
aid in optimizing the approach and achieve 
safe maximal resection.  

Patients/Materials and Methods: Recent 
advances in probe technology, image 
fusion, 3D techniques have provided 
significant improvements to image quality. 
By integrating neuronavigation and 2D 
ultrasound it is possible to create 3D US 
volumes and to navigate directly based on 
3D US data.  

We have used a system (SonoWand 
Invite) where the 3D US volume is 
reconstructed from 100–200 2D images, 
created by making a move or tilt over the 
area of interest with a precalibrated and 
tracked US probe. The optical tracking 
system reads the position of the patient 
reference frame and the US probe. In 
addition to tissue images it is also possible 
to make images of vessels (US angiography) 
based on recordings of the power Doppler 
signals from the blood stream.  

In our practice the main applications of 
intraoperative ultrasound (iUS) were: 
neurooncology (tumour localization, 
tumour resection control - corpus callosum 
glioblastoma, third ventricular 
craniopharyngioma, occipital anaplastic 
astrocytoma, recidivant vestibular 
schwannoma); vascular (ACoA aneurysm, 
AVM Spetzler-Martin grade 4), 
spontaneous intracerebral hemorrhages.  

Lesion localization and planning of 
optimal approach: once the craniotomy has 
been performed, the iUS can be used to 
localize the lesion and neuroanatomical 

structures such as the ventricle, falx, main 
vessels and to assess the brain shift 
(responsible factors - gravity, brain 
swelling, loss of CSF, tumour debulking). 
At the end of the procedure, once the dura 
is closed but before bone replacement, a 
quick iUS scan facilitates assessment of 
early haemorrhage or hydrocephalus.  

Resection control: in lesions with clear 
margins before excision, iUS can be used to 
check if the exeresis is complete.  

Vascular structures: power Angio 
provides information on blood flow and 
vasospasm in AVM and aneurysm surgery. 
This allows real time evidence of vessel 
patency or flow disruption following 
clipping, and facilitates identification of an 
aneurysm within a haematoma.  

Results: Using neuronavigation system 
with integrated US in our practice helps us 
to optimize neurosurgical treatment of the: 
supra- and infratentorial tumours, AVM, 
aneurisms, spontaneous intracerebral 
hemorrhages.  

Conclusions: iUS provides low cost real 
time imaging that is easy to use and has a 
rapid learning curve. With the future 
development of ultrasound technology 
intra-operative 3D US will be used on a 
daily basis in most neurosurgical 
departments. 

MANAGEMENT OF DIFFICULT 
TUMORS OF SPINE  
Prof. Mehmet Zileli, M.D., Ph.D. (Turkey) 

 
Spine surgery has evolved in the last 

decades. New techniques by application of 
detailed knowledge of anatomy and new 
implants for fixation, diifcult tumors of the 
spine could be removed radically. Especially 
primary tumors and solitary metastasis are 
amenable to extramarginal resections.  



 
 
 

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In this paper, the author will present his 
experience on spine tumors, especially 
primary tumor in difficult areas such as 
craniocervical junction and sacrum. The 
technical pitfalls and complications will be 
discussed.  

SURGERY FOR KYPHOSIS  
Prof. Mehmet Zileli, M.D., Ph.D. (Turkey) 

 
Kyphosis is a difficult topic of spinal 

surgery and its management contains many 
controversies. Surgical management needs 
consideration of different aspects of the 
kyphotic deformity such as neurological 
status, the presence of spinal cord 
compression, angle of the kyphosis, the 
quality of bone and accompanying diseases. 
In case of significant cord compression and 
neurological compromise, anterior surgery 
should have the priority. However, in 
smooth angled kyphosis and ankylosing 
spondylitis patients, deformity can easily be 
reduced by a posterior only approach. Since 
they have no nerological deficits, and large 
spinal canals, most suitable patients for 
pedicle subtraction osteotomy are the 
patients with ankylosing sponylitis  

In lumbar kyphosis one level pedicle 
subtraction osteotomy (especially at L2 or 
L3 levels), in thoracic kyphosis multilevel 
osteotomies, in cervicothoracic kyphosis an 
osteotomy at C7-T1 level should be 
preferred.  

Pedicle subtraction osteotomy is a 
technically demanding procedure that 
requires surgeons to perform meticulous 
technique and consider biomechanical 
issues to achieve satisfactory results and 
avoid complications. An attempt to correct 
the rigid fixed spinal deformity is a diffcult 
task and requires the capability of a highly 
experienced spine surgeon. Although the 

physical outcome and patient satisfaction of 
surgical treatment is quite good, risks and 
complications shoould always be 
considered by both the physician and 
patient. 

SELLAR AND PARASELLAR 
MENINGIOMAS - HOW TO 
APPROACH  
I.S. Florian*, G. Ungureanu*, Bianca 
Pintea**, Zorinela Andrasoni**  
*University of Medicine and Pharmacy “Iuliu 
Hatieganu” Cluj-Napoca, Department of Neurosurgery 
Cluj-Napoca Romania  
** County Emergency Hospital, Department of 
Neurosurgery Cluj-Napoca Romania  

 
Objective: Suprasellar meningiomas 

originating from the tuberculum sellae, 
diaphragma sellae and planum sphenoidale 
are uncommon. Tuberculum sella 
meningiomas characteristically lie in a 
suprasellar subchiasmal midline position. 
Occasionally meningiomas have no 
attachment to the tuberculum and appear to 
arise from the diaphragma sella; these are 
called diaphragmatic meningiomas. We 
aimed to determine relevant, clinical, 
imagistic, surgical and histological 
particularities, correlating these case 
specifics to the postoperative results. This 
study was done to evaluate the importance 
of the size of the lesions and early 
identification of the symptoms and their 
effect on the outcome in patients with sellar 
meningiomas.  

Design: We emphasize our surgical 
techniques for resection of these tumors 
and we discuss the advantages of different 
approaches, depending on the size of tumor 
and the relationship of the tumor to the 
optic nerves.  



 
 
 
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Patients/ materials and methods: We 
retrospectively analyzed our series of 78 
consecutive patients, who were admitted 
and operated for a tuberculum sella or a 
diaphragma sella meningioma between 
01.01.2000 and 01.07.2012 at the 
Department of Neurosurgery of County 
Emergency Hospital Cluj- Napoca.  

All patients were evaluated by MRI and 
CT scans before surgery, and tumor 
location, size and relation to neighboring 
anatomical structures were determined. We 
discussed the tumor’s characteristics that 
could influence the treatment decision and 
the choice of the most reliable approach.  

Results: We encounterd 78 cases of sellar 
meningiomas; with dural insertion at the 
tuberculum sellae (40 cases), sellar 
diaphragm (26 cases) and planum 
sphenoidale (12 cases).We noted a sex ratio 
F: M, about 1.8, with female predominance 
in all age groups. The age of the patients 
ranged from 24 to 70 years (average 53 
years), with the highest number of patients 
in their 50s. All our cases underwent 
surgery by transcranial approach; standard 
fronto-temporal approach was performed in 
74 of cases, while in 4 of the cases a 
bifrontal osteotomy was preferred. The 
most common ophthalmic presentation was 
blurred vision, in 90% of cases. Headache, 
the second most common presentation, was 
presented in 68% of cases. In 70 patients 
(90%) complete tumor removal was 
achieved graded as Simpson 1 and 2. Short-
term postoperative complications consisted 
in: wound infections (2 cases), hematomas 
(3 cases), hydrocephalus (4 cases), and 
transient visual alteration (6 cases). During 
the short follow-up period of our patients, 
no such recurrence was detected in any of 
our patients. The mortality rate was 1%.  

Conclusions: Most suprasellar 
meningiomas can be removed completely 
and safely. The most used surgical approach 
is the standard fronto-temporal approach, 
with preservation and even improvement of 
visual function after surgery. The pterional 
approach is a well-known pathway, and the 
direct verification of the optical nerves, the 
carotid arteries, the pituitary stalk, the 
meningioma and its relationship with the 
suprasellar structures represents a safer 
surgical decision. 

SURGICAL MANAGEMENT OF 
SELLAR AND PARASELLAR 
MENIGIOMAS  
R. Chinezu, A. Balasa  
County Emergency Hospital, Department of 
Neurosurgery Tg. Mures, Romania  

 
Objective: Sellar and paraselar 

meningiomas represent 4 – 10 % of all 
intracranial meningiomas. Due to their 
close proximity to the arteries of the 
anterior circulation, anterior visual 
pathways, hypothalamus and pituitary stalk 
the have always been regarded as 
challenging cases. Traditionally these cases 
have been operated via intracranial 
approaches (subfrontal, frontopterional, 
supraorbital) but advances hardware and 
technique have included this pathology in 
the indications of transsphenoidal 
endoscopic operations.  

Material and method: Patients operated in 
the past 5 years at the Neurosurgery 
Department of the Targu Mures Clinical 
Emergency Hospital.  

Results: A number of 30 cases have been 
operated for sellar and parasellar 
meningiomas: 13 meningiomas of the 1/3 
inner sphenoid wing and anterior clinoid, 
12 tuberculum sellae meningiomas, 5 



 
 
 

Romanian Neurosurgery (2012) XIX 4: 309 – 355          319 

 
 
 

planum sphenoidale meningiomas. All cases 
have been operated by cranial approach ( 
subfrontal , frontopterional) The mean age 
of the group is 51+/- 17 years, sex ratio 
F/M is 23/7. Primary symptoms were visual 
disturbances (loss of sight or visual 
impairment, diplopia), followed by 
convulsive seizures and personality changes. 
22 cases presented increase in visual acuity, 
in 5 cases preservation of sight has been 
achieved while in 3 case patients 
postoperatively presented decreased visual 
acuity. We had 1 scalp infection that 
required surgical removal of the bone and 
later cranioplasty. In one case there was a 
severe thrombosis of the intracavernous 
carotid that resulted in the death of the 
patient.  

Conclusion: Microscopic intracranial 
approaches are a safe technique and widely 
used technique. Endoscopic approaches 
have been proven to be effective in selected 
cases, but further studies are required. 

OPERATIVE TREATMENT OF 
TUBERCULUM SELLAE 
MENINGIOMAS  
Ligia Tătăranu*, V. Ciubotaru**, D. 
Păunescu**, Adriana Dediu, M. R. 
Gorgan*, Anica Dricu***  
*“Carol Davila” University of Medicine and Pharmacy, 
Neurosurgical Clinic, “Bagdasar – Arseni”  
Clinical Hospital, Bucharest, Romania  
**Neurosurgical Clinic, “Bagdasar – Arseni” Clinical 
Hospital, Bucharest, Romania  
***University of Medicine and Pharmacy, Craiova, 
Romania  

 
Objective: Tuberculum sellae 

meningiomas have a close relationship with 
the arteries of the anterior circulation, 
anterior visual pathways and the 
hypothalamus. The authors report on a 
series of tuberculum sellae meningiomas, 

resection being achieved by different 
surgical approaches.  

Methods and results: A retrospective 
analysis was conducted on 24 consecutive 
patients with tuberculum sellae 
meningiomas, operated on at the 3rd 
Neurosurgical Clinic, “Bagdasar – Arseni” 
Clinical Hospital Bucharest, between 
January 2002 and July 2012. The mean age 
of the 19 women and 5 men enrolled in the 
study was 51 years (range 21 – 75 years). 
The presenting symptom was visual 
compromise in 83.3 % of the patients (20 
cases). In addition, 25 % of the patients (6 
cases) had preoperative hormonal 
abnormalities. The radiological evaluation 
was made predominantly by MRI and angio 
MRI. A frontolateral approach was used in 
21 patients (87.5 %) and an endoscopic 
endonasal extended transsphenoidal 
approach was used in 3 patients (12.5 %). 
These approaches allowed quick access to 
the tumor and were minimally invasive 
with less brain exposure, while keeping the 
complications to a minimum. Radical 
tumor removal was possible in all but 2 
patients (91.7 %). Postoperatively, vision 
improved in 19 patients (79.2 %), did not 
change in 4 patients (16.7 %) and worsened 
in one patient (4.2 %). There was no 
perioperative mortality. The follow-up 
period ranged from 3 to 85 months 
(median: 46 months).  

Conclusion: In the majority of patients 
with tuberculum sellae meningiomas, total 
resection is the goal of treatment and can 
usually be accomplished safely, with 
minimal postoperative complications and 
morbidity. The extent and duration of 
visual symptoms, encasement of the 
anterior cerebral artery complex and size of 
the tumor are the important factors that 
influence the treatment strategies. 



 
 
 
320          Selected Abstracts          The 8th International Congress of the RSN 

 
 
 

UNILATERAL VERSUS BILATERAL 
SURGICAL APPROACH IN 
ANTERIOR CRANIAL FOSSA 
MENINGIOMAS  
F. Stefanescu, M. Radoi, R. Olteanu  
National Institute of Neurology and Neurovascular 
Diseases, Bucharest, Romania  

 
Introduction: Large anterior cranial fossa 

meningiomas arise at the cribriform plate of 
the ethmoid bone and the area of the suture 
adjoining the planum sphenoidale. These 
meningiomas, which are predominantely 
represented by olfactory groove 
meningiomas, cover the entire crista gali to 
the posterior part of the planum 
sphenoidale, and grow simetrically to the 
anterior sagittal sinus and falx or mainly to 
one side.  

Material and methods: We conducted a 
retrospective study of 56 patients with large 
anterior cranial fossa meningiomas, which 
were evaluated and operated in the 
Neurosurgical Department of the National 
Institute of Neurology and Neurovascular 
Diseases between 2000 – April 2012. The 
diameter of the meningioma varied 
between 4.7 – 10 cm. Tumors were 
operated on through the unilateral 
frontolateral (42 patients) and bifrontal 
approaches (14 patients). The extent of the 
tumor resection was classified according to 
the Simpson classification. All the 56 
patients were followed-up with annual CT 
or MRI scans and neurologically evaluated 
in our clinic. The follow-up period ranged 
widely from 4 to 324 months (mean, 98 
months).  

Results: Total tumor removal (Simpson 
Grade 1 or 2) was achieved in most of the 
cases, 51 patients (91%).). Meningiomas 
operated through the bifrontal approach 
were entirely resected in 12 (85.71%) out of 

14 cases. In patients operated through the 
frontolateral approach (42 patients), total 
tumor removal was achieved in 39 cases 
(92.85%). As postoperative complications, 
were encountered: subdural hygroma, 
postoperative hemorrhage, cerebrospinal 
fluid (CSF) leak, postoperative seizures, 
diffuse cerebral edema and local infection. 
Postoperative mortality was 7.14% (4 
patients). In our series, tumor recurrence 
occurred in 4 patients (7.14%). All of them 
required surgery. The recurrence rate was 
higher in patients with tumors having 
paranasal extension and which were mainly 
operated through bifrontal approach. None 
of the patient underwent postoperative 
radiation or radiosurgery.  

Conclusions: For the removal of large 
anterior cranial fossa meningiomas we used 
two different surgical approaches: unilateral 
frontolateral approach and bifrontal 
approach. The use of microsurgical 
techniques allowed total removal of the 
large meningiomas, with low rates of 
mortality and mortality. Considering the 
operative morbidity and mortality 
encountered in the resection of large 
anterior cranial fossa meningiomas, we 
could conclude that, the frontolateral 
approach provided an important 
improvement compared with the bifrontal 
one. 



 
 
 

Romanian Neurosurgery (2012) XIX 4: 309 – 355          321 

 
 
 

PARASAGITAL AND FALX 
MENINGIOMAS A FIVE YEARS 
EXPERIENCE IN BAGDASAR - 
ARSENI HOSPITAL, 
NEUROSURGICAL CLINIC  
M.R. Gorgan*, A.V. Ciurea*, V. 
Ciubotaru*, V. Munteanu**, Ligia 
Tătăranu*, Al. Tascu*, A. Buliman**, 
Nicoleta Diaconu**,  
B. Ghinguleac**, V. Prună**  
*“Carol Davila” University of Medicine and Pharmacy,  
**Neurosurgical Clinic, “Bagdasar – Arseni” Clinical 
Hospital, Bucharest, Romania  

 
Our work is based on 1084 cases of 

meningiomas treated between 2007-2012. 
151 of this cases where parasagital and falx 
meningioma.  

