Microsoft Word - 8_SelectedAbstracts


 
 
 
180         Abstracts         3rd National Conference of Neuro-Oncology (NCNO 2013)  

 
 
 

3rd National Conference of Neuro-Oncology (NCNO 2013) with 
International Participation 

16th - 20th April 2013 

ABSTRACTS 

 

Intramedullary mass lesions – function 
directed surgery  
Vladimír Beneš, Svatopluk Ostrý  

Dept. Neurosurgery, Charles Univ, Prague  
 
Recent advances of electrophysiological 

monitoring allow for safe surgery within 
the spinal cord.  

We have evaluated our series over the 
past 8 years to determine the effects of 
monitoring and to establish in how many 
cases the surgery was altered and directed 
by the electophysiological findings.  

In a period 2005-2012 total of 77 patients 
with various intramedullary pathologies 
were operated. The dominant lesions were 
ependymomas followed by astrocytomas 
and cavernomas. This series was compared 
to earlier series of 29 patients in whom 
electrophysiological monitoring was not 
used.  

The radicalism of surgery increased 
from 30 to 70%. In general clinically the 
patients remained the same as 
preoperativelly in both groups. In 29 
patients the steps and techniques of surgery 
was changed according to MEP and D wave 
findings during the procedure.  

Conclusions: Thanks to MEPs and D 
wave are highly sensitive and specific in 
outcome prediction.  

The better the preop neurological 
findings the better the outcome.  

Monitorability depends on preop 
findings.  

The outcome depends on intraop 
monitoring.  

The surgeon must be able to change the 
surgical strategy whenever the warning is 
announced by the electrophysiologist.  

Any surgery of the spinal cord should be 
performed with intraop monitoring  

Posterior fossa meningiomas  
Vladimír Beneš  

Dept. Neurosurgery, Charles Univ, Prague  
 
Posterior fossa meningiomas are deemed 

to be difficult lesions. However, this seems 
to be true for certain tumors only.  

Series of 123 posterior fossa 
meningiomas operated in a period 1998-
2011 was reviewed and divided into various 
location groups and related to the extent of 
surgery and neurological outcome.  

Overall MM rate was 5,7% and overall 
S1 and 2 resection was 73%. The tumours 
were finally divided into two groups only – 
A. anterior to the cranial nerves (n=63) and 
B. posterior to the nerves (n=60).  

MM rate in group A was 9,5% with 
some minor morbidity in another 23,6%. In 
the group B MM rate was 1,7% with zero 
minor morbidity. S1 and 2 resection was 
achieved in 73% of patients in group A and 
in 95% of patients in group B.  



 
 
 

 Romanian Neurosurgery (2013) XX 2: 180 – 213          181 

 
 
 

In conclusion surgery should be offered 
to all patients with tumors located posterior 
to the cranial nerves. In patients with 
tumors located anterior to the nerves other 
treatment modalities should be considered.  

Anterior fossa midline skull base 
meningiomas – preservation of N.I 
function  
Vladimír Beneš, Václav Masopust  

Dept. Neurosurgery, Charles Univ, Prague  
 
Using a standard anterior skull base 

approach for olfactory groove meningioms 
does not allow preserving the function of 
the first cranial nerves. Series of 67 
meningiomas located in the midline skull 
base of anterior fossa was reviewed. The 
tumours growing from posterior (sellar) or 
from the side (sphenoid wing, clinoid) and 
reaching the cribriform plate were 
excluded. In the years 1998-2002 total of 21 
such cases were treated. All the tumours 
were approached via anterior midline and in 
neither case the first nerve has been 
preserved. There was 0 mortality and 9% 
minor morbidity. Anosmia was present in 
all patients. Since 2003 we have preferred 
pterional approach to these tumors. In a 
period 2003 - 2011 we have treated 46 
patients. The overall mortality was 4% and 
minor morbidity 4%. In 17 surgeries 
anterior midline cranitomy was introduced, 
in 3 endoscopic endonasal route was used, 
and in 26 pterinal approach was introduced.  