Meningiomas are slow-growing, extra 
axial tumors with arachnoid cap-cell origin. 
There are curable intracranial tumors, only 
if they are completely removed,which is not 
always possible. Most commonly located 
are along falx, convexity and sphenoid bone 
they account for 14-19% of primary 
intracranial tumors. The peak incidence is 
around 45 years of age with a sex ratio 1,8/1 
for women. 1,7% of this are hystologicaly 
malignant. They evolve for long time 
asymptomatically. All these cases were 
initially investigated using CT scan with 
I.V. contrast and MRI. In approximately 
95% of cases we had an angio-MRI. In all 
cases we performed an angiography, 
especially to see the sagittal sinus patency, 
but also the external carotid vascularization 
with the characteristic tumor blush. In 
more than 85 percent of cases we 
performed a total removal of the tumor and 
in the other 15% a grade II resection on the 
SIMSON scale was performed (due to large 
falx insertion). All patients have been cured 
of the prior existing seizures linked to the 

mass effect lesion. In 18% of cases after 
surgery we observed an increase of a prior 
existing deficit or a new one occurred. In 
these cases, 15% of the patients had a deficit 
4 out of 5 on the ASIA scale after a six 
months period.3% of the cases had a 
persisting disabling deficit which required 
help day by day. We have records of 6 
patients who died after 8 and 10 months, 
one of pulmonary oedema and one after 
myocardic infarction.  

Conclusion: We consider for this 
pathology, that surgery is the best treatment 
followed by gamma knife terapy where 
required. 

THE ROLE OF CORTICAL 
MAPPING ON SURGICAL 
MORBIDITY IN ROLANDIC AREA 
MENINGIOMA TREATMENT 
PLANNING  
J. Ciurea, Coman Teodora Camelia, B. 
Bălănescu, G. Grigore, A. Rasina  
Clinic Hospital Bagdasar-Arseni, Bucharest, Romania  

 
Objective: This study relives the role of 

transcranial magnetic stimulation (TMS) in 
neurosurgical planning for meningiomas 
located in rolandic area of the brain.  

Patients and method: The study included 9 
cases of meningiomas in eloquent areas 
which were operated during the last year. 
There were 8 females and 1 male with age 
between 30-70 year old. Preoperative TMS 
was performed in all cases to give us a brain 
map of the rolandic area in order to 
improve the surgical outcome in this type 
of tumor. From all the 9 cases, 6 were 
located on the right side and 3 on the left 
side. In 7 cases the rolandic area was found 
to be displaced because of meningioma shift 
in comparison with the opposite side. In all 
cases total removal (Simpson 1 and 2) was 



 
 
 
322          Selected Abstracts          The 8th International Congress of the RSN 

 
 
 

performed. The tumor resections begin 
with tumor debulking in cases with 
rolandic area displacement in order to avoid 
postoperative morbidity caused by brain 
edema, microthrombosis, etc. In the other 2 
cases the meningioma resection was 
performed “en bloc”. In all cases the 
ultrasonic aspiration (CUSA) was used for 
tumor resection under microscopic 
magnification.  

Results: From histological point of view, 
5 cases were meningothelial, 2 cases 
transitional and 2 cases atipic meningiomas. 
Postoperative morbidity consists in 
transitory controlateral hemiparesis in 3 
cases and transitory aphasia in 2 cases. 
None of cases in which the rolandic area 
was not displaced presents postoperative 
morbidity. All 9 cases presents without 
neurological deficits 3 months 
postoperatively.  

Conclusions: TMS can be considered an 
alternative to the intraoperative direct 
cortical electrical stimulation without 
adverse effects and with similar results. The 
advantage of the TMS consists in: non-
invasive method, useful in preoperative 
planning, and an accurate preoperative 
evaluation of the displacement of functional 
areas or compression.  

In our opinion the TMS is useful in 
neurosurgical planning for meningiomas 
located in rolandic area. The type of 
surgical approach depends on the rolandic 
area shift relived preoperatively by TMS. 
This method avoid postoperative morbidity 
after total removal of the tumor. 

 

 

POSTERIOR CRANIAL FOSSA 
MENINGIOMAS - 5 YEARS 
EXPERIENCE AND RESULTS 
CLINIC EMERGENCY HOSPITAL 
“BAGDASAR-ARSENI” BUCHAREST  
M.R. Gorgan*, Bucur Narcisa**, Neacsu 
Angela**, V. Pruna**, F.M. Brehar*, 
Sandu Aurelia Mihaela**, V. Ciubotaru**, 
Tataranu Ligia Gabriela*, D. Paunescu**, 
A. Tascu*, A.V. Ciurea*, C. Pascal**, J. 
Ciurea**, Catioara Fanica Cristescu**, A. 
Buliman**  
*“Carol Davila” University of Medicine and Pharmacy, 
Neurosurgical Clinic, “Bagdasar – Arseni” Clinical 
Hospital, Bucharest, Romania  
**Neurosurgical Clinic, “Bagdasar – Arseni” Clinical 
Hospital, Bucharest, Romania  

 
Authors presents a retrospective study 

based on 103 case series of posterior fossa 
meningiomas treated in Clinic Emergency 
Hospital “Bagdasar-Arseni” between June 
2007- June 2012, in four neurosurgery 
departments, sharing the same methods and 
principles of treatment. Our center in a 
national reference university hospital 
deserving about 6 million people. Data was 
collected and analyzed from electronic data 
base and hospital registry. They were 20 
man and 83 women with a median age of 
54.5 years old. Main methods of treatment 
consisted in: observation, open surgery, 
gamma-knife surgery and combined 
methods. 13 patients were observed for one 
year, and then they decided for: open 
surgery, 8cases, and gamma-knife surgery, 5 
cases. 39 cases were treated only by gamma-
knife surgery and followed up after 
treatment for a medium interval of 43 
months. 57 patients supported open surgery 
in one or more stages, depending on tumor 
size and location, 26 of them benefited too 
from a ventriculoperitoneal shunt, 4 in an 



 
 
 

Romanian Neurosurgery (2012) XIX 4: 309 – 355          323 

 
 
 

acute phase. Tumor size was between 3-5 
cm in 33 cases, and over 5 cm in 21 cases. 2 
of this category of patients supported 2 and 
respectively 3 stages of resection. According 
to Simpson Scale, total resection was 
achieved in 20.34%, grade II in 11.86 %, 
grade III in 35.9 %, and grade IV in 28.81%. 
The most frequent location was petroclival 
area (37.86%) followed by cerebellar 
convexity (27.18%) and pontocerebellar 
angle (24.27%). Most frequent pathological 
samples showed transitional meningioma 
(33.9%) followed by meningothelial 
(15.09%) and fibrous type (13.21%). They 
were 10 cases with atypical and anaplastic 
meningiomas (19%). In 95.15 % of cased 
the postoperative neurological status 
remained the same or improved. 5 cases 
(4.85%) presented neurological 
deterioration, 3 reversed on the follow-up 
period, and 2 remained permanent. One 
case with a giant hemifossa tumor deceased 
by complications related to brain stem 
decompression. They were 2 CSF 
postoperative fistulas, one postoperative 
wound infection, two postoperative 
cerebellar hematomas, and 17 patients 
presented decompensations of previous 
illnesses (heart and lung). They were 
recorded 5 tumor re-growth in malignant 
meningiomas, and 4 in the non-malignant 
group. All cases benefited of treatment: 6 
cases- gamma-knife and 3 cases-open 
surgery. Mean general follow up period was 
32 months.  

Conclusion: General results of the 
treatment of posterior fossa meningioma 
are very good in our clinic, due to 
homogenous neurosurgical attitude, 
experienced teams and adequate 
perioperative treatment. Rate of total 
resection is significant affected by lesions 

over 5 cm diameter, and lesions located in 
petroclival area. 

MODERN MANAGEMENT 
STRATEGIES IN POSTERIOR 
FOSSA MENINGIOMA 
TREATMENT  
B. Iliescu*, S. Gaivas*, Ziyad Faiyad*,  
I. Poeată**  
*“Prof. Dr. Nicolae Oblu” Clinical Emergency 
Hospital, Iasi, Romania  
**University of Medicine and Pharmacy “Gr T Popa” 
Iasi, Romania  

 
Introduction: Posterior fossa meningioma 

is the second most common tumor in the 
cerebellopontine angle, accounting for 10% 
to 15% of neoplasms in this area. Unlike 
acoustic neuroma, posterior fossa 
meningioma presents a real surgical 
challenge. The variable location of these 
tumors, their usually large size at diagnosis, 
their frequent encroachment on neural and 
vascular structures, and their potentially 
invasive behavior are some of the criteria 
that make the resection of these lesions a 
difficult task.  

Material and methods: 29 posterior fossa 
meningioma patients managed in our 
department in the last three years were 
reviewed. 24 patients underwent surgery 
with 26 surgical procedures. The 
approaches used were retrosigmoid in 16 
cases, far lateral in 2 cases, subtemporal 
transtentorial in 3 cases, suboccipital in 2 
cases and combined suboccipital 
supracerebellar in one case.  

Results: Gross total removal was achieved 
in 17 cases, with partial resection in the rest 
of 7 cases. In 2 cases the complete removal 
was possible just after a second surgical 
procedure. In 3 cases the subtotal removal 
was the planned surgical strategy due to 



 
 
 
324          Selected Abstracts          The 8th International Congress of the RSN 

 
 
 

obvious imagistic restrains and the 
availability of Gamma-Knife adjuvant 
therapy. Facial nerve was preserved in 79% 
of the cases with various degrees of 
dysfunction in the rest. 2 cases presented 
with significant cranial nerve (other than 
facial) dysfunction. There were only two 
cases of perioperative deaths and 2 cases 
showed radiological recurrence so far. The 
cases that were not operated were sent 
directly to GK (3 cases) and observed (2 
cases).  

Conclusion: Radical extirpation of 
posterior fossa meningioma with the least 
possible morbidity requires the flexible 
utilization of different approaches, the 
choice of which should be adapted to each 
individual case. Surgical removal was the 
treatment of choice of posterior fossa 
meningioma. However, in selected cases it 
was felt prudent to delay surgery. The 
availability of non-invasive radiosurgery 
brings a salutary therapeutic option for 
selected cases be it as a first intention 
treatment or as adjuvant therapy, improving 
the overall outcome of posterior fossa 
meningioma patients. 

UPPER CERVICAL SPINE TUMOR 
PATHOLOGY C1-C2 - 
THERAPEUTIC ATTITUDE  
D. Serban, N.A. Calina, F. Exergian, M. 
Podea, C. Zamfir  
Spinal Surgery Department, I Neurosurgical Clinic, 
Emergency Hospital “Bagdasar-Arseni”, Bucharest, 
Romania  

 
Surgical treatment of upper cervical 

spine tumors, whether they are vertebral, 
epidural, subdural or intramedullary, raises 
technical and decisional difficulties 
regarding the approach of the region as well 
as in maintaining its stability.  

The authors performed a retrospective 
study on C1, C2 spinal tumor pathology, 
managed surgically in the Spinal Surgery 
Department of ”Bagdasar Arseni” Clinical 
Hospital, between January 2007 and 
December 2011.  

We included in the study 44 patients, 
operated for C1, C2 cervical spine tumors, 
23 men and 21 women with ages between 
13 and 71 years. The pathology included 24 
C1-C2 vertebral tumors, 11 subdural 
tumors, 2 epidural tumors and 7 
intramedullary tumors.  

Presenting symptoms were cervical pain, 
occipital neuralgia, medullary compression 
syndrome, and/or cranio-spinal junction 
instability.  

The purpose of surgery was to establish 
a histopathologic diagnosis and to 
decompress the neural elements by 
attempting a total tumor removal as well as 
to stabilize the cranio- cervical junction in 
order to improve the patient’s quality of 
life. The approach was chosen based on 
tumor location, prognosis and the need for 
fixation. For 6 patients an anterior approach 
was used, for 31 pacients we used a 
posterior approach and 7 patients required a 
combined anterior and posterior approach.  

Neurological improvement was 
observed in 17 patients, with a mean 
increase of 8 points on ASIA scale, 7 
patients worsened immediately 
postoperatively with a mean decrease of 10 
points on ASIA scale and 20 patients 
without neurological deficits preoperatively 
remained unchanged. In all cases where the 
craniospinal junction instability was the 
cause of occipito-cervical pain we noted the 
disappearance of pain after surgery.  

The development of new surgical 
techniques and fixation systems paved the 
way to a successful treatment for these 



 
 
 

Romanian Neurosurgery (2012) XIX 4: 309 – 355          325 

 
 
 

difficult tumors, some of them considered 
inoperable in the past. 

CRANIO-SPINAL JUNCTION 
TUMORS: A SERIES OF 24 CASES  
A.S. Iencean M.D.***, Faiyad Ziyad*, M. 
Ivanov**, S. Gaivas*, B. Iliescu*, Al. 
Chiriac*, S.M. Iencean***, I. Poeata***  

*“Prof. Dr. Nicolae Oblu” Clinical 
Emergency Hospital, 3rd Department of 
Neurosurgery, Iasi, Romania  

**Plymouth Hospitals NHS Trust, Derriford 
Hospital Plymouth, Great Britan  

***University of Medicine and Pharmacy 
“Gr.T.Popa”/“Prof. Dr. Nicolae Oblu” Clinical 
Emergency Hospital, Iasi, Romania  

 
Objective: We present our surgical 

experience in the treatment of 24 patients 
with tumors of the cranio-spinal junction 
that were warded between 2007-2012 in 
our department.  

Design: The pathology of the cranio-
spinal junction is complex and the tumors 
of this region may present diagnostic and 
management problems.  

Methods: In six years we treated twenty-
four patients with tumors of the cranio-
spinal junction: eight foramen magnum 
meningiomas, six vertebral tumors C1/C2, 
four jugular foramen tumors, four cases of 
lower brainstem tumors and two occipital 
condyle tumors. All patients were explored 
preoperatively by MRI or CT.  

Results: The suboccipital (midline and 
paramedian) approach was performed in 
nine cases, seven of them required 
additional resection of the posterior arch of 
C1/C2. In six patients the surgical approach 
implied only the resection of posterior arch 
of C1/C2; the far-lateral approach was used 
in eight patients and in one case we used 
the transoral approach. All patients 

benefited by a microsurgical approach; 
gross total removal was achieved in 10 out 
of 24 cases.  

Conclusions: The preoperative diagnosis 
and the operative planning are very 
important for the surgical handling of 
cranio-spinal junction tumors. The 
microsurgical approaches provide the best 
operative results. 

SURGICAL APPROACHES FOR 
THE CRANIO-CERVICAL 
JUNCTION TUMOURS  
I.S. Florian,* T. Maior*, C. Abrudan**, 
Zorinela Andrasoni**  
*University of Medicine and Pharmacy “Iuliu 
Hatieganu” Cluj-Napoca, Department of Neurosurgery,  
Cluj-Napoca, Romania  
**Cluj County Emergency Hospital, Department of 
Neurosurgery Cluj-Napoca, Romania  

 
Choosing the most adequate surgical 

approach it is an intriguing topic not 
because it is a difficult region to deal with, 
but also because there is a place where 
along neurosurgeons there are other 
specialties that are disputing the priorities 
and arguing the best management to 
perform surgery like ENT surgeons, spinal 
surgeons or those specialized in cranio-
facial surgery.  

The great difficulty of approaching this 
region consists not only in the osteo-
muscula ligament complex that permits 
stability and complex movement of the 
head, but also in the great number of vital 
neurovascular structures and their great 
anatomical variability.  

When dealing with a tumor of the CVJ 
the selection of a certain approach is 
depending on several factors like tumor 
location, type and size, neurological and 
general status of the patient, and the 



 
 
 
326          Selected Abstracts          The 8th International Congress of the RSN 

 
 
 

relation to the dura, namely if the tumor is 
epi or intra dural. Nevertheless the 
surgeon’s preference and confidence for a 
certain approach is a factor that is less 
discussed, but in fact it is a decisive one. In 
the present thanks to the progresses in the 
surgical techniques, a tumor located in this 
region can be circumferentially approached, 
from anterior, antero-lateral, lateral 
postero-lateral and median posterior. The 
idea is to approach the tumor on the 
shortest distance, and to intersect less 
neurovascular structures.  