We were able to preserve at least some 
smell in 19 patients (41%). The best results 
were achieved in pterional craniotomy 
group – 50% smell preservation and 85% 
Simpson 1 and 2 resections.  

The major advantage of pterional 
approach, apart from potential contralateral 

n.I preservation, is early exposure of 
important structures in the sellar region and 
early CSF drainage. The potential of 
endonasal endoscopic approach is yet to be 
established. Anterior subfrontal approach is 
reserved for the tumours reaching the most 
anterior parts of the anterior fossa and for 
the extra large tumours.  

The role of stereotactic biopsy in the 
management of infiltrative and 
multicentric cerebral gliomas  
Felix Brehar, Mircea Gorgan,  
Alexandru Tascu  

“Carol Davila” University of Medicine and Pharmacy 
Bucharest, Faculty of Medicine, Department of 
Neurosurgery Bucharest, Romania 

 
Diffuse and multi-centric growth-

pattern of glioma precludes the gross-total 
resection of these tumors and represents 
the main cause of the poor outcome of the 
patients. Therefore, stereotactic biopsy is an 
alternative option for the management of 
these types of tumors. The authors present 
their experience in 102 cases of stereotactic 
biopsies performed for infiltrative, 
multicentric and deep-seated cerebral 
gliomas.  

One hundred and two patients with 
infiltrative, multicentric and deep-seated 
cerebral gliomas admitted in our clinic 
between November 2008 and February 
2013 were 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. The histopatological results (according 
to World Health Organization (WHO) 



 
 
 
182         Abstracts         3rd National Conference of Neuro-Oncology (NCNO 2013)  

 
 
 

classification) were: 66 cases of 
glioblastomas (grade IV) (64,7%), 7 cases of 
anaplastic astrocytomas (grade III) (6,9%), 
14 cases of grade II diffuse astrocytomas 
(13,7%), 7 cases of grade I astrocytomas 
(6,9%), one case of grade II 
oligodendroglioma (0,09%), 3 cases of 
anaplastic oligodendrogliomas (grade III) 
(2,9%), one case of grade I ganglioglioma 
(0,09%), one case of anaplastic 
ganglioglioma (grade III) (0,09%), and 2 
cases of anaplastic ependymomas (grade III) 
(1,9%). In 32 cases (31,4%) 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 9 patients (8,8%).  

In conclusion, image-guided stereotactic 
biopsy represents now a safe and accurate 
diagnostic method for infiltrative and deep-
seated cerebral gliomas, which can 
favorably infl uence the therapeutic 
management of the patients.  

Key words: Stereotactic biopsy, 
infiltrative gliomas, immunohistochemistry.  

New trends in treatment of elderly 
patients with high-grade glioma  
Dana Cernea1, Stefan Florian2, Paula 
Pruteanu1, Cristina Cercea1, Diana Sabau1, 
Andrei Stoian1, Raluca Stahiescu1, Silviu 
Halasag1, Nicolae Todor1  

1Oncology Institute “Prof. Ion Chiricuta” Cluj-Napoca, 
Romania; 2Neurosurgery County Hospital Cluj-
Napoca, Romania  

 
Background: optimal treatment for elderly 

patients with high-grade glioma is not well 

defined. They are often excluded from 
multimodal approach due to concerns of 
increased morbidity due to poor 
performance index and associated diseases. 
We present our results in treatment of 
patients over 65 years with different type of 
high grade gliomas. The primary end point 
was overall survival. Some data of recent 
clinical studies that will perhaps change the 
treatment decision for these patients will be 
presented.  