The different kind of approaches are 
presented based on the procedure, extent of 
exposure, common pathology, advantages 
offered, limitations, and risk and long-term 
side effects. The data presented is well 
illustrated by cases from the authors’ 
personal experience. 

OUR EXPERIENCE IN TWO CASES 
OF DURAL ARTERIOVENOUS 
FISTULAS AT THE 
CRANIOCERVICAL JUNCTION  
Al. Chiriac,* I. Poeată**, Faiyad Ziyad*, 
N. Dobrin*, A.S. Iencean*  
*University of Medicine and Pharmacy “Gr T Popa” 
Iasi, Romania  
**Clinical Emergency Hospital “Prof. Dr. N.Oblu” 
Iasi, Romania  

 
Background: Dural arteriovenous fistulas 

(DAVF) at the craniocervical junction are 
uncommon lesions that may result in 
various neurological presentations. These 
lesions are a rare cause of intracranial 
subarachnoid hemorrhage (SAH).  

Methods: We performed a retrospective 
study on two patients with craniocervical 
junction DAVF. The clinical and imagistic 
dates with surgical video recordings were 
reviewed by the authors. The follow-up six 

month dates were also analyzed.  
Results: One patient presented with 

meningeal symptoms due to a subarachnoid 
hemorrhage, and the other one had a slowly 
progressive cervical myelopathy (with 
progressive quadriparesis) associated with a 
single episode of lost of consciences. This 
last patient had a C4 – C6 DAVF with 
single or main ascending venous route into 
the intracranial vein. Both cases were 
treated by surgical interventions technique. 
The overall clinical outcomes were good 
during an average follow-up period of 10 
months. In particular, follow-up 
angiographs performed one months later 
revealed the complete disappearance of 
DAVF in both patients.  

Conclusions: DAVF of the craniocervical 
junction are unusual condition 
characterized by important severe 
neurological deficits referable to this region. 
Our experience showed that microsurgical 
approach of these lesions a clinical cure of 
the patients with their clinical 
improvement. 

OUR EXPERIENCE IN CHIARI 
MALFORMATIONS SURGICAL 
TREATMENT  
A. Bălasa, D. N. Gherasim  
County Emergency Hospital, Department of 
Neurosurgery Tg. Mures Romania  

 
Introduction: “As described and classified 

over a century ago, herniation of the 
cerebellar tonsils more than 5 mm into the 
cervical spinal canal with obliteration of the 
cerebellomedullary cistern and obstruction 
of foramen magnum is the primary feature 
of Chiari I malformation.”  

Pathophysiology: The Chiari malformation 
constitutes an heterogeneous and 
multifactorial entity, in which congenital 



 
 
 

Romanian Neurosurgery (2012) XIX 4: 309 – 355          327 

 
 
 

forms of Isolated presentation or with a 
genetic background and forms of acquired 
etiology exist. No unitary clasification exists 
to this date.  

Clinic and symptoms: One estimate based 
on extrapolations from a previous study 
suggested a prevalence of tonsillar ectopia 
inthe general population of approximately 
3.5%. The proportion of these individuals 
who go on to develop symptoms is 
unknown. Nevertheless, the disorder can 
be associated with significant 
symptomatology, risk of secondary injury 
due to trauma and the risk of progression 
and damage of the spinal cord due to 
associated syringomyelia.  

Surgical treatment: The goal of surgery is 
to relieve cord compression and to 
reestablish adequate csf flow. There have 
been no prospective studies in which one 
treatment form is directly compared with 
another.  

Conclusions: In light of the many theories 
of pathophysiology, broad clinical 
presentations, and multitude of surgical 
interventions with variable outcomes, it is 
no wonder that a single surgical approach 
does not exist. We recommend tailoring the 
surgical approach to treat the dominant 
clinical problem. Early diagnosis and 
treatment is critical in obtaining the best 
outcome for the patient. The presence of 
syringomyelia is a sign of advanced 
structural abnormality, as it is associated 
with the presence of sensory and motor 
deficits, as well as with the presence of 
spinal deformity. The preoperative presence 
of deficit is a predictor of poorer 
neurological outcome, making a strong case 
for early surgical intervention. 

 
 
 

MINIMALLY INVASIVE SPINE 
SURGERY: THE WAY OF THE 
FUTURE  
G. Tender  
Louisiana State University, New Orleans, US  

 
Minimally invasive spine surgery 

involves surgical techniques that require 
smaller incisions, result in less soft tissue 
disruption, and involve limited surgical 
corridors. They are typically associated with 
decreased blood loss, decreased infection 
rates, and decreased hospital stay.  

Historically, Prof. Yasargil used the 
operative microscope for the first time in 
1976 to perform a lumbar discectomy. In 
the early ‘90’s, laparoscopic 
cholecystectomy became the method of 
choice for removing the diseased gall 
bladder. After 2000, minimally invasive 
spine techniques became increasingly 
popular.  

The initial operations involved simple 
spinal decompressions. Through a skin 
incision of less than 2 cm in length, a 
system of tubular dilators was used to split 
the muscle fibers and allow for placement 
of an 18mm-diameter tubular retractor that 
rested on the lamina or facet of the diseased 
segment. The most common operation was 
the lumbar microdiscectomy, but other 
pathology, such as segmental spinal 
stenosis, lateral soft cervical disc 
herniations, or gunshot wounds to the 
spine with retained bullet fragments, was 
also addressed via this tubular retractor.  

Later, technological advancements like 
better instrumentation, illumination and 
magnification, as well as a better 
understanding of the anatomical 
approaches, allowed for more complex 
operations to be performed using the 
minimally invasive techniques. Lumbar 



 
 
 
328          Selected Abstracts          The 8th International Congress of the RSN 

 
 
 

fusion patients were by far the main 
beneficiaries of these techniques. The 
posterior and transforaminal lumbar 
interbody fusions (PLIF or TLIF) have 
become in recent years the preferred 
method in cities with advanced surgical care 
like New York and Los Angeles. Other 
surgical techniques take advantage of new 
pathways to the lumbar spine. The extreme 
lateral interbody fusion (XLIF), used at or 
above the L4-5 level, is indicated in patients 
with previous midline approaches as well as 
patients with segmental deformity. The 
presacral approach (AxiaLIF) provides 
similar advantages at the L5-S1 segment 
and has the lowest complication rate of all 
fusion procedures. More advanced surgical 
interventions, like thoracic or high lumbar 
corpectomies for trauma, infection, or 
tumor, can also be currently treated with 
small skin incisions and reduced 
postoperative morbidity.  

The minimally invasive spine surgery 
techniques are currently the fastest growing 
trend in the US and are employed by about 
80% of the spine surgeons in the large cities 
with highly educated patients. It is probable 
that MISS will become the treatment of 
choice for elective spine patients all across 
US in the near future. 

TRAUMATIC PATHOLOGY OF 
THE THORACIC AND LUMBAR 
SPINE - OUR PERSPECTIVE  
Tiberiu Maior  
Department of Neurosurgery, Cluj County Emergency 
Hospital, Romania  

 
Objective & design: The paper presents the 

surgical treatment protocol in trauma 
pathology located in dorsal and lumbar 
spine area. Aspects related to vertebral body 
surgery, lengths and type of 

instrumentation, reason of treatment, and 
pitfalls in trauma surgery are discussed.  

Material and methods: 180 of cases were 
studied with at least one year post-op 
follow-up, operated according to the same 
criteria. The treatment algorithms area 
presented, including some representative 
cases of posterior approaches, and of 
combined (anterior and posterior) 
approaches. All presented cases are from the 
author’s personal archive and underwent 
surgery using the same system of 
stabilization and the same technique.  

Results & conclusions: Obvious advantages 
of the transpedicualr stabilization, 
ligamentotaxis and the reconstruction of the 
vertebral body. Images of illustrated cases 
are presented. 

THE ADVANTAGES OF THE 
ANTERIOR APPROACH IN THE 
TUMOR PATHOLOGY OF THE 
SPINE  
Tiberiu Maior  
Department of Neurosurgery, Cluj County Emergency 
Hospital, Romania  

 
Objective & design: This paper proposes to 

highlight the necessity, the advantages of 
the anterior approaches in spine tumor 
pathology. The current tendency in this 
field is total removal of the tumor; in this 
respect the “en block” resections become 
the gold standard, especially in primary 
spine tumors. As a result of the outstanding 
progresses in the oncological field total 
removal (ideal “en block) became also a 
standard in spine metastasis, even in 
multiple spine metastases.  

Material and methods: The paper analyzes 
55 complex surgeries of spinal pathology, 
which had as a result the total removal of 



 
 
 

Romanian Neurosurgery (2012) XIX 4: 309 – 355          329 

 
 
 

the tumors using combined approaches: 
anterior and posterior.  

All presented cases are from the author’s 
personal archive and they are representative 
for all regions of the spine, with special 
emphasize on the transition areas.  

Results & conclusions: The present paper 
underlines the mandatory aspect of the 
anterior approaches in order to obtain a 
total tumor resection. Meanwhile practical 
aspects are presented among which pitfalls, 
tricks and tips are considered by the author 
essential in performing these types of 
surgeries. 

MANAGEMENT OF BRAINSTEM 
LESIONS  
I.St. Florian*, Attila Kiss**, Zorinela 
Andrasoni**  
*University of Medicine and Pharmacy “Iuliu 
Hatieganu” Cluj-Napoca, Department of  
Neurosurgery, Cluj-Napoca, Romania  
**Cluj County Emergency Hospital, Department of 
Neurosurgery, Cluj-Napoca Romania  

 
Objective & design: The surgical approach 

of the brainstem lesions is very difficult 
because of high density of vital areas at this 
level of the central nervous system.  

Our aim is to share the experience that 
we achieved in diagnosis, therapeutical 
protocol, and the neurosurgical approaches 
of brainstem lesions in the past fourteen 
years.  

Materials and methods: This study consists 
in a retrospective analysis of 76 cases of 
patients diagnosed with brainstem lesions 
and surgically treated in our department 
between January 1998 and December 2011. 
We studied epidemiological aspects, 
pathological findings, clinical features, 
diagnosis methods, surgical approaches, and 
outcomes of our case series.  

Results: From all brainstem lesions, 62 
cases were tumors and 14 cavernomas. 
Brainstem tumors represent almost 15 % of 
posterior fossa tumors operated in our 
department. Our peak incidence is in the 
first four decades of life. Gender 
distribution shows a slightly male 
predominance (35 cases). Signs of 
intracranial hypertension, motor 
deficiencies and cranial nerve palsies were 
the main clinical findings. In each case 
cerebral MRI was performed, with or 
without cranial CT scan. Fourty nine 
patients were operated by open surgery. In 
all cases suboccipital craniectomy in sitting 
position was preferred, except in two cases 
of diencephalo – mezencephalic tumor the 
subtemporal approach was chosen. Using 
the sitting position, in combination with a 
meticulous microsurgical technique, ECG, 
blood pressure, central venous line, end-
tidal carbon dioxide, and oxygen pressure 
monitoring, no clinical evidence of air 
embolism was detected. Total resection was 
possible in 20 cases versus subtotal re-
section in 29 cases of brainstem tumors and 
we performed only drainage of 
hydrocephalus in 13 cases, without tumor 
resection. Histological finding shows that 
the most common tumors are low grade 
gliomas. Brainstem cavernomas represent 
25 % of al cavernomas treated surgically in 
our department. Complete surgical removal 
of cavernoma was successfully performed in 
all cases using the same sitting position.  

Conclusions: Despite of their location, 
many of brainstem lesions can be totally 
removed surgically due to their benign 
nature. In this case the neurosurgical 
treatment can have healing effect. In the 
presence of malignancy signs, the possibly 
maximum tumor resection with or without 
drainage of hydrocephalus can improve 



 
 
 
330          Selected Abstracts          The 8th International Congress of the RSN 

 
 
 

rapidly the patient clinical status and it 
creates good conditions for the adjuvant 
therapy. 

OUR EXPERIENCE IN IMAGE 
GUIDED STEREOTACTIC BIOPSY 
FOR INFILTRATIVE CEREBRAL 
GLIOMAS  
F.M. Brehar,* Aura Sandu**, M. 
Lisievici**, M.R. Gorgan**  
*“Carol Davila” University of Medicine and Pharmacy 
Bucharest, Faculty of Medicine, Department of 
Neurosurgery, Bucharest, Romania  
**“Bagdasar-Arseni” Emergency Clinic Hospital, 
Department of Pathology Bucharest, Romania  

 
Objective: Minimally invasive approaches, 

like stereotactic biopsy, are frequently 
required in many cases of infiltrative 
cerebral gliomas, because the invasive 
growth pattern precludes the gross total 
resection of these types of lesions. The 
authors present their experience in 85 cases 
of stereotactic biopsies performed for 
infiltrative cerebral gliomas.  

Materials and methods: Eighty-five patients 
with infiltrative, multicentric and deep-
seated gliomas have been included in this 
study. All patients underwent the 
stereotactic biopsy according to the 
standard protocols. Stereotactic and 
neuroimagistic tools used for these 
procedures included the Leksell stereotactic 
system and the software: Stereotactic 
Planning System (SPS), NTPS 8.2.  

Results: The histopatological results 
(according to World Health Organization 
(WHO) classification) were: 51 cases of 
glioblastomas (grade IV) (60%), 7 cases of 
anaplastic astrocytomas (grade III) (8,2%), 
13 cases of grade II diffuse astrocytomas 
(15,3%), 6 cases of grade I astrocytomas 
(7,1%), one case of grade II 

oligodendroglioma (1,2%), 3 cases of 
anaplastic oligodendrogliomas (grade III) 
(3,5%), one case of grade I ganglioglioma 
(1,2%), one case of anaplastic ganglioglioma 
(grade III) (1,2%), and 2 cases of anaplastic 
ependymomas (grade III) (2,3%). In 21 
cases (24,7%) the immunohistochemistry 
has been performed in order to obtain an 
accurate histopathological result. In this 
series, the early postoperative mortality was 
0%, with no cases of clinically significant 
hemorrhages after biopsy procedures. 
Temporary increase of neurological deficits 
has been noticed in 7 patients (8,2%).  

CONCLUSIONS  
In conclusion, image-guided stereotactic 

biopsy represents now a safe and accurate 
diagnostic method for infiltrative, 
multicentric and deep-seated cerebral 
gliomas. 

THE EXPERIENCE OF THE 
SURGICAL MANAGEMENT OF 
THE INTRACRANIAL VASCULAR 
MALFORMATIONS  
I.St. Florian*, S. Trifoi**, Andreea 
Mogyoros**, Zorinela Andrasoni**  
*University of Medicine and Pharmacy “Iuliu 
Hatieganu” Cluj-Napoca, Department of  
Neurosurgery Cluj-Napoca, Romania  
**Cluj County Emergency Hospital, Department of 
Neurosurgery, Cluj-Napoca, Romania  

 
Objectives & design: Nowadays, the 

multimodal treatment (microsurgery, 
radiosurgery, interventional neuro-
radiology) is used to provide a more 
effective and less morbid therapy for the 
arteriovenous malformations. The purpose 
of this paper is to describe our surgical 
experience and current management of 
these vascular disorders, which lead to 
successful surgical removal in the absence 



 
 
 

Romanian Neurosurgery (2012) XIX 4: 309 – 355          331 

 
 
 

of endovascular preoperative embolisation, 
neuronavigation or intraoperative 
monitoring opportunities.  

Material and methods: We report a 
retrospective analysis of 184 intracranial 
vascular malformations treated by surgical 
excision in our medical center between 
June 1996 and December 2011. From these 
67% were diagnosed as AVMs and 33% as 
cavernomas. The preoperative evaluation 
consisted of clinical exam, CT, MRI and 
angiography. Clinical data analysis found 
the peak incidence in the 5th decade and a 
slight male preponderance was observed 
(55%).  