Patients and methods: 65 patients, with a 
median age of 69 years, have been treated 
between 2005 and 2010 in our Institution. 
Female/male ratio was 37/28. Histological 
type was: glioblastoma multiforme (GBM) 
44 patients ( 66.6 %), anaplastic astrocitoma 
7 patients (10.61 %), oligoastrocitoma grade 
3 in one patient (1.54%). Other histological 
types were less frequent representing 13, 
86%. Surgery was performed in all patients: 
complete resection in 50 patients (76.9%), 
subtotal resection in 13 patients (20%), and 
2 biopsies (3.1%). Postoperative 3D 
conformal radiotherapy was performed 
with two different type of fractionation: a) 
standard fractionation: TD= 40-60 Gy, 
mean dose 56 Gy; and 2) hypofractionation: 
TD= 3-45 Gy, mean dose 32 GY. 
Concomitant and adjuvant chemotherapy 
with Temozolomide was done in 33.33% of 
patients, concomitant radiochemotherapy 
only in 22.75 % of patients and 37.88% of 
patients performed radiotherapy alone. At 
the beginning of postoperative treatment 
58.4% of patients had Karnofski index (KI) 
> 70. Main associated diseases were high 
blood pressure, cardiovascular diseases, 
diabetes.  

Results: Overall survival at 36 month was 
13% (CI: 7%-25%) with the worst survival 
for patients with GBM ( 8%). Toxicity 
during radiotherapy was measured after 



 
 
 

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RTOG scale and generally was 0-1 (6.07% 
of patients) with no significant difference 
between the two type of fractionation.  

Conclusions: The number of patients in 
our study was small, but study show that 
elderly patients could be treated with radio-
chemotherapy without major toxicity. 
Hypofractionated radiotherapy was well 
tolerated and could be a good option in 
order to shortening the treatment time for 
these patients. Important decision factors 
for treatment type must be KI and the 
status of associated diseases.  

Supratentorial low grade glomas latest 
developments in diagnosis and 
treatment  
A.V. Ciurea1, D.A. Nica2, I. Ogrezeanu3,  
A. Mohan4, H. Moisa1  

1Carol Davila University School of Medicine, Sanador 
Medical Center, Department of neurosurgery, Bucharest, 
Romania; 2St. Pantelimon Teaching Hospital, 
Department of Neurosurgery, Bucharest, Romania; 
3Bagdasar-Arseni Teaching Hospital, Department of 
Neurosurgery, Bucharest, Romania; 4Oradea County 
Teaching Hospital, Department of Neurosurgery, Bihor 
County, Romania 

 
Introduction: Low grade gliomas (LGG) 

are slow growing tumors. The aim of the 
treatment is to simultaneously combine an 
optimal resection by preservation of 
functional integrity with correct grading of 
tumor malignancy and the adequate 
adjuvant therapies in order to achieve a long 
survival, with a good postoperative quality 
of life. There are some important questions 
regarding LGG: What is the delimitation of 
LGG? What are the therapeutical decisions: 
observation, surgical removal or biopsy? 
Does surgical removal alone ever cure 
LGG? If recurrences appear, is another 
surgery recommended? What is the 

efficiency of radiotherapy and 
chemotherapy in LGG recurrences? What 
are the indications of Gamma Knife 
Surgery (G.K.S.)?  

Material and methods: Our experience in a 
series of 160 adult patients with 
supratentorial LGG, operated over a period 
of 11 years (January 2002- December 2012) 
is presented, focusing on the newest 
achievements in the diagnostic of gliomas 
(neuroimaging, immunohistochemical 
analysis of tumor specimens), surgical 
treatment (intraoperative electrophysiology) 
and adjuvant therapies (oncological 
protocols).  

The preoperative diagnosis was based on 
1T MRI images. Microsurgical resection 
was performed in all cases: total removal 79 
cases (49,3 %), partial removal 81 cases 
(50,6 %), with no perioperative mortality. 
The outcome at 6 months (GOS) showed: 
good recovery in 135 cases (84,3%), 
moderate disability in 21 cases (13,1%), 
severe disability in 4 cases (2,5%). The 
follow-up period ranged between 12 
months and 9 years with a medium range of 
4,5 years. The histological grading was 
assessed by classical pathologic examination 
and showed: fibrilary astrocytomas in 102 
cases, oligodendriogliomas in 26 cases, 
oligoastrocytomas in 21 cases, 
dysembryoplastic neuroepithelial tumor in 
5 cases, protoplasmic astrocytoma in 4 
cases, ganglioglioma in 2 cases.  

In our data at 5 years postoperative we 
find: 11 lost patients, recurrences to grade 
III-IV in 49 cases, regrowth grade II-III in 
53 cases, 47 cases remain in evidence (grade 
II).  

The total number of regrowth-
recurrences is 102 (63,8%). It’s very 
important to perform a check-up MRI 
every 6 months.  



 
 
 
184         Abstracts         3rd National Conference of Neuro-Oncology (NCNO 2013)  

 
 
 

LGG causing long-standing and 
medically refractory epilepsy are more 
likely to be associated with multiple 
epileptogenic foci, therefore intraoperative 
electrocorticography was used for tailoring 
the resection, together with intraoperative 
localization of central sulcus using 
somatosensory evoked potentials in tumors 
localized around the central area. 
Intraoperative electrophysiological 
monitoring was performed in 31 cases.  

Because actually, the final diagnosis 
requires immunohistochemistry and also, 
study of the molecular biology of these 
tumors is an important step for 
understanding the genesis and biological 
behavior of these diseases, in the last years 
of the study we have performed also 
immunohistochemical analysis of the 
tumor specimens. We have studied in order 
to identify, quantify and compare, in a 
series of 37 cases of glioma surgical 
specimens (low grade and high grade 
gliomas), previously classified concerning 
their histological grade (WHO), the 
following immunohistochemical markers: 
Ki-67 proteins and PCNA (markers of the 
cellular proliferation), p53 (product of the 
tumor suppressor gene TP53), CD 34, 
VEGF, VEGFR2, bFGF (markers for 
angiogenesis).  

Surgical specimens were immunostained 
for p53 (Clona DO-7, Biogenex USA); Ki-
67 (MIB-1; 1:50, DAKO- Glostrup, 
Denmark) and proliferating cell nuclear 
antigen (PCNA; 1:10, PC10 Dakote). 
Proliferative activity (nuclear immunostain) 
was measured.  

P53 immunoreactivity was positive in all 
grade III and IV gliomas, and in 50% of low 
grade gliomas. With a median of 12% and 
24% for MIB-1 and PCNA respectively, for 
all neoplasms in the study, the mean 

percentage positive nuclear area for MIB-1 
and PCNA was 3.06% and 13.11% in low-
grade (II) astrocytomas, 14.34% and 29.68% 
in highgrade (III) astrocytomas, and 18.77% 
and 44.11% in glioblastoma multiforme 
(grade IV).  

One-way analysis of variance showed a 
significant correlation between the 
histological grade and MIB-1 and between 
the histological grade and PCNA. Isolated 
cases of low grade gliomas with high MIB 
and PCNA percentage were noticed.  

CD34, VEGF, VEGFR2 and bFGF 
expression were determined by 
immunohistochemistry (CD34, Clone Q 
band, Immunotech; VEGF, sc-152, Santa 
Cruz Bioth.; VEGFR2, sc-7269, Santa Cruz 
Bioth; bFGF, bFGF88, Biogenex). 
Immunoreactivity for CD34 was positive in 
all types of the tumors. Immunoreactivity 
for VEGF, VEGFR2 and bFGF was seen in 
both endothelial cells and tumor cells, with 
increased levels in more aggressive tumors, 
comparing with normal tissue where 
immunoreactivity was present only in 
endothelial cells.  

Conclusions: LGG could be treated only 
surgically. We advocate the idea, that 
patients with LGG and medically refractory 
epilepsy, may undergo tailored resections.  

Incompletely resected tumors may be 
managed with irradiation in the tumor bed, 
or by observation alone. Proliferation in 
gliomas, measured as MIB-1 and PCNA, 
correlates significantly with histological 
grade, providing useful additional 
information for diagnosis evaluation of the 
tumor recurrence susceptibility. 
Angiogenesis markers could indicate the 
invasiveness tendency of the tumor. 
Correlated with the proliferation markers, 
they express the agressive tendency of the 
tumor and consequently, the prognosis. As 



 
 
 

 Romanian Neurosurgery (2013) XX 2: 180 – 213          185 

 
 
 

a result, the correct treatment and prognosis 
of the case could be evaluated, especially in 
LGG where the indication of radiotherapy 
is debatable.  