Results: In our series the major clinical 
findings were hemorrhage, seizures, 
progressive neurological deficits, and 
headache and according to Spetzler-
Marting grading system the majority of the 
cases were grade II and grade III (64%) 
Postoperative morbidity consisted of 
transient neurological deficits (12%), 
hydrocephalus and re-bleeding. We 
obtained GOS score of 4 and 5 in 88% of 
the patients. The association of intranidal 
aneurysms was observed in 12% of AVMs, 
and they were addressed in the same 
operative session. First of all the decision 
for the surgical treatment should take into 
consideration the sum of the risks of all the 
interventions and should be compared to 
the natural history of the lesions. The non-
surgical treatment has a significant impact 
on the patients suffering from these 
cerebrovascular lesions, but still has some 
unsolved problems.  

Conclusion: Due to the shortage of 
endovascular/radiosurgery facilities in our 
department, surgery remains the single 
treatment strategy to cure these lesions. 
Even though many of the cases were 
admitted with a severe neurological status, a 

successful surgical treatment requires 
besides microsurgical techniques, 
microsurgical gestures too. 

OUR FIRST EXPERIENCE IN 
STENT AND STENT-ASSISTED 
COIL EMBOLIZATION OF 
INTRACRANIAL ANEURYSMS  
Al. Chiriac*, N. Dobrin**, A.St. 
Iencean**, I. Poeata***  
*University of Medicine and Pharmacy, Iasi, Romania  
**Clinical Emergency Hospital “Prof. Dr. N.Oblu”, 
Iasi, Romania  
***„Gr. T. Popa” University of Medicine and 
Pharmacy, Iasi, Romania  

 
Background and purpose: The endovascular 

detachable coil embolization for cerebral 
aneurysms treatment has become an 
important method witch poses a significant 
technical challenges, particularly in wide-
necked aneurysms. We present the results 
of our initial experiences in using a self-
expanding neurovascular stent and 
detachable coils in the management of 
wide-necked intracranial aneurysms.  

Methods: Two consecutive patients with a 
wide-necked intracranial aneurysm were 
treated by Neuroform Stent deploying as 
flow-diverting embolization and 
Neuroform Stent-Assisted Coil 
embolization. We assessed patients’ history, 
aneurysm morphology, indications for 
stenting technique, and technical feasibility 
and efficacy of the procedures, 
complications and midterm follow-up data.  

Results: In all patients, the stent 
placement in the desired position with 
complete or nearly complete embolic efect 
of the aneurysms was achieved. Both 
patients had followed a strong 
anticoagulation regimen immediately after 
procedure. In one patient, some urologic 



 
 
 
332          Selected Abstracts          The 8th International Congress of the RSN 

 
 
 

complication had occurred with necessitate 
transfer to a specialized clinic. Six-month 
follow-up demonstrated no focal 
neurologic sequelae in any of the patients, 
except slight memory dysfunction in the 
patient with vertebro-basilar junction 
aneurysm.  

Conclusion: These preliminary data 
results indicate that stent-assisted coil 
embolization can be an easily, safely and 
effective technique in the treatment of 
intracranial wide-necked aneurysms. 
Further studies by long-term angiographic 
and clinical follow-up are needed to 
evaluate the permanent vessel patency and 
long-term durability of stent-assisted 
aneurysm occlusion. 

ANEURYSMS IN CHILDREN – 
PARTICULARITIES - AN 
EXPERIENCE OF 40 CASES  
A.V. Ciurea*, A. Tascu*, A. Iliescu**, D. 
Talianu**, F. Brehar*, A. Giovani**  
*Carol Davila University School of Medicine, Bagdasar-
Arseni Teaching Hospital, 1st  
Neurosurgical Unit, The National Center for Excellency 
in Neurosurgery, Bucharest, Romania  
**Bagdasar-Arseni Teaching Hospital, 1st 
Neurosurgical Unit, The National Center for Excellency 
in Neurosurgery, Bucharest, Romania  

 
Introduction: Intracranial aneurysms in 

children are a very rare pathology which 
generally appears in the literature in limited 
series of 15-30 cases. Most cases of 
intracranial aneurysms in children are 
preponderantly congenital and often 
associated with other malformations such as 
polycystic kidney disease, aortic coarctation, 
Ehlers- Danlos syndrome, thalassemia, etc. 
A limited number of cases are with familial 
incidence. Aneurysmal rupture is extremely 
rare in the first decade of life. The 

incidence gradually increases each decade 
and peaks in the fourth decade of life.  

Material & method: The authors present 
40 cases of children with intracranial 
aneurysms (0-16 y.o.), which represent 
6.1% of all cases (648 cases) of intracranial 
aneurysms operated by the authors between 
January 1997 and December 2011 - 15 
years. The mean age was 14,3 years In all 
literature data the median age was between 
14-18 y.o.  

There were more boys (24 cases, 59%) 
than girls, like in all official data. The 
clinical features are dominated by headache 
(98%), neck stiffness (94%), vomiting 
(92%), focal neurological deficit (81%), an 
altered level of consciousness (67 %), 
seizures (46 %), fever (36%).  

The majority of patients has Hunt & 
Hess Scale grade II at admittance (21 cases, 
53%). All neuroimagistic investigations 
were done in the first 48 hours. The 
anterior communicating artery aneurysm 
(14 cases, 35,3%), followed by middle 
cerebral artery aneurysms (11 cases, 26,5%) 
and carotid artery bifurcation aneurysms (8 
cases, 20,5%) were preponderant.  

There was one case concerning multiple 
aneurysms. Many aneurysms are large and 
giant (14 cases, 35,2%). The particularities 
of the microsurgical approach are: easy 
aneurismal dissection, no ateromatous 
plaques in the cerebral vessels and an easy 
management of brain edema via versatile 
anesthetic control.  

In these conditions the surgical timing is 
essential. All aneurysms were clipped 
directly, with non-important complications 
in the pediatric intensive care unit 
(P.I.C.U.).  

There was one case of preoperative 
mortality in our data. All cases received a 



 
 
 

Romanian Neurosurgery (2012) XIX 4: 309 – 355          333 

 
 
 

perfect neuro-rehabilitation therapy. In our 
data no embolization was performed.  

Conclusions: Intracranial aneurysms in 
children are very rare and were discovered 
and treated in neurosurgical pediatric 
departments.  

Early microsurgical approach is 
mandatory and has excellent results (good 
recovery).  

Aneurysms represent an important 
challenge for all neurosurgeons. 

QUALITY OF LIFE AND GLOBAL 
OUTCOME IN INTRACRANIAL 
CAVERNOUS ANGIOMAS  
A.V. Ciurea*, A. Tascu*, A. Iliescu**, F. 
Brehar*, F. Stoica**, R. Rizea*, H. 
Moisa***  
*Carol Davila University School of Medicine, Bagdasar-
Arseni Teaching Hospital, 1st  
Neurosurgical Unit, The National Center for Excellency 
in Neurosurgery, Bucharest, Romania  
**Bagdasar-Arseni Teaching Hospital, 1st 
Neurosurgical Unit, The National Center for Excellency 
in Neurosurgery, Bucharest, Romania  
***Carol Davila University School of Medicine, 
Romania  

 
Introduction: Intracranial cavernomas (IC) 

count of 0.02 - 0.53% of all intracranial 
lesions and 8-15% of all AVMs. The 
association with AVM is found in 10-30% 
cases. The lesions become symptomatic 
when the size of the lesion is bigger than 1 
cm. These vascular malformations have 
started to be easily diagnosed with the 
introduction of routine MRI scans.  

Material and method: The cohort of 109 
consecutive operated cases of intracranial 
cavernomas were admitted in the 1st 
Department of Neurosurgery of the 
Bagdasar-Arseni Hospital in the period of 
time between January 1998- January 2012 
(14 years). All cases received a complex 

neuroimagistic diagnosis based on CT, 
MRI & DSA Angiography. The cases were 
operated and followed up in the Bagdasar-
Arseni Hospital in Bucharest for a period 
ranging from 6 months to 9 years.  

The sex distribution was 55 males and 
54 females aged between 11- 56 years old 
with a peak of incidence in 31 year olds.  

The cavernomas localization was as 
follows: supratentorial in 75 cases (68,8%), 
infratentorial in 24 cases (22,0%), deep, 
basal ganglia & multiple 10 cases (9.1%). 
The lesions were located: Frontal lobe 34 
cases (31.2%), Parietal lobe 15 cases 
(13.7%), Temporal lobe 23 cases (21.1%), 
Occipital lobe 3 cases (2.7%). Multiple 3 
cases (2.7%), deep and basal ganglia 7 cases 
(6.4%) brainstem 19 cases (17.4%), and 
cerebellum 5 cases (4.5%). In what 
concerns multiple cavernomas, we 
proceeded with surgery only for those 
either manifesting mass effect or presenting 
with hemorrhagic attack.  

The clinical symptoms were 
characterized by seizures 70 cases (64.2%), 
neurological deficits 16 cases (14.6%) 
hemorrhage 23 cases (21.1%).  

A special chapter of the study was 
dedicated to non-operated cases. They 
were: 7 cases multiple lesions, 9 
asymptomatic and 5 lesions deep situated. 
In 2 cases of deep situated lesions, the 
therapy with gamma-knife surgery was 
applied.  

Results: In this series of 109 operated 
patients, the Global Outcome Scale (GOS) 
at 6 months was: good recovery 82 cases 
(75.2%), moderate disability 18 cases 
(16.5%), severe disability 9 cases (8.2%), 
vegetative state 0 cases (0%) and death 0 
cases (0%). The severe disability appears 
especially in brainstem cavernomas, but, in 
time, the cases improved exponentially.  



 
 
 
334          Selected Abstracts          The 8th International Congress of the RSN 

 
 
 

The follow-up period was between 6 
months and 9 years, with a mean range of 
7,6 years. Out of the 70 cases exhibiting 
seizures, all cases were operated: in 52 cases 
(74,2%) we performed a lesionectomy with 
perifocal gliosis excision and in 18 cases 
(25,7%) only lesionectomy.  

Conclusions: Intracranial cavernous 
angiomas (cavernomas) are rare lesions 
characterized by epilepsy in the majority of 
cases or intracerebral hemorrhagic onset. 
When the main symptoms are seizures, the 
best prognosis results after the excision of 
the lesion and the perilesional gliosis. The 
Neuronavigator-guided approach achieved 
in all cases the removal of the lesions with a 
good accuracy in the “Target”, avoiding the 
post-operative deficits and improving the 
clinical Outcome. Furthermore, it avoids 
the discomfort of the stereotactic frame. In 
multiple lesions, the hemorrhagic or mass 
effect lesion must be managed. The option 
of gamma-knife surgery (GKS) in 
cavernomas is disputed. In asymptomatic 
cavernomas, the best management is 
clinical follow-up and MRI observation. 

TWENTY YEARS OF LUMBAR DISK 
SURGERY  
S.M. Iencean  
Grigore T. Popa University of Medicine and Pharmacy, 
Iasi, Romania  

 
Objective: The objective of the study was 

to determine the 20 -year clinical outcomes 
of discectomy for the treatment of lumbar 
disc herniation.  

Design: This report retrospectively 
evaluates 1500 cases of surgical lumbar 
discectomy performed by one 
neurosurgeon to evaluate the indications 
and efficacy of lumbar discectomy.  

Materials and methods: Only 1500 patients 
who underwent lumbar discectomy, based 
on specific objective criteria, were reviewed. 
Diagnosis and localization of the root 
compression were determined 
preoperatively by the lumbar myelogram 
during the years 1989 – 1994, by lumbar 
computed tomographic myelography 
during the years 1995 – 2002 and spinal 
MRI during the years 2003 – 2010.  

Results: 81% patients were rated as 
excellent, 16% as good, 2 % as fair, and 1 % 
as poor. Only 2,5 % patients required 
additional surgery due to a recurrence of 
herniation. 72% of the patients were able to 
maintain their primary occupations.  

Conclusions: The 20-year follow-up study 
showed that the clinical outcomes of of 
surgical lumbar discectomy are very good 
and satisfacatory. 

PERCUTANEOUS 
NUCLEOPLASTY VERSUS OPEN 
DISCECTOMY IN PATIENTS WITH 
LUMBAR DISC PROTRUSIONS  
D. Adam  
“Carol Davila” Medicine and Pharmacy University, 
“Victor Babes” Clinic, Bucharest, Romania  

 
Introduction: Degenerative disc disease 

can be treated conservative or operative by 
many approaches.  

Nucleoplasty by coblation is a minimally 
invasive procedure increasingly applied for 
treatment of lumbar disc herniations.  

Material and method: During 1 year period 
(september 2009-september 2010) two 
cohorts of 80 patients each were operated 
by nucleoplasty and open discectomy 
respectively. There were not significant 
differences regarding sex distribution, age, 
or level of disease. Inclusion criteria are 
different: MRI evidence of contained disc 



 
 
 

Romanian Neurosurgery (2012) XIX 4: 309 – 355          335 

 
 
 

herniation £ 6 mm for nucleoplasty, > 6 
mm for open discectomy. Common criteria 
were radicular pain resistant to conservative 
treatment for a period of at least 6 weeks, 
one level protrusion, and virgin spine at the 
level of interest.  

Nucleoplasty was performed in an 
outpatient setting, with the patient in lateral 
decubitus. The entry point was situated at 
10-12 cm from midline. With a bipolar RF 
probe six channels were created in the 
nucleus by advancing the RF probe in 
ablation mode and withdrawing it in 
coagulation mode using coblation energy 
which dissolve nuclear material through 
normothermic molecular dissociation. 
Open discectomy was performed in a 
standard fashion by interlaminar approach 
with foraminotomy.  

Results: VAS score was reduced at 3 
months follow-up with 40% and 60% for 
nucleoplasty and open discectomy 
respectivelly, and at 1 year follow-up 60% 
and 78% respectivelly.  

All patients with coblation return to 
work 3 days later. Most of discectomy 
patients remain work-off for 3 months 
followed by temporary retirement. Results 
of Roland-Morris questionnaire show an 
improvement at 12 months of 60% in 
nucleoplasty group, and 78% in discectomy 
group. Patients satisfaction after 
nucleoplasty was 73%.  

Conclusions: Nucleoplasty is a relative 
new technique, situated at middle way 
between conservative and open surgical 
treatment of patients with degenerative disc 
disease and lumbar disc protrusion.  

Nucleoplasty is efficacy and safe 
procedure. 

 
 
 

DORSAL RHIZOTOMY IN 
CHILDREN WITH SPASTIC 
PARAPLEGIA: A NEW SIMPLIFIED 
SURGICAL TECHNIQUE  
J. Ciurea, A. Rasina, B. Bălănescu,  
Teodora Coman  
The 5-th Dept. of Functional Neurosurgery, Clinical 
Emergency Hospital Bagdasar-Arseni, Bucharest  

 
Introduction: Over a hundred years the 

lumbosacral dorsal rhizotomy is the 
neurosurgical indication in spastic children 
with cerebral palsy.  

Objective: Analysis of clinical and 
functional results obtained with a new 
simplified surgical technique, quintessence 
of the two technical principles that govern 
dorsal rhizotomy: anatomical approach and 
selective functional approach.  

Method: We illustrated eight cases of 
spastic paraplegia children: five ambulatory 
spastic subjects operated at L5-S1 spinal 
root level and three non-ambulatory cases 
with more severe functional spastic 
paraplegia, clinically presented as quadriped 
crawlers or bunny hoppers, operated at L4-
S1 spinal root level. Statistical analysis using 
the Wilcoxon test (SPSS program) shows 
both a clinical improvement on Ashworth, 
Tardieu and Penn scales and an 
improvement on main functional scales as 
Gillette, test get-up and go or Physician 
Rating Score.  

Discussions: Our anatomical and 
electrophysiological intraoperative 
observations are the basis for a new 
technical approach that respects both the 
classical selective sectoral surgical direction 
promoted by Gros and Sindou, the partial 
limited one of Lazareff and the partial 
limited one promoted by Peacock, Steinbok 
and Mittal.  



 
 
 
336          Selected Abstracts          The 8th International Congress of the RSN 

 
 
 

Conclusion: Postoperative clinical and 
functional improvement allows 
presentation of the main advantages of our 
surgical technique: nerve root ablation 
standardization and reduction of operative 
time. 