Despite the optimism associated with 
prognostic in LGG, these tumors usually 
recur, having a higher grade of malignancy. 
We consider that new, even more aggressive 
treatment protocols are needed for their 
management.  

Key words: low grade gliomas, 
supratentorial, microsurgery, intraperative 
electrophysiology, immunohistochemistry, 
neuro-oncology, Gamma Knife Surgery 
(G.K.S.)  

Treatment of brain metastases with 
cyberknife robotic radiosurgery  
Alfredo Conti1, G. Iata1, A. Pontoriero1,  
G. Marino1, L. Frosina1, F. Midili2,  
C. Siragusa2, A. Brogna2, S. Pergolizzi1,  
C. De Renzis1, F. Tomasello3  

1Department of Radiation Oncology; 2Department of 
Medical Physics; 3Department of Neurosurgery 
University of Messina, Messina, Italy  

 
Objectives: CyberKnife robotic 

radiosurgery is a potentially effective 
treatment strategy for brain metastases, 
including large or multiple lesions.  

Aims of study: To evaluate efficacy and 
toxicity of Cyberknife robotic stereotactic 
radiosurgery (SRS) alone or in combination 
with whole brain radiotherapy (WBRT) in 
the treatment of metastatic brain lesions.  

Case report: We retrospectively reviewed 
data of patients with brain metastases who 
underwent CyberKnife SRS at the 
University of Messina, ITALY between July 
2007 and February 2013  

Material and methods: In the study, we 
included 252 patients with 343 lesions with 

>18 months follow up. Recursive 
partitioning analysis (RPA) was used to 
categorize clinical status of patients. 
Treatment planning was obtained on CT 
and contrast-enhanced MRI. The clinical 
target volume (CTV) adopted was the gross 
tumor volume (GTV) plus an isometric 
margin of 1-2 mm. Follow up examinations 
were carried out 2-6-12 months after SRS, 
then yearly.  

Results: Follow-up ranged 18-50 months. 
All patients were treated in single fraction, 
median tumor volume was 1.9 cc (range 
0.06-22.9 cc), median dose was 20 Gy 
(range 11-24 Gy), median isodose 80% 
(range 60-90%). 55/252 patients were lost to 
follow up. Median survival at 1 and 2 years 
were 63% and 55% respectively. One and 
two years local disease control were 84% 
and 62% respectively. Median survival was 
14, 7.6 and 4.8 months for RPA class 1, 2 
and 3 respectively. 80% of the patients 
treated with SRS only were alive at 40 
months versus 43% of the patients treated 
with SRS plus WBRT. Patients who had 
been treated for lesions ≠2.5 cm who 
survived at 24 months were 78%versus 43% 
of the patients with lesions > 2.5 cm. Early 
and late neurological effects were recorded 
in 17% of patients located in eloquent brain 
areas.  

Conclusions: Our results confirm the 
efficacy of Cyberknife stereotactic 
radiosurgery in the treatment of brain 
metastases. Best results were obtained in 
patients in RPA class 1, with lesions of ≠
2.5 cm and in patients without or with 
controlled extracranial disease. 
Furthermore, the preliminary data of this 
study suggest that the combination SRS 
with WBRT adds no benefit over SRS alone 
for oligo-metastatic patients.  

 



 
 
 
186         Abstracts         3rd National Conference of Neuro-Oncology (NCNO 2013)  

 
 
 

Brain tumor related seizures  
Lacramioara Perju Dumbrava  

Neurology I, University of Medicine and Pharmacy 
“Iuliu Hatieganu” Cluj-Napoca, Department of 
Neuroscience Cluj Napoca Cluj, Romania  

 
Approximately 4% of all seizures are 

secondary to brain tumors. Seizures are the 
onset symptom in about 20-40 % of 
patients with a brain tumor diagnostic and 
about 20-45% of these patients will present 
a type of seizure during the course of the 
disease.  

Objectives: The objective of our study was 
to analyse all cases of patients with a brain 
tumor diagnostic during a thirty nine 
month period, observing the incidence of 
seizures, seizure type, the relation of the 
seizure with the tumor type, the moment of 
the diagnostic and the treatment applied.  

Aims of study: We were interested to 
create a clear picture of the relation between 
brain tumor and seizures in our 
Neurological Unit from Emergency 
County Hospital Cluj.  

Case report: The study has a retrospective 
design, including a number of 112 patients 
with a brain tumor, admitted from January 
2010 to March 2013.  

Material and methods: We analyzed brain 
tumor patients, grouping them according to 
demographical date, onset of seizure in 
relation with the moment of diagnostic, 
seizure type, tumor type and the 
antiepileptic treatment applied. Results: 
From the 112 brain tumor patients included 
in this study, 76 patients (64.3%) never 
developed a seizure, 26 patients (23.2%) 
presented a seizure before the diagnostic 
and 21 patients (18.75%) developed seizures 
after the diagnostic was established. Most of 
the cases were meningiomas (27.67%) and 

astrocitomas (24.1%). 56% of the pacients 
suffered from primary generalized seizures 
and 31.3% suffered from partial motor 
seizures. 41 pacients were submitted to 
monotherapy and 7 patients received dual 
AED therapy.  

Conclusions: Our results demonstrated 
once more that seizures are a major 
complication of brain tumors, the 
management of these patients being 
particularly difficult.  

Angiogenesis in gliomas and plasma 
levels of vascular endothelial growth 
factor (vegf) and basic fibroblast 
growth factor (bFGF)  
Yavor enchev1, D. Handziev1, T. Avramov1, 
B. Iliev1, T. Kondev1, G. Kiuchukov2  

Department of Neurosurgery  
1University Hospital “Sv. Marina” Varna, Bulgaria; 
2University Hospital “Sv. Anna”, Medical University of 
Varna, Varna, Bulgaria 

 
Objectives: Glioma progression and 

patient’s survival is strongly dependent on 
the development of a new vascular network 
that occurs primarily by angiogenesis. The 
knowledge of the plasma detectability of 
distinct angiogenic factors in patients with 
brain tumours is very limited.  

Aims of study: The purpose of the study 
was to evaluate the plasma levels of the 
angiogenic factors Vascular Endothelial 
Growth Factor (VEGF), and Basic 
Fibroblast Growth Factor (bFGF) in 
patients with brain tumours.  

Material and methods: Plasma samples of 
25 patients with histologically confirmed 
intracranial tumours, divided in 2 groups- 
Group I (gliomas- glioblastoma 
multiforme, WHO grade IV, n=6; 
astrocytoma, WHO grade II-III, n=4; 



 
 
 

 Romanian Neurosurgery (2013) XX 2: 180 – 213          187 

 
 
 

astrocytoma, WHO grade I, n=4) and 
Group II (meningiomas, n=11), were 
analyzed. Group III (the control group) 
included 10 clinically healthy patients. The 
plasma concentrations of the examined 
angiogenic factors were evaluated by highly 
specific enzyme-linked immuno sorbent 
assays (ELISAs).  

Results: Median levels of VEGF and 
bFGF in plasma were significantly higher in 
patients with high-grade gliomas as 
compared with patients with low-grade 
gliomas or meningiomas. The serum levels 
of the investigated angiogenic factors 
demonstrated correlation to tumour grade 
and vascularity.  

Conclusions: Despite the limited number 
of patients, our data suggest that the plasma 
levels of VEGF and bFGF correlate with 
the tumour type and grade. The levels of 
the angiogenic factors in the plasma 
correlate with the degree of tumour 
vascularity. The plasma detectability of the 
individual angiogenic factors seems to 
depend at least partly on the tumour type as 
well as on tumour progression.  