CEREBROLYSINE: AN 
IMPORTANT FACTOR FOR THE 
IMPROVEMENT OF THE LIMITS 
OF THE BRAIN  
A.V. Ciurea*, R.M. Gorgan*, N. 
Ianovici**, C. Mihalache***, H. Moisa*  
*“Bagdasar-Arseni” Clinic Hospital, 1st neurosurgical 
unit & The National Center for Excellency in  
Neurosurgery, Bucharest, Romania; Carol Davila 
University School of Medicine, Department of  
Neurosurgery  
**Grigore T. Popa University School of Medicine, Iasi, 
Romania  
***Dpt. Of Neurosurgery, Sf. Andrei Clinic Hospital – 
Galati, Romania  

 
The development of the human bypedal 

posture has led to major modifications in 
the structure of the CNS and especially that 
of the cerebral cortex. The cerebral cortex 
or pallium (shell) is a structure 2-4 mm 
thick being made out of aprox. 50 billion 
neurons, about 500 billion neuroglial cells 
and a dense capillary bed. Microscopy 
reveals the cortex to have both a laminar 
and a columnar structre. The general 
cytoarchitecture varies in detail from one 
region to another, permiting the cortex to 
be mapped into dozens of histologically 
different areas, each with its own 
functionality – the so called areas of 
Brodman. The normal human brain 
contains about 100 billion (1014) neurons 
which give birth to a very complex network 
containing from 60 trillion synapses, 
(6x1018) up to 240 trillion synapses 
(24x1019)The literature data states that a 

number of 85.000 neurons die each day 
(aprox. 1 per second). In these 
circumstances a human being could live up 
to the age of 300 years. Furthermore, each 
living cells end it’s life cycle with the 
phenomenon of apoptosis. There are a 
series of factors that increase the rate of 
occurrence for apoptosis in neurons.These 
include the neuronal refractary period, 
vascularization, nutritional needs, lesions, 
Blood Brain Barrier modifications, 
endogenous and exogenous toxicity, 
vascular dementia, neuronal flux variations, 
stress, structural damage, narcotics and last 
but not least drugs.  

To limit the effects of the factors 
mentioned above we feel that a 
physiological nutritional balance has to be 
installed, social interactive factors have to be 
as well taken into account. The balance 
between activity and rest, the importance of 
pauses and food, the prevention of head 
injuries, the reduction of stress factors, the 
decrease of exposure to radiations, and the 
restriction of alcohol consume, avoiding 
smoking and drugs and cell phone use. 
Furthermore, the work of Dr. Masaru 
Emoto has proven that the human 
consciousness and emotions have an 
important effect on the molecular structure 
of the water. The effect is very important 
given the fact that the human brain is 77-
78% composed of water.  

Cerebrolysine brings a significant 
improvement in cerebral function. A 
mixture of low molecular polypeptide, 
extracted from pig brain, the drug, increases 
motor function, enhances cognitive 
performances, increases memory & 
attention and improves the bioelectrical 
activity in the brain. In the literature there 
are more than 500 substances studied for 
neuroprotective properties but 



 
 
 

Romanian Neurosurgery (2012) XIX 4: 309 – 355          337 

 
 
 

Cerebrolysine with its low molecular 
weight passes easily through the BBB. The 
effect of Cerebrolysin for neuroprotection 
consist in activation of Calpaine system. 
The important additional Cerebrolysin 
effects are: cerebral excitability and hypoxia, 
improving EEG signal and motor activity 
after mild brain ischemia and also 
antioxidative properties.  

In conclusion, after presenting various 
data regarding the anatomy and physiology 
of the brain, the authors militate for what 
would be referred as a Cerebral Hygiene – 
just as bodily hygiene. Cerebral hygiene 
would lengthen the functional period of the 
human nervous system in the conditions of 
the improvement of average lifespan and it’s 
quality. All the substances with 
neuroprotective effects (like cerebrolysine) 
are very efficient in improving the cerebral 
function.  

Last but not least we advocate that 
Cerebrolysine is proven clinically as a 
protector factor in TBI and ischemic brain 
lesions. 

TRAUMATIC DIFFUSE AXONAL 
INJURIES  
I.St. Florian, Dana Racasan, D.F. 
Muresanu, S. Horatiu  
Department of Neurosurgery, University of Medicine and 
Pharmacy “ Iuliu Hatieganu”, Cluj-Napoca, Romania  

 
Background: Traumatic brain injury 

(TBI) is a common cause of morbidity and 
mortality emphasized by the fact that it 
affects all age groups. Diffuse axonal 
injuries (DAI) associated with TBI are a 
great challenge to physicians due to the 
difficulty of early diagnosis and effective 
treatment. No efficient criteria for 
prognosis of the disease have been 
developed so far, due to the lack of efficient 

imaging and other diagnostic techniques. 
The purpose of this study is to evaluate 
prognostic criteria for mortality, functional 
and neurocognitive outcome.  

Material and method: A systematic review 
of literature was performed, using the 
PubMed, MBase, The Cochrane Library, 
Willey Online Library, Scopus, Science 
Direct medical databases between January 
1990 and July 2011. 11.398 articles were 
found using the keywords “diffuse axonal 
lesions/injury ,”traumatic brain injury”, 
“treatment of traumatic brain injury”, 
“treatment of diffuse axonal injury”, 
“prognosis of TBI/DAI”, ”outcome after 
TBI/ DAI”,”neurocognitive impairment 
after TBI/DAI|”, “patient perspective after 
TBI/DAI”. The analyzed articles were 
indexed according EFNS criteria. Article 
abstracts reporting original research and 
reviews were consulted. 77 articles were 
finally selected for inclusion.  

Results: DAI is a predisposing factor for 
memory, executive and behavioral 
dysfunction. A reduced score on GCS scale, 
older age, pupillary reflex abnormalities and 
corpus callosum lesions are associated with 
a poor outcome. Younger age is associated 
with dysautonomia, being correlated with a 
poorer outcome. MRI is more accurate than 
CT for diagnosis and prognosis of DAI. 
DWI and DTI have prognostic value in 
evaluating functional outcome, with DTI 
being an efficient biomarker for 
microstructural changes and neurocognitive 
impairment. No efficient biomarkers for 
DAI were highlighted until now.  

Conclusions: Clinical case history and 
advanced imaging techniques can improve 
our ability to diagnose DAI and have the 
potential to become valuable instruments in 
establishing prognosis for this condition. 

 



 
 
 
338          Selected Abstracts          The 8th International Congress of the RSN 

 
 
 

CEREBROLYSIN TREATMENT IN 
TRAUMATIC BRAIN INJURY – A 
RETROSPECTIVE, MULTI-
CENTRIC COHORT STUDY  
R. M. Gorgan*, F. M. Brehar,*A.V. 
Ciurea*, Eva Gheorghita*, Narcisa Bucur,* 
F. Stefan**, N. Ianovici***, St.M. 
Iencean***, D. B. Davidescu****, C. 
Mihalache,***** V. Prună*, B.O. 
Popescu,** D. F. Muresanu**  
*Emergency Clinical Hospital “Bagdasar-Arseni”, 
Bucharest, Romania  
**University of Medicine and Pharmacy “Iuliu 
Hatieganu”, Cluj-Napoca, Romania  
***Emergency Clinical Hospital “Sf. Treime”, Iasi, 
Romania  
****Emergency Clinical Hospital Constanta, Romania  
*****Emergency County Hospital Galati, Romania  

 
Introduction: Traumatic brain injury 

(TBI) represents a leading cause of death 
and disability and mainly affect the young 
adults. Neuroprotection remains an 
important strategy for TBI, targeting 
deleterious pathophysiological processes 
which lead to secondary tissue damage and 
related functional deficits. Cerebrolysin is 
the only clinically available drug that 
contains active fragments of different 
neurotrophic factors with low molecular 
weight that are able to pass the blood-brain 
barrier. The primary objective of this study 
was to test the outcome in Cerebrolysin 
treated patients compared to the control 
group, at 10 and 30 days post-TBI, and the 
secondary objective to evaluate the safety of 
Cerebrolysin for TBI patients.  

Material and method: In this study were 
included 7769 adult patients with traumatic 
brain injury (TBI), admitted in 10 
departments of Neurosurgery in Romania, 
between 2005 -2010. From the medical 
records, general data were collected at 
admission (gender, age, etiology, medical 

history, concomitant medication, Glasgow 
Coma Scale score, clinical neurological 
examination, CT result, whether a surgical 
intervention was performed). At days 10 
and 30 post- TBI patients were ranked on 
Glasgow Outcome Scale (GOS) and 
Modified Rankin Disability Score (RDS). 
1618 patients received cerebrolysin and 
6151 patients were in the control group.  

Results: In mild TBI, treatment with 
Cerebrolysin, both 20 ml and 30 ml/day 
regimens, significantly improves GOS and 
RDS scores at 10 days as compared to 
control patients. Treatment with 
Cerebrolysin in medium TBI, both 20 ml 
and 30 ml/day regimens, significantly 
improves GOS and RDS scores at 10 and 
30 days as compared to control patients. 
Moreover, a significant dose dependent 
effect is seen for Cerebrolysin on GOS 
score at 10 and 30 days. Treatment with 
Cerebrolysin, both 20 ml and 30 ml/day 
regimens, significantly improves GOS and 
RDS scores at 10 and 30 days as compared 
to control patients in severe TBI.  

Moreover, a significant dose dependent 
effect is seen for Cerebrolysin on GOS 
score at 10 and 30 days. The frequency of 
usual adverse events is similar between the 
control group and Cerebrolysin groups. No 
severe adverse events were noticed in 
Cerebrolysin groups.  

Conclusions: This large retrospective 
study shows significant beneficial effects on 
outcome of early Cerebrolysin treatment in 
TBI and supports the basis for a large 
Cerebrolysin prospective study in TBI. 



 
 
 

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NEED OF IMMEDIATE 
NEUROPROTECTION IN 
TRAUMATIC SPINAL CORD 
INJURIES  
St.M. Iencean*, I. Poeata*, D. 
Cuciureanu*, B. Costachescu*, Al. 
Chiriac*, A. St. Iencean**  
*“Grigore T Popa” University of Medicine and 
Pharmacy, Iasi, Romania  
**A. St. Iencean M.D., **Clinic of Neurosurgery, 
“Prof. Dr. Nicolae Oblu” Hospital, Iasi, Romania  

 
Objective: Analysis of current status and 

effectiveness of immediate neuroprotection 
in traumatic spinal cord injuries.  

Design: Traumatic spinal cord injury 
(SCI) has major effects and these patients 
have not any treatment. In acute complete 
traumatic SCI, methylprednisolone as a 
standard treatment option is insufficient 
and it is necessary to add new immediate 
procedures at the standard treatment 
performed today.  

Materials and methods: The study included 
analysis of two groups of 50 patients with 
cervical and thoracal traumatic SCI who 
received (A) surgery for decompression, to 
realign and to stabilize the spine and ( B) 
standard methylprednisolone treatment and 
surgery and (C) 5 cases of traumatic SCI 
with standard methylprednisolone and 
surgery treatment and also adenosine 
triphosphate (ATP) to improve blood flow 
at the site of injury and indomethacine as 
local anti inflammatory.  

Results: No significant differences were 
found between groups A and B at 6 months 
and 18 months postinjury; the 5 patients in 
group C had a more rapid stabilization of 
spinal injury.  

Conclusions: Although the number of 
cases is small and further study is needed it 

can be estimated as immediate use of 
neuroprotection, even at the scene of spinal 
injury, may improve prognosis of these 
patients. 

IMAGISTIC DIAGNOSTIC TRAPS - 
MULTIPLE FACES OF 
MENINGIOMA  
B. Iliescu, S. Gaivas*, Z. Faiyad*, I. 
Poeata*, C. Apetrei*, Anca Dabija**  
*Clinic of Neurosurgery, “Prof. Dr. Nicolae Oblu” 
Hospital, Iasi, Romania  
**Supermeditest, Iasi, Romania  

 
Introduction: An accurate and reliable 

imagistic diagnosis represents a key element 
in the surgical planning. Numerous aspects 
of the surgical setup and strategy are based 
on the possible behavior of a certain 
intracranial mass occupying lesion. The 
progress of MR technique and the various 
algorithms that help a differential diagnosis 
between various intracranial pathologies 
brought a significant improvement in our 
ability to formulate a more accurate 
preoperative imagistic diagnosis. However, 
the variability in intracranial tumor 
development allows for a good probability 
of misdiagnosis.  

Material and methods: We analyze the 
meningioma cases that presented with 
imaging aspects that were far from the 
classic appearance of this tumor over a 
period of 3 years. The selected cases are 
discussed in terms of imaging 
characteristics, preoperative assessment, and 
discuss the potential places of misjudgment 
and possible strategies to improve the 
preoperative imagistic diagnostic.  

Results: The controversial imagistic cases 
represented 7% of the total meningioma 
cases newly diagnosed and operated in our 
department over a period of 3 years (2010-



 
 
 
340          Selected Abstracts          The 8th International Congress of the RSN 

 
 
 

2012). The error generators were 
represented by extensive cystic components 
that disrupted the homogenous structure 
typically associated with meningioma, 
excessive necrosis and intratumoral 
bleeding, or a combination of atypical 
imagistic composition with less frequent 
localization.  

Conclusion: Although a lesion with a 
typical imagistic appearance and clear 
diagnostic features especially on MR 
images, meningiomas present in specific 
cases a very unusual imagistic anatomy that 
can mimic cerebral or bony malignancies. 
In these cases the correct diagnosis is 
usually an intraoperative surprise. Careful 
analysis of the preoperative imaging data 
and a cautious preoperative planning allow 
for a good diagnosis and a successful 
surgery. 

INTRAORBITAL MENINGIOMAS - 
REAL NEUROSURGICAL 
CONTROVERSIES  
I. Szabo, Bataneant Lucy  
Department of Neurosurgery, Cluj County Emergency 
Hospital, Romania  

 
Objective & design: Primary intraorbital 

meningiomas are tumors developed from 
the optic nerve dural sheath, ectopic 
arachnoid cells within the orbit or from the 
arachnoid cells around the superior orbital 
fissure. Secondary intraorbital meningiomas 
are extended from the surrounding 
intracranial regions into the orbit.  

Material and methods: We present our 
personal cases, the medical records of all 
patients with intraorbital menigiomas 
admitted in the Neurosugical Department 
of the Cluj County Emergency Hospital 
between 1969 - 2012. In this period of time, 
858 cases of orbital masses were admited, 

68 cases were intraorbital meningiomas 
(7.9%) Clinical data, neuroimagistical 
aspects, treatment and postoperative course 
of the desease and the quality of life are 
discussed.  

Results: - Primary intraorbital meningio-
mas are rare, 11 cases (12.7%). The most 
important primary intraorbital 
meningiomas were optic sheath 
meningiomas (6 cases – 6.9%) and 
intraorbital ectopic meningiomas ( 5 cases - 
5,8).  

- Secondary intraorbital meningiomas 
were more frequently found in 
neurosurgical practice, 57 cases (87.3%): 
internal sphenoid wing meningioams with 
intraorbital extension, 26 cases (30,2%), 
cavenous sinus meningiomas with 
intraorbital extension, 9 cases (10.4%), 
multiple meningiomatosis with intraorbital 
extension, 6 cases (6.9%), olfactory grove 
meningiomas with intraorbital extension, 5 
cases (5.8%), clinoid meningiomas with 
intraorbital extension, 3 cases (3.4%), 
orbital roof meningiomas with intraorbital 
extension, 3 cases (3.4%). In 2 cases, 
secondary intraorbital meningiomas were 
associated with NF type1. Recurrent 
intraorbital meningiomas - 1 recurrency in 
8 cases, 2 recurrecies in 6 cases 3 or more 
recurrecies in 3 cases.  

The treatment is individually 
recommended in each case, depending on 
the location, dimensions and growth rate of 
the tumor, - consists of ON 
decompression, tumor biopsy, partial or 
total removal of the tumor, according to the 
balance of risk and benefits after surgery.  

Conclusions: In the intraorbital 
meningioma cases, not only the treatment, 
but even some diagnostic and 
neuroimagistical data are controversial. In 
primary optic sheath meningiomas radical 



 
 
 

Romanian Neurosurgery (2012) XIX 4: 309 – 355          341 

 
 
 

surgery always lead to visual loss, in deep 
apically located meningiomas, postoperative 
sequelae are hardly acceptable. In this cases, 
late surgical treament is recommended. 
Secondary intraorbital extensions of the 
intracranial meningiomas present the better 
postoperative outcome after total removal. 
In some cases, subtotal extension and 
radiotherapy is the best choice. 

IN VITRO INFLUENCE OF 2-
METHOXYESTRADIOL ON 
GLIOBLASTOMA STEM CELLS  
G.Ungureanu*, C. Berce**, O. Soritau***, 
I. Iancu*, I.S. Florian*  
*Department of Neurosurgery, Cluj County Emergency 
Hospital, Romania  
**University of Medicine and Pharmacy “Iuliu 
Hatieganu” Cluj-Napoca, Romania  
***“Prof Ion Chiricuta” Oncology Institute Cluj-
Napoca, Romania  

 
Objectives and design: Glioblastomas 

(GBM) are the most frequent type of glial 
tumors. Although extensive research has 
been done in search for a curative 
treatment, the actual multimodal treatment 
still offers only poor prognosis. 2-
methoxyestradiol (2-ME) is a natural 
steroid hormone, formed by hydroxylation 
and O-methylation of the estradiol 
molecule. Our purpose was to investigate 
the effect of 2-ME on the proliferation of 
glioblastoma stem cells and if it influenced 
the effect of other consecutive therapies.  

Material and method: Cultures of glial 
tumor stem cells-isolated from the GBM of 
a 55 year old female patient, characterised 
by a very high proliferation rate, were 
treated with increasing doses of of 2, 10, 25 
and 50 μM 2-ME and 10 μM 2-ME and 100 
mg of Temozolomide. Cells were then kept 
either in normal or hypoxic conditions for 

48 h. Radiation therapy consisting of a 
unique dose of 6 Gy was then applied to 
some of the cultures. Proliferation rate was 
measured at 72 h using the MTT protocol.  

Results: Hypoxia didn’t exert any 
significant influence over proliferation. The 
25 μM 2-ME dose inhibited proliferation 
both in hypoxic and normal conditions 
(P<0.05, 95% CI of 0.225-0.039, 0.11-
0.0734 respectively). The 50 μM 2-ME 
dose had the same inhibitory effect 
(P<0.05, 95% CI of 0.235-o.047, 0.13-
0.0632 respectively. This effect was visible 
both in irradiated and non-irradiated cells. 
The combination of 2-ME and 
temozolomide had the same inhibitoty 
effect both in irradiated and non-irradiated 
cultures.  

Conclusions: We conclude that 2-ME 
could be a viable part in the multimodal 
therapy of glioblastoma. The effect of 2-ME 
is not dose dependent. Also the inhibitory 
effect on proliferation of GBM stem cells is 
independent of consecutive applied 
radiation or other chemotherapy. 

CERVICAL SPINAL CORD 
HERNIATION AT SEVEN YEARS 
AFTER SURGERY FOR CERVICAL 
EPENDIMOMA  
A.St. Iencean*, S. Gaivas,* Z. Faiyad*, B. 
Chirita*, St.M. Iencean**, I. Poeata**  
*“Prof. Dr. Nicolae Oblu” Clinical Emergency 
Hospital, 3rd Department of Neurosurgery, Iasi, 
Romania  
**University of Medicine and Pharmacy 
“Gr.T.Popa”/“Prof. Dr. Nicolae Oblu” Clinical 
Emergency Hospital, Iasi, Romania  

 
Objective: We describe the case of a man, 

50 years old, who was operated for a 
cervical ependimoma 7 years ago. He 
presented with a 2-year hystory of 



 
 
 
342          Selected Abstracts          The 8th International Congress of the RSN 

 
 
 

progressive tetraparesis and the imaging 
studies showed a postoperative cervical 
spinal cord herniation.  

Design: Herniation of the spinal cord is a 
relative rare pathology and can be 
spontaneous, iatrogenic and posttraumatic.  

Materials and methods: A 50-year-old male 
patient presented with progressive 
tetraparesis that began 2 years ago; he had 
surgery 7 years ago for a cervical 
ependimoma, that was removed totally. 
Imaging studies showed a spinal cord 
herniation at C2-C3 level through a 
posterior dural defect. The surgery was the 
resection of the dural scar around the spinal 
cord herniation and reconstruction of dura 
with a musculo-adipose patch.  

Results: Postoperatively, the patient made 
significant neurological improvements, and 
MRI showed the resolution of spinal cord 
compression.  

Conclusions: Spinal cord herniation is a 
reversible cause of medullary dysfunction. 
The treatment of choice, particulary if there 
is associated a neurological deficit, is the 
surgical repair of the dural defect. Because 
this condition is rare and relatively 
unknown, there is often a delay in the 
diagnosis and surgical treatment. This 
pathology must be recalled when 
addressing a patient with progressive 
neurologic disturbance, especially if the 
patient has a clinical record of surgery 
involving the spinal cord. 

 

 

 

 

POSTERS 

PERCUTANEOUS INTERSPINOUS 
DEVICE FOR LUMBAR SPINAL 
STENOSIS  
D. Adam*, E. Pevzner**  
*“Carol Davila” Medicine and Pharmacy University, 
“Victor Babes” Clinic, Bucharest, Romania  
**Sapir Medical Center, Meir General Hospital Kfar 
Sava, IL  

 
Introduction: The percutaneous 

interspinous distraction devices are an 
alternative to conventional open surgical 
procedures in the treatment of symptomatic 
degenerative lumbar spinal stenosis. A new 
interspinous process implant, Superion, is 
used under local or general anesthesia, to 
treat patients with lumbar spinal stenosis.  

Material and method: A cohort of 103 
patients were operated between July 2007 - 
July 2008. All patients had back pain, 
neurogenic claudication with relief in 
flexion. MRI of the lumbar spine showed 
moderate foraminal or canal stenosis. In 18 
patients Superion was implanted at 2 levels. 
In 85 patients it was implanted at 1 level: 
L4/5 (n=45), L3/4 (n=40). The mean 
follow-up was 35 months.  

Results: VAS, SF-12 and ODI were 
improved in all but 15 patients. In 2 
patients the implants were collapsed after 1 
and 2 months. Two other patients 
underwent formal laminectomy with 
fusion.  

Conclusion: Implantation of Superion is a 
minimally invasive alternative to traditional 
spinal surgery, a safe and effective treatment 
for patients with moderate lumbar stenosis. 

 
 
 



 
 
 

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LUMBAR EPIDURAL 
LIPOMATOSIS IN A PATIENT 
WITH HODGKIN LYMPHOMA  
M. Dabija, D. Andronic, C. Ghiorghita  
“Prof. Dr. Nicolae Oblu” Clinical Emergency Hospital, 
3rd Department of Neurosurgery, Iasi, Romania  

 
Background/Objectives: Spinal epidural 

lipomatosis (SEL) is a pathological 
condition in which fat tissue is deposed in 
the spinal canal around the thecal sac in 
excess, causing neurological 
symptomatology (7, 9, 12). Fat tissue is 
present in our body almost everywhere. 
When the normal quantity is exceeded is 
created a pathological situation.  

Case presentation: We present a 33 old 
man case with fat tissue excess deposited in 
lumbar spine canal. The pathological 
history of our patient includes a nodular 
form of stage IA Hodgkin lymphoma 
diagnosed in 2011 for what he went 
combined radio-chemotherapy. He also has 
ben diagnosed with grad I obesity. In last 
month he presented with rapidly 
progressive symptoms like lower back pain, 
parparesis and sphincters dysfunctions.  

Findings: Thoracic magnetic resonance 
imaging (MRI) establishes a lumbar 
lipomatosis located in L3-S5 spinal canal. 
Pathology results confirm the imagistic 
diagnostic. Under surgery was performed a 
median laminectomy with fat tissue 
excision with good results in patient 
symptomatology.  

Conclusion: Cortisone chronic therapy 
may lead to SEL. However in our case, 
Hodgkin lymphoma therapy led to 
cortisone complications. Neurological 
symptomatically patients should be treated 
surgically. 

DORSAL RHIZOTOMY IN 
CHILDREN WITH SPASTIC 
PARAPLEGIA: A NEW SIMPLIFIED 
SURGICAL TECHNIQUE  
J. Ciurea, A. Rasina, B. Balanescu,  
Teodora Coman  
The 5-th Dept. of Functional Neurosurgery, Clinical 
Emergency Hospital Bagdasar-Arseni, Bucharest, 
Romania  

 
Introduction: Over a hundred years the 

lumbosacral dorsal rhizotomy is the 
neurosurgical indication in spastic children 
with cerebral palsy.  

Objective: Analysis of clinical and 
functional results obtained with a new 
simplified surgical technique, quintessence 
of the two technical principles that govern 
dorsal rhizotomy: anatomical approach and 
selective functional approach.  

Method: We illustrated eight cases of 
spastic paraplegia children: five ambulatory 
spastic subjects operated at L5-S1 spinal 
root level and three non-ambulatory cases 
with more severe functional spastic 
paraplegia, clinically presented as quadriped 
crawlers or bunny hoppers, operated at L4-
S1 spinal root level. Statistical analysis using 
the Wilcoxon test (SPSS program) shows 
both a clinical improvement on Ashworth, 
Tardieu and Penn scales and an 
improvement on main functional scales as 
Gillette, test get-up and go or Physician 
Rating Score.  

Discussions: Our anatomical and 
electrophysiological intraoperative 
observations are the basis for a new 
technical approach that respects both the 
classical selective sectoral surgical direction 
promoted by Gros and Sindou, the partial 
limited one of Lazareff and the partial 
limited one promoted by Peacock, Steinbok 
and Mittal.  



 
 
 
344          Selected Abstracts          The 8th International Congress of the RSN 

 
 
 

Conclusion: Postoperative clinical and 
functional improvement allows 
presentation of the main advantages of our 
surgical technique: nerve root ablation 
standardization and reduction of operative 
time. 

IS “METABOLIC COUPLING” 
ACROSS PRIMARY MOTOR AREAS 
AND CEREBELLUM ALTERED IN 
CERVICAL MYELOPATHY?  
S.C. Craciunas*, M.R. Gorgan*, Ali Bani-
Ahmed**, Carmen M. Cirstea**  
*Bagdasar-Arseni Hospital Bucharest, Romania  
**Kansas University Medical Center Kansas City, US  

 
Introduction: In patients with cervical 

spondylotic myelopathy (CSM), proton 
magnetic resonance spectroscopy (1H-
MRS) studies reported abnormal cerebral 
metabolites concentrations within 
radiologically normal-appearing motor-
related brain areas. Recently, we found 
significantly higher choline, a marker of cell 
membrane integrity, in primary motor 
cortices (M1), and generally lower N-
acetylaspartate, a marker of neuronal 
integrity, and higher myo-inositol, a 
putative marker of glial cells, in M1 and 
cerebellum1. In some instances, choline 
levels relate to clinical severity1. Although 
brain metabolic demands might be 
accomplished through pathways that link 
metabolites across multiple areas, how 
altered metabolite concentrations within 
one area are related to metabolite changes 
within another in cervical myelopathy is yet 
to be determined. Thus, our goal was to 
identify whether correlations among 
metabolites or “metabolic coupling” 
between M1 and cerebellum was altered in 
CSM patients.  

Methods: In moderately impaired CSM 

patients, N-acetylaspartate, myo-inositol, 
and choline were quantified (LCModel) in 
left and right M1 and cerebellum using 
PRESS at 1.5 Tesla (TE=30ms, 
TR=1500ms, flip angle=90, spectral 
width=1000Hz, 15x15x15mm in M1, 
20x20x20mm in vermis). Thirteen CSM 
patients (confirmed by T2-weighted MRI) 
were studied before surgery. Spearman 
Rank Order correlation was used to 
determine the putative relationships 
between metabolites within (intra-regional) 
and across (inter-regional) our regions of 
interest. The mean metabolite correlation 
between these specific regions was 
compared between CSM patients and 14 
age- and sex-matched healthy controls 
(Mann-Whitney U-test).  

Results: Intra-regional correlations: 
Generally lower mean correlations between 
all metabolites were found in left M1 (-
0.02±0.27 vs. 0.35±0.08, p=0.08) and 
cerebellum (0.33±0.30 vs. 0.57±0.14, 
p=0.2). Myo-inositol-choline correlation 
was the most altered (0.15 vs. 0.42 in left 
M1, 0.09 vs. 0.59 in cerebellum). Inter-
regional correlations: Significant weaker 
metabolite correlations between right M1 
and cerebellum were found (-0.12±0.36 vs. 
0.16±0.10, p=0.03). A trend to weaker 
correlations was also found between right 
M1 and cerebellum (0.04±0.38 vs. 
0.21±0.20, p=0.2). Cerebral myo-inositol-
cerebellar choline and cerebral N-
acetylaspartate-cerebellar N-acetylaspartate 
correlations were significantly decreased in 
CSM patients (left M1-cerebellum: -0.68 
vs. 0.12, 0.07 vs. 0.67 respectively; right 
M1-cerebellum: -0.62 vs. 0.10, -0.17 vs. 
0.33 respectively).  

Conclusions: These preliminary results 
are the first evidence for the presence of 
weaker “metabolic coupling” (as measured 



 
 
 

Romanian Neurosurgery (2012) XIX 4: 309 – 355          345 

 
 
 

by correlation coefficients) within and 
between M1 and cerebellum in patients 
with cervical myelopathy, suggesting an 
alteration of neuron-glial interactions and 
consequently perturbed neuronal function. 
By moving beyond analysis of change in 
metabolite concentration within individual 
brain region, these results can increase our 
understanding of how 1H-MRS markers of 
metabolic processes are related in patients 
with cervical myelopathy.  

Aknowledgments: This study was 
supported by AOSpine International (grant 
HJW2011-SU20). 

ABLATION OF DEEP BRAIN 
CEREBRAL TUMORS USING 
STEREOTACTICALLY GUIDE  
P. Patrascu, A. Iliescu, S. Gheorghe, C. 
Tudor  
Bucharest Emergency University Hospital, Bucharest, 
Romania  

 
“By using the stereotactic guide in deep 

brain ablation lesions, huge advantages are 
conferred, approach to the lesion being 
done with minimal damage to the brain 
parenchyma and avoid areas elocventel.  

In Neurosurgery Clinic I of Bucharest 
Emergency University Hospital there have 
been few cases of deep brain lesions 
operated using stereotactic guide.  

We present the case of a 34 years old 
man operated for deep temporal lesion.  

The surgery was a success using 
stereotactic guide and patient was 
discharged without neurological deficits. 

RUPTURED ANEURYSM OF 
ABERRANT FRONTOPOLAR 
ARTERY EMERGING FROM 
ANTERIOR COMMUNICATING 
ARTERY: A CASE REPORT  

Diana Iordache*, Andreea Rusu*, Z. 
Faiyad**, A. Chiriac,** B. Iliescu**, I. 
Poeata*  
*University of Medicine and Pharmacy 
“Gr.T.Popa”/“Prof. Dr. Nicolae Oblu” Clinical 
Emergency Hospital, Iasi, Romania  
**“Prof. Dr. Nicolae Oblu” Clinical Emergency 
Hospital, Iasi, Romania  

 
Introduction: Aneurysms are often 

associated with anomalies of cerebral 
arteries and they should be identified pre 
and intra-operatory. A large number of 
studies focused on the anatomical variations 
of the anterior cerebral – anterior 
communicating artery (ACA – AcoA) 
vascular complex. In this region we are 
interested in the frontopolar (Fpa) which 
normaly branches off ACA distal to AcoA 
(A2 segment). Literature reports of the 
aberrant origin of the frontopolar artery, 
refer only to its anomalous origin from the 
A1 segment of ACA, from a common 
vascular trunk with orbitofrontal artery and 
from calosomarginal artery, but no 
reference mentions its origin from the 
AcoA. Aneurysms of the ACA branches are 
very rare and they are frequently saccular 
and rather small.  