The value of microRNA as a 
prognostic factor in high grade gliomas  
Yavor Enchev, D. Handziev, T. Avramov, 
B. Iliev, T. Kondev, A. Tonchev  

Department of Neurosurgery University Hospital “Sv. 
Anna”, Medical University of Varna, Varna, Bulgaria 

 
Objectives: MicroRNA (miRNA) is a 

class of highly conserved, single-stranded, 
noncoding small RNAs. After maturation, 
they entry into the RNA interference 
pathway and regulate gene expression on 
the post-transcriptional level by inhibiting 
the translation of protein from mRNA or 
by promoting the degradation of mRNA. 

Many studies have shown that miRNAs 
control cell proliferation, differentiation, 
and apoptosis in different types of cells.  

Aims of study: The purpose of the study 
was to evaluate the expression of a miR 
cluster in high grade glial tumours.  

Material and methods: Tumour samples 
(n=20) of high grade gliomas 
neurosurgically treated in our clinic were 
simultaneously fixed in formalin for 
histological analysis and refrigerated to -
80oC in RNALater(Ambion). After the 
isolation of pure and intact total RNA from 
the samples, the expression of the miR 
cluster was investigated by RT-PCR.  

Results: The histological examination 
confirmed the glial character of the 
tumours and demonstrated their high-
grades according to the WHO classification. 
The molecularbiological analysis validated 
the existence of the examined miR cluster.  

Conclusions: The miR cluster was 
expressed in high grade gliomas. The 
correlation between the expression levels 
and the histological grade and patients’ 
survival could be valuable for identifying 
new biomarkers predicting the behavior of 
theses tumours. MicroRNAs may be 
clinically useful as prognostic biomarkers.  

Intracranial meningiomas-an overview  
Ioan Ştefan Florian1,2, Pintea Bianca1,2, 
Ungureanu G.2, Leat F.2, Ilyes A.1, 
Morosanu C.O.1, Cosma G.M.1, Florian 
I.A.1  

1University of Medicine and Pharmacy “Iuliu 
Hatieganu” Cluj-Napoca; 2Cluj County emergency 
Hospital, Department of Neurosurgery 

 
Introducere: Intracranial meningiomas 

represent the second most frequent type of 
cerebral tumors encountered in 



 
 
 
188         Abstracts         3rd National Conference of Neuro-Oncology (NCNO 2013)  

 
 
 

neurosurgical practice. Despite being 
characterized as benign tumors, the risks of 
recurrence or malignant transformation last 
for a lifetime. Based on our surgical 
experiences, we wish to illustrate that, aside 
from the histopathological type or subtype, 
two other factors independently infl uence 
the risk of recurrence of these tumors: the 
tumor resection ratio and its location.  

Material and methods: Our retrospective 
study is based on the experience of the 
main author, encompassing 688 locations of 
intracranial meningiomas encountered in 
657 patients (some patients with multiple 
meningiomas) requiring 817 surgical 
interventions (including recurrences). In 
our practice, intracranial meningiomas 
accounted for 22,9% out of the total of 3004 
cerebral tumors surgically treated by the 
same author between 01.01.2000 and 
31.12.2012. We present some surgical key 
point for different location and analyze the 
recurrence rate of meningiomas in relation 
to tumor location, World Health 
Organization (WHO) grading and gender 
and tested the statistical significance by 
using the Chi square test.  

Results: 597 cases with documented total 
macroscopic ablation met the inclusion 
criteria for statistical analysis. Out of these, 
83 cases were recurrences (13.9%), which 
had a median recurrence period of 3 years. 
65% of the recurrences had a non skull base 
location, the most frequent cases being 
parasagittal and falcine meningiomas (35%), 
followed by convexital recurrences (30%). 
When analyzing the risk of recurrence in 
the case of parasagittal and falcine 
meningiomas, we found an Odds Ratio 
(OR) of 1.92 (CI [1.17, 3.17]), p=0.008) 
compared to other locations. The risk of 
having a skull base meningioma recurrence 
was 1.41 (CI [0.85, 2.29], p=0.15). The OR 

for recurrences in WHO grade II-III 
meningiomas was 3.3 (CI [1.73, 6.29], 
p=0.0001). We also found an OR of 1.31 
(CI [0.82, 2.1], p=0.24) for tumor 
recurrence in male patients.  

Conclusion: Considering that total 
ablation was noted in all of the tumors 
taken into calculation (Gross Total 
Removal GTR, Simpson grades I and II), 
we clearly demonstrated that falcine and 
parasagittal meningiomas tend to recur, the 
risk of recurrence being almost twice 
greater compared to other locations. In 
addition, our study shows that there is a 
significant association between WHO grade 
II-III meningiomas and recurrences, the 
risk of recurrence being 3 times greater 
when harboring aggressive types of 
meningiomas.  

Key words: intracranial meningiomas, 
surgery, recurrences, locations.  

Cerebral gliomas-resuming a surgical 
experience  
Ioan Ştefan Florian1,2, Abrudan C.1,2, 
Baritchii A.2, Cheptea M.3, Zoican A.1, 
Durutya Al.1, Aldea C.1, Florian I.A.1  

1University of Medicine and Pharmacy “Iuliu 
Hatieganu” Cluj-Napoca; 2Cluj County emergency 
Hospital, Department of Neurosurgery 3“Prof. Dr. Ion 
Chiricuta” Oncology Institute 

 
Introduction: The cerebral glioma category 

includes numerous histopathological types 
with varying peculiarities considering 
evolution, diagnosis, imaging and 
treatment. Therefore, encompassing them 
within a single presentation might prove 
hazardous. In spite of their differences, all 
these tumors share, apart from their 
ultrastructural origin, two major 
similarities: their fatal evolution in large 



 
 
 

 Romanian Neurosurgery (2013) XX 2: 180 – 213          189 

 
 
 

majority of the cases and the principles of 
surgical treatment. This is why we are 
attempting to highlight some of the 
elements concerning the role of 
neurosurgery in the treatment of cerebral 
gliomas, with particularities regarding 
histopathological types, location, surgical 
strategy and results.  

Material and methods: The presented 
retrospective study is based on the 
experience of the first author (Prof. Dr. 
Florian) of 997 gliomas operated between 
01.01.2000 and 31.12.2012, accounting for 
33,18% out of the total of 3004 tumors 
operated within the same interval. 311 cases 
of HGG and 224 cases of LGG met the 
inclusion criteria for multivariate statistical 
analysis in order to define the role of radical 
surgery in multimodal glioma treatment.  

Results: High-grade gliomas (HGG) 
represent 59,87% (597 cases) of all cerebral 
gliomas: anaplastic astrocitomas (25.7%), 
glioblastoma multiforme (65.5%), high-
grade oligodendrogliomas (5.8%) and high-
grade ependimomas (3%). From a total of 
400 LGG cases (41,13% of all gliomas) 
pilocytic astrocitoma represent 23,5% (94 
cases), Grade II gliomas (astrocitomas, 
mixed glioams) represent 44,5% (178 
cases), oligodendrogliomas 10,7% (43 cases) 
and ependimomas (grade I and II) 15,25% 
(61 cases). 121 of all glioma operated cases 
(12,13%) where at the pediatric age, the 
majority being represented by LGG (83,47 
%). Gross total removal (GTR) was 
achieved in 86% of HGG and in 88% of 
LGG. In HGG, at 24 months follow-up, 
the median survival was 12 months with 
GTR and only 6 months with STR. The 
improvement of the KPS scale is 
significantly higher (p< 0,05) in patients 
with LGG in whom gross total removal of 
the tumor was achieved.  

Conclusions: The age and type of surgery 
were prognostic factors that had 
significantly infl uenced the survival rate at 
12, 18 and 24 months for patients with 
HGG. In LGG extent of removal 
independently infl uences the outcome, but