Case presentation: We present a case of a 
ruptured, fusiform aneurysm located on an 
aberrant FpA originating in the AcoA. A 19 
year old man presented with severe 
headache, nausea and photophobia. 
Computer tomography (CT) showed focal 
subarachnoid hemorrhage in the 
interhemispheric fissure while cerebral 
angiography (Seldinger) revealed a 
prominent aneurysm emerging from an 
artery with the origin in the AcoA. 
Intraoperative diagnosis was that of 
voluminous, fusiform aneurysm stemming 
from the left FpA that arises from the left 
side of the anterior communicating artery. 



 
 
 
346          Selected Abstracts          The 8th International Congress of the RSN 

 
 
 

The aneurysm was successfully clipped via 
pterional approach. The postoperative 
outcome was favorable and the patient had 
no neurological deficit.  

Conclusion: Our review of the literature 
revealed no reports on the aberrant origin 
of the FpA from the AcoA nor an aneurysm 
related to this anomaly. This may be 
because injuries of the FpA have little 
clinical impact and this particulary origin of 
FpA from AcoA is extremely rare. The 
particularity of the presented case consists 
also in the unusual shape and the 
considerable size of the aneurysm that led 
to clinically significant complications. So 
we call attention to another rare anomaly of 
the ACA branches. All these points 
emphasize how important is for 
neurosurgeons to recognize the anatomical 
variations of the cerebral arteries in order to 
reduce poor postoperative outcome. 

EMERGENCY DECOMPRESSIVE 
CRANIOTOMY FOR INCIDENTAL 
MIGRATION OF COILS INSIDE 
ICA-CASE REPORT  
Bucur Narcisa*, Neacsu Angela*, V. 
Pruna*, Sandu Aurelia Mihaela*, A. 
Chefneaux**, Cristescu Catioara Fănica 
***, M.R. Gorgan*  
*Clinic Emergency Hospital ‘Bagdasar-Arseni’ 
Bucharest, Fourth Neurosurgical Department, Romania  
**Interventional Neuroradiology Department, Clinic 
Emergency Hospital ‘Bagdasar-Arseni’ Bucharest, 
Romania  
***Anesthesiology and ICU Department, Clinic 
Emergency Hospital ‘Bagdasar-Arseni’ Bucharest, 
Romania  

 
The team presents the case of a 30 years 

old woman admitted to our department for 
SAH predominat in the anterior basal 
cisterns, in a good neurological condition 
(WFNS 1, GCS 15, Fisher 1). DSA 

angiography revealed an left ICA sacular 
aneurysm located on the C6 segment, 3.2 
mm distal of the origin of ophtalmic artery 
and 2.4 mm proximally of the left P Com 
artery. The maximum size was 16.01 mm 
/4.51 mm. The patient solicited 
endovascular embolisation. The procedure 
was performed according with standards. At 
starting the neuroradiologist remarqued 
vasospasm and injected 20 ml Nimotop IV 
in 20 minutes. He introduced safely the 
microcatheter and the coil  

(standard 11/30) inside the aneurysm. 
After coil detachment the coil was displaced 
and a new microcatheter was introduced in 
order to correct the position. A new control 
angiography in the next 15 minutes, 
revealed the irreducible displacement of an 
important part of coil inside the left carotid 
artery with complete occlusion. The 
circulation was partially compensated by 
vertebral arteries and controlateral ICA. A 
rapid decompressive craniotomy was 
decided in combination with IV 
anticoagulant, taking into consideration the 
next factors: dominat hemisphere, good 
neurological status pre-embolisation, young 
age, possible circulatory compensation 
through an efficient Willis polygone. The 
patient was immediately operated and after 
24 hours she was weaned from advanced 
life support with a mild right hemiparesis 
and drowsiness. She recovered completely 
in 6 days and cranioplasty was performed 
after 3 weeks. Two months after, the 
patient returned to her previous life.  

Conclusion: Emergency decompressive 
craniotomy in acute incidental ICA 
occlusion is a life saving procedure. When 
Willis polygone is efficient for circulatory 
compensation the postoperative quality of 
life might be the normal one. 



 
 
 

Romanian Neurosurgery (2012) XIX 4: 309 – 355          347 

 
 
 

OPERATIVE STRATEGIES IN 
RUPTURED POSTERIOR 
INFERIOR CEREBELLAR ARTERY 
ANEURYSMS  
V. Pruna, Bucur Narcisa, Angela Neacsu, 
F.M. Brehar, R.M. Gorgan  
Clinic Emergency Hospital ‘Bagdasar-Arseni’ Bucharest, 
Fourth Neurosurgical Department, Romania  

 
Introduction: Posterior Inferior Cerebellar 

Artery (PICA) aneurysms represent 
approximately 3% of all intracranian 
aneurysms. The most frequent location is 
on the vertebral artery-PICA bifurcation. 
The distal locations are less frequent but 
these aneurysms have a more fragile 
aneurysm wall and are more prone to re-
bleeding.  

Materials and methods: The authors of this 
study present their experience in four 
patients with ruptured PICA aneurysms 
admitted and operated in our clinic 
between 2004 and 2012. All patients have 
been investigated by CT scan, 3D CT-
Angiography or 3D DSA and have been 
operated using operative strategies 
according to the location of aneurysm on 
PICA segments. In three patients the 
aneurysm was clipped using a Yasargil 
vascular clip and in one case a wrapping has 
been performed. The follow-up period was 
between 4 months and 7 years (mean 3, 5 
years).  

Results: In our series there was one death 
at three days postoperatively secondary to a 
pulmonary embolism. The other three 
patients had a good outcome with no 
neurological deficits postoperatively. All 
three patients required ventriculo-
peritoneal shunts during the follow-up 
period, between 5 and 31 days after the 
operation.  

Conclusions: The PICA aneurysms 
remain a neurosurgical challenge even for 
the most experienced neurosurgeons. The 
operative strategies must be adapted to the 
location of the aneurysm on the PICA 
segments and to the size and the 
configuration of the aneurysm. 

FAR - LATERAL APPROACH FOR A 
GIANT DUMBBELL-SHAPED C2 
CERVICAL SCHWANNOMA - CASE 
REPORT  
M. Catană, V. Prună, M.R. Gorgan  
Clinic Emergency Hospital ‘Bagdasar-Arseni’ Bucharest, 
Fourth Neurosurgical Department, Romania  

 
Introduction: Schwannomas are some of 

the most common extramedullary tumors, 
whose location at the cranio-vertebral 
junction is very rare. Giant tumors appear 
as dumbbell-shaped tumors and they 
develop mainly extradural with a huge 
extension outside the spine. The intradural 
position followed by penetration of the 
dural sac is very rare, especially when it is in 
front of the spinal cord. The far-lateral 
approach allows adequate exposure of the 
lesion to prevent manipulation of neural 
and vascular structures.  

Case presentation: We report a case of 63 
years old man, admitted in our clinic for 
neck pain and left body dysesthesia. 
Cervical MRI highlights a giant left C2 
dumbbell-shaped intradural - extradural 
tumor (4/3 cm) which shifts spinal cord to 
the right side. Surgery was performed by a 
far-lateral approach with total resection of 
the posterior arc C1, left hemilaminectomy 
C2 and left suboccipital craniectomy. 
Complete resection of paravertebral 
component of the tumor was done, with 
left C2 nerve root section. After incision of 
the dura mater, the intradural component is 



 
 
 
348          Selected Abstracts          The 8th International Congress of the RSN 

 
 
 

distinguished, which ascend in the posterior 
cranial fossa in front of the spinal cord and 
the bulbo-medullary jonction. The left XI 
nerve was preserved and the dentate 
ligament was sectioned. After tumor 
debulking, the total resection was 
completed. Outcome was favorable with 
improvement of preoperative symptoms. 
The pathological diagnosis was 
schwannoma.  

Conclusion: Far – Lateral approach is one 
of the best ways for surgical resection of 
these tumors and provides optimal 
visualization, without spinal cord 
manipulation. 

BRAIN ABSCESS IN 95 PATIENTS: 
FACTORS INFLUENCING 
OUTCOME AND MORTALITY  
M.R. Gorgan, Angela Neacsu, Narcisa 
bucur, V. Pruna, Catalina Lipan, Aurelia 
Mihaela Sandu, Catioara Fanica Cristescu  
Clinic Emergency Hospital ‘Bagdasar-Arseni’ Bucharest, 
Fourth Neurosurgical Department, Romania  

 
Objective: To analyze the management 

and variables determining morbidity, 
mortality and outcome in 84 subjects with 
brain abscesses treated over a 12-year 
period.  

Methods: A retrospective study was 
performed on a series of 84 patients with 
brain abscesses surgically treated with open 
craniotomy excision between January 2000 
– December 2011, in the Fourth 
Neurosurgical Department by the same 
team. Such variables as age, gender, clinical 
presentation, number of days to diagnosis, 
location, number of lesions, predisposing 
factors, mechanism of infection, etiological 
agent and therapy were analyzed 
independently.  

Results: In our series, the average age was 
42.96 years (range: 11-75), 72.62% (n=61) 
were males and 27.38% (n=23) females. 
The median number of days to diagnosis 
was nine (range: 2-45 days). Majority of 
cases (76.19% - 64 cases) presented a 
supposed medical condition favoring 
dissemination of a previous Most frequent 
clinical presentation included headache 
(40.47%, n=34), fever (35.71%, n=30), 
focal neurologic deficits (29.76%, n=25), 
increased intracranial pressure (28.57%, 
n=24) and seizures (11.90%, n=10). 
Mechanism of infection was hematogenous 
spread (35.71%, n=30), contiguous spread 
(33.33%, n=28), post-neurosurgical 
procedures (13.09%, n=11), and open head 
injury (5.95%, n=5). The route of 
transmission was unknown for 23.8% of the 
patients (n=20). According to our 
treatment policy all cases except two, 
(treated by burr-hole and aspiration) 
benefited of open surgery and removal of 
the lesions by craniotomy with resection of 
the capsule, without local recurrence. 
Outcome was favorable in 82.14% (n=69) 
of the subjects. Six cases remained with 
permanent motor deficit (7.14%), only one 
patients had new neurological deficits 
postoperatively. Four patients (4.76%) 
remained with controllable seizures. 
General morbidity was 26.19% (n=22), and 
mortality stood at 7.14% (n=6). Out of a 
total 33.33% (n=28) of complications, 
64.28% were secondary to medical causes 
(66.66%, n=4, of deaths were due to 
medical causes not directly related to 
surgery) .  

Age was related to favorable 
postoperative outcome. The mean age of 
patients with good outcome was 
40.57±16.25 years, and 55.48±20.34 years 
in the case of subjects with poor GOS 



 
 
 

Romanian Neurosurgery (2012) XIX 4: 309 – 355          349 

 
 
 

scores. Compared with other mechanisms 
of infections, hematogenous spread 
correlated with unfavorable outcome.  

Conclusions: Co-morbidities, advances 
age and hematogenous spread were 
predictors of poor prognosis. Most of the 
complications following brain abscess 
management were not directly related to 
surgery. 

ANTERIOR CLINOIDAL 
MENINGIOMAS: MICROSURGICAL 
MANAGEMENT AND OUTCOME 
IN A CONSECUTIVE SERIES OF 38 
PATIENTS  
Ligia Tătăranu*, V. Ciubotaru**, Adriana 
Dediu**, D. Păunescu**, Anica Dricu***  
*“Carol Davila” University of Medicine and Pharmacy, 
Bucharest, Romania  
**Neurosurgical Clinic, “Bagdasar – Arseni” Clinical 
Hospital, Bucharest, Romania  
***University of Medicine and Pharmacy, Craiova, 
Romania  

 
Objective: Anterior clinoidal 

meningiomas are difficult and challenging 
to remove completely and safely especially 
when they compress, or displace the 
adjacent critical neurovascular structures. 
The purpose of this paper is to delineate the 
advantages of the surgical techniques in 
achieving an improved extent of tumor 
excision and enhancing the patients’ overall 
outcome.  

Methods and results: A retrospective 
analysis was performed on 38 consecutive 
patients with anterior clinoidal 
meningiomas who underwent surgical 
resection at the “Bagdasar – Arseni” Clinical 
Hospital between January 2007 and 
December 2011. The patients’ age ranged 
from 18 to 75 years old with an average age 
of 47 years old. There were 25 females 

(66%) and 13 males (34%). The presenting 
symptoms were mostly visual impairment; 
others symptoms were also encountered, 
such ad raised intracranial pressure 
syndrome, cranial nerve palsies, seizures, 
mental changes, hemiparesis. The diagnosis 
was made predominantly by the MRI and 
angio MRI. Angiography was still useful to 
show relationship between the tumor and 
arteries. All patients had preoperative and 
postoperative ophthalmological evaluations. 
A fronto-temporal approach was used in 29 
patients (76.3 %) and cranio-orbital 
approach with resection of the zygomatic 
arch was used in 9 (23.7 %). In 8 cases (21 
%), according to the grading scale of Al-
Mefty, the masses were group I, having 
originated from the lower part of the 
clinoid; in 27 cases (71 %) the masses were 
group II, having originated from the upper 
or lateral part of the clinoid process; and in 
3 cases (8 %) the masses were group III 
since they arose from the optic foramen. 
The complete removal was obtained in 26 
cases (68.4 %). Postoperatively, 18 patients 
showed an improvement (47.4 %), 11 were 
unchanged (28.9 %) and 9 presented 
further deficits (23.7 %). Three patients (7.9 
%) died after surgery: one from pulmonary 
thrombembolism, one from cerebral 
ischemia after severe vasospasm of the 
internal carotid artery (unresponsive to 
treatment) and one from acute renal failure. 
The mean follow-up was 26.4 months. 
During this period, there were three 
recurrences and one patient underwent 
resection again. Adjuvant radiotherapy was 
not performed.  

Conclusion: Although the use of modern 
microsurgical technique has clearly 
improved the outcome of clinoidal 
meningiomas, the chance for surgical cure 
remains problematic, especially in cases 



 
 
 
350          Selected Abstracts          The 8th International Congress of the RSN 

 
 
 

with adherences to the internal carotid 
artery and its branches, involvement of the 
cavernous sinus and orbital structures. 

OUTCOME OF 
TRANSSPHENOIDAL SURGERY 
FOR CLIVAL CHORDOMAS  
Ligia Tătăranu*, V. Ciubotaru**, Adriana 
Dediu**, D. Păunescu**  
*“Carol Davila” University of Medicine and Pharmacy, 
Bucharest, Romania  
**Neurosurgical Clinic, “Bagdasar – Arseni” Clinical 
Hospital, Bucharest, Romania  

 
Objectives: Chordomas are uncommon 

tumors, arising from remnants of the 
primitive notochord and frequently located 
within the clivus. The location of the tumor 
determines the path of its growth and the 
surgical approach. The authors describe 
their experience with surgical access to the 
clivus via an extended endonasal 
transsphenoidal approach and discuss the 
utility of incorporating an endoscope into 
an open surgical procedure.  

Material and methods: Between January 
2001 and December 2011, 21 patients 
underwent extended endonasal 
transsphenoidal surgery for clival 
chordomas (13 males and 8 females, mean 
age – 47 years). In one case, an additional 
suboccipital approach was necessary to 
accomplish resection of an intradural 
extension of tumor. Patients were followed 
up from 6 months to 11 years. 27 endonasal 
transsphenoidal approaches were 
performed in 21 patients (two patients had 
second surgery and two patients had two 
additional surgeries). In 15 cases, the 
approach was endoscopically assisted.  

Results: Postoperative MRIs after the 
initial operation showed gross total 
resection in 8 cases (38.09 %). Near total 

removal (> 90%) was achieved in 7 cases 
(33.33 %). Subtotal resection was noted in 6 
cases (28.57 %). Tumor regrowth imposed 
additional surgery in 4 cases (19.04 %). Use 
of the endoscope was associated with gross 
total or near-total removal. Gamma-knife 
radiosurgery was used in 4 cases (19.04 %).  

Conclusions: The extended endonasal 
microscopic transsphenoidal approach 
yields excellent access to the clivus, medial 
cavernous sinus and intradural space 
anterior to the brainstem. The addition of 
the endoscope allows for a more panoramic 
view and permits widening of the approach 
in all directions. 

RESULTS AFTER SURGERY FOR 
NON-FUNCTIONING PITUITARY 
ADENOMAS  
V. Ciubotaru**, Ligia Tătăranu*, D. 
Păunescu**, Violeta Ioana Pruna***  
*“Carol Davila” University of Medicine and Pharmacy, 
Bucharest, Romania  
**Neurosurgical Clinic, “Bagdasar – Arseni” Clinical 
Hospital, Bucharest, Romania  
***Clinica Oftapro, Bucharest, Romania  

 
Aims: Clinically non-functioning 

pituitary adenomas range from being 
asymptomatic to causing significant 
hypothalamic and pituitary dysfunction and 
visual field defects. The object of this study 
was to evaluate the efficacy and safety of 
surgery in our cases of non-functioning 
pituitary adenomas.  

Methods: The authors performed a 
retrospective analysis of 154 patients who 
underwent resection of non-functioning 
pituitary adenomas from January 2009 
through May 2011. There was 87 male and 
67 female (mean age = 52.3 years; follow-
up = 6 - 28 months).  



 
 
 

Romanian Neurosurgery (2012) XIX 4: 309 – 355          351 

 
 
 

Results: Tumors where usually large at 
the time of diagnosis, commonly presenting 
with headache (109 cases – 70.7 %), visual 
field defects (56 cases – 36.3 %) and 
hypopituitarism (80 cases – 51.8 %). 
Pituitary apoplexy was the presenting 
symptom in 33 cases (21.4 %). 
Transsphenoidal surgery was the primary 
treatment for adenomas, whereas 
transcranial surgery was reserved for the 
cases in which the sphenoid sinus was not 
pneumatised or when the tumour was 
mainly extrasellar. Gross total removal was 
achieved in 95 out of 154 patients (61.7 %). 
Residual tumours or tumour regrowth 
imposed additional surgery in 34 cases (22.0 
%). The improvement of vision was 
achieved in 85.7 % of cases. Postoperatively, 
patients showed varying improvement of 
pituitary function. There were no serious 
operative complications. Stereotactic 
radiosurgery was used for control of 
residual tumours.  

Conclusions: Transsphenoidal surgery 
remains the treatment of choice for rapid 
decompression of neighbouring structures 
in non-functioning pituitary adenomas, 
often bringing to normalisation or 
improvement of visual and pituitary 
function. 

ENDOSCOPIC ENDONASAL 
TRANSSPHENOIDAL SURGERY 
FOR PITUITARY ADENOMAS  
Ligia Tătăranu*, V. Ciubotaru**, Adriana 
Dediu**, Violeta Ioana Pruna***  
*“Carol Davila” University of Medicine and Pharmacy, 
Bucharest, Romania  
**Neurosurgical Clinic, “Bagdasar – Arseni” Clinical 
Hospital, Bucharest, Romania  
***Clinica Oftapro, Bucharest, Romania  

Aim: To assess the effectiveness of the 
endoscopic endonasal transsphenoidal 

approach in the management of pituitary 
adenomas.  

Methods: We retrospectively analyzed 152 
patients with pituitary adenomas who was 
operated on between January 2003 and 
December 2011 (85 women and 67 men; 
mean age = 43 years; follow-up = 6 
months - 9 years). The series consisted of 
49 GH-secreting adenomas, 20 PRL-
producing adenomas, 21 mixed GH&PRL-
producing adenomas, 8 corticotroph 
adenomas, one case of thyrotroph adenoma 
and 53 non-functioning pituitary 
adenomas.  

Results: Among the 20 patients with 
prolactinomas, 14 patients exhibited 
normalized prolactin levels postoperatively. 
In the acromegalic patients, there were 12 
macroadenomas and 58 microadenomas. 
Among the macroadenomas, 
endocrinologic remission was observed in 4 
cases, minimal improvement in 2 cases and 
no changes in 6 cases. Among the 
microadenomas, endocrinologic remission 
was observed in 34 cases, improvement in 
10 cases, minimal improvement in 4 cases 
and no changes in 10 cases. When a residual 
tumor in the cavernous sinus was 
identified, gamma-knife surgery was used. 
The 8 patients with Cushing’s disease had 
resolution of hypercortisolism clinically and 
chemically. The surgery was curative also in 
the case of thyrotroph adenoma. 
Postoperative morbidities included 
cerebrospinal fluid leak in 4 cases (2.63%), 
temporary diabetes insipidus in 8 cases 
(5.26%) and sinusitis in 2 cases (1.31%).  

Conclusions: The endoscopic endonasal 
transsphenoidal approach is an effective 
surgical option for pituitary adenomas. A 
low incidence of complications has been 
observed, likely because of the improved 
visualization of the anatomy and the 
decreased surgical trauma. 



 
 
 
352          Selected Abstracts          The 8th International Congress of the RSN 

 
 
 

1001 LUMBAR DISC HERNIA - 
MICROSCOPIC APROACH – 
RESULTS - A 5 YEAR EXPERIENCE  
V. Munteanu, Nicoleta Diaconu, R. 
Stanescu, G. Grigore, A. Spatariu  
Neurosurgery, “Bagdasar – Arseni” Clinical Hospital, 
Bucharest, Romania  

 
Removal of a herniated disc with the use 

of the operative microscope was first 
performed by Yasargil in 1977. However, it 
began to be used more and more only in 
the late 1980s. The merits of this technique 
are that it allows every type of disc 
herniation to be excised through a short 
approach to skin, fascia and muscles as well 
as a limited laminoarthrectomy. For these 
reasons, it has been, and still is, considered 
the “gold standard” of surgical treatment for 
lumbar disc herniation, and the method 
used by the vast majority of spinal surgeons.  

The series that we present here was 
selected as only lumbar disc hernia without 
any other associated pathology (lumbar 
stenosis, spondylolisstesys, etc). All cases 
have been treated by microdiscectomy 
technique. We use Zeiss Vario Opmi+ S88 
microscope. In all caseses the intersomatic 
control have been achieved by seing at the 
and of the surgery the anterior longitudinal 
ligament, all fragments being taken away, 
the root being left mobile and free beyond 
the ganglia and the conjunction foramina 
being controlled and left mobile and free by 
any disc fragments. After removal of the 
disc the space was washed with bethadine 
solution.The suture has been carried on 
with Vicryl 2-0 in a continuous way, as well 
as the subcutaneous tissue. Skin closure 
with 3-0 silk, continuously.  

No infections after 5 years we 
encountered, and for five patients we do 
perform another surgery at the same level, 

two of them after mild lumbar trauma.  
The other patients went well with 

kinetotherapy, and from 32% of cases with 
mild to severe deficits before surgery, more 
than 90% recovery was very good (4+ out 
of 5 motor scale). 

MULTIPLE LITTLE 
INTRACRANIAN ANEURYSMS 
WITH FAMILIAL INHERITANCE  
V. Munteanu*, M.R. Gorgan**, N. 
Diaconu***  
*Student in Neurosurgery, “Carol Davila” University of 
Medicine an Pharmacy Bucharest, Faculty of  
Medicine, Departament of Neurosurgery, Romania  
**”Carol Davila” University of Medecine an Pharmacy 
Bucharest Arseni – Bagdasar Hospital, Romania  
***Neurosurgery, “Bagdasar – Arseni” Clinical 
Hospital, Bucharest, Romania  

 
In this particular case, the authors have 

studied a family in wich two of the 
members on the same genetic line-mother 
and daughter have suffered intracranial 
bleeding from ruptured aneurysm. The 
congenital nature and the patterns of 
inheritance of the disease are discussed. 
The indications for elective investigation of 
the asymptomatic relatives and surgical 
prophylaxis on asymptomatic aneurysms 
are also discussed.  

Material and method: Two cases, same 
hereditary line, same nosocomial pattern, 
rare case of multiple intracranial aneurysms. 
Surgical treatment of ruptured and 
unruptured aneurysm, same part, same 
time.  

Results: Operated patient done well 
without neurological deficits after one year.  

Conclusions: Making good judgment 
based on complete investigations lead to a 
good outcome. Further investigations on 
family hereditary aneurysm small lesions 
should be perform. Familial intracranial 



 
 
 

Romanian Neurosurgery (2012) XIX 4: 309 – 355          353 

 
 
 

aneurysms are uncommon. Multiple 
familial intracranial aneurysms are much 
more uncommon. According to our review 
of the literature, only few families are 
known to have more than one of their 
members with multiple aneurysms. Our 
report describes a family in which mother 
and daughter had multiple intracranial 
aneurysms. 

ROLE OF NEURONAVIGATION IN 
ELOQUENT AREA LESIONS  
V. Munteanu, Nicoleta Diaconu, G. 
Grigore, A. Spatariu  
Neurosurgery, “Bagdasar – Arseni” Clinical Hospital, 
Bucharest, Romania  

 
This work is ment to present the 

important role of neuronavigation either in 
localizing small lesion especially in 
eloquent areas but as well the help during 
surgery in modifying the technic and 
simplifying the judgment during surgery.  

We have now 17 cases of cerebral lesions 
in a 6 year period, (5 cavernomas, 5 
meningiomas, 4 metastasis, 3 gliomas).  

In all cases we perform an contrast 
cerebral IRM and angio-IRM, and planned 
the surgery according with the calculations 
made on the console. The shortest route 
has been choosed, the as possible fine 
dissection has been carried on, and in 8 
patients we have an improved neurological 
deficit after the surgery, 6 cases with 
seizures free postoperative course, 2 cases 
with hemorrhage in tumoral bad witch 
necessitate evacuation and one with 
melanotic metastasis with a 46 days free of 
symptoms with good radiologic control, 
and after with a smaller recurrence in the 
same place.  

We do learn after using the 
neuronavigation system that even the work 

is more time consuming in planning the 
surgery the satisfaction by easing the 
surgery itself worth using. 

PITUICYTOMA - MR IMAGING, 
CLINICAL SIMPTOMS AND 
OUTCOME  
V. Munteanu, Nicoleta Diaconu  
Neurosurgery, “Bagdasar – Arseni” Clinical Hospital, 
Bucharest, Romania  

 
We report a case of pituicytoma, a rare 

primary tumor of the neurohypophysis. A 
48-year-old woman presented with 
progressive visual complaints, bitemporal 
hemianopsia, and headache with vomiting. 
In the past year the pacient have been 
hospitalise in psihiatric departement for 
acute depressive state, during the last being 
scanned on CT wich disclosed a large 
suprachiasmatic multicistic mass lesion and 
had been refferd to us.  

Imaging studies revealed distinctive 
features of a mass lesion that thickened the 
pituitary stalk with a multicistic protrusion 
extending into the hypothalamus, temporal 
lobe, mesencefalon and cavernous sinus.  

Pituicytomas are very rare primary 
tumors of the adult neurohypophysis, and 
only a few case reports of true pituicytomas 
exist in the literature.  

Pituicytes are glial cells of the 
neurohypophysis that support the large 
axons of vasopressin and oxytocin-
producing hypothalamic neurons. 
Pituicytomas are considered low-grade 
astrocytomas of the neurohypophysis, 
distinct from intracranial granular cell 
tumors (GCT) and pilocytic astrocytomas. 
They are histologically benign, but their 
hypervascular nature makes surgical 
resection difficult.In the literature local 
recurrence after subtotal resection is 



 
 
 
354          Selected Abstracts          The 8th International Congress of the RSN 

 
 
 

common. The imaging characteristics of 
pituicytomas are nonspecific, but MR 
imaging are essential for surgical planning 
and can reveal details about the extension 
and structures being compressed by the 
tumor. 

SACRAL ARACHNOIDIAN CYST – 
CASE REPORT, SURGICAL 
TEHNICAL METHOD  
V. Munteanu, Nicoleta Diaconu, G. 
Grigore, A. Spatariu  
Neurosurgery, “Bagdasar – Arseni” Clinical Hospital, 
Bucharest, Romania  

 
We present a case of a young woman, 39 

years old, medical nurse, who came first 
time in our hospital with moderate nuchal 
pain, easily reliefed by common antalgic 
treatment. She has been investigated with 
cervical spine MRI which show moderate 
modifications of cervical discs.  

Two weeks after his first presentation, 
suddenly present slowly growing pain in 
the lumbar region, from light pain to 
unbearable pain and has been address in 
emergency to another hospital for 
emergency treatment.  

The day after we admitted the patient 
and perform an lumbo-sacral MRI which 
show multiple sacral S2-S3 cysts of 5 cm in 
contact, with pressure on the sacral anterior 
wall and bone destruction both anteriorly 
and posteriorly, the pressure effect making 
the maximum thickness of the bone around 
1 mm.  

Any treatment ot all could this time kill 
the pain so we propose surgery and the 
patient accepted willingly.  

A linear midline lumbosacral incision 
and we found a translucid bone under 1mm 
thickness that we removed under the 
microscope. The cyst on the left side appear 

immediately and we made a linear incision, 
drain the fluid and observe the rooth inside 
floating free. A reshape of the cyst wall was 
performed by cutting free 1 cm on both 
side of the incision edge, superposed the 
margins on another 1cm common soil and 
making a noninterrupted, nonresorbable 5-
0 suture.  

The pain disappears the day after the 
surgery, no deficits, no urinary 
disturbances.  

Ten days a small leakage at the incision 
site appears of CSF witch has been solved 
with bad rest and local pressure.  

Eight month after the surgery the patient 
is back on her job. 

ANTERIOR CIRCULATION 
INTRACRANIAL ANEURYSMS - 
PERSONAL SERIES  
C. Toader*, M. Stroi**  
*”Carol Davila” University of Medecine an Pharmacy 
Bucharest Arseni – Bagdasar Hospital, Romania  
**National Institute of Neurology and Neurovascular 
Diseases, Bucharest, Romania  

Cerebral aneurysms represents the most 
common cause of nontraumatic 
subarachnoidian hemorrhage.Overall, 
about half the patients die within the first 
month of their hemorrhage.They 
represents major cerebrovascular 
emergencies, whose management requires a 
tight collaboration between neurologist, 
neurosurgeon and neuroradiologist.The 
treatment modalities are numerous, but 
surgical clipping remains the most effective 
and safe method of management.Surgical 
clipping of the neck of the aneurysms and 
flow preservation in all the efferent vessels 
remains the gold standard of intracranial 
aneurysms therapy.Intracranial aneurysms 
may pose formidable surgical problems, 
even to the most experienced 



 
 
 

Romanian Neurosurgery (2012) XIX 4: 309 – 355          355 

 
 
 

neurosurgeons.Surgical approaches must be 
large, with minimal retraction and maximal 
surgical exposure.  

We present a series of 48 intracranial 
anterior circulation aneurysms in 42 
consecutive patients admitted to the 
Neurosurgical Departament of the 
National Institute of Neurology and 
Neurovascular Disease, between September 
2010-september 2012, and whose 
management consisted in surgical clipping 
in 91,8%.  

SURGICAL NUANCES IN DISTAL 
ANTERIOR CIRCULATION 
INTRACRANIAL ANEURYSMS  
C. Toader*, M. Stroi**  
*”Carol Davila” University of Medecine an Pharmacy 
Bucharest Arseni – Bagdasar Hospital, Romania  
**National Institute of Neurology and Neurovascular 
Diseases, Bucharest, Romania  

 
Distal anterior cerebral artery(DACA) 

aneurysms, also called the pericallosal artery 
aneurysms are rare, being encountered in 
about 6% of all intracranial aneurysms and 

are located distally to the anterior 
communicating artery (ACoA) on the A2–
A5 segments of the ACA, the most 
common at the A3 segment, anterior to the 
genu of the corpus callosum. DACA 
aneurysms are small, and often with wide 
necks and presents more often with 
intracerebral hematomas than ruptured 
aneurysms in general and are associated 
with anomalies of the ACA. Surgical 
clipping is a safe and effective treatment 
method, which requires detailed knowledge 
of the microanatomy of the anterior 
cerebral artery and the surrounding 
structures.The challenge is to select the 
appropriate approach,locate the aneurysm 
deep inside the interhemispheric fissure, 
and to clip the neck adequately without 
obstructing the branching arteries.  

We present a personal series of four cases 
who underwent surgical clipping between 
February and August 2012 in the 
Neurosurgical Department of the National 
Institute of Neurology and Neurovascular 
Diseases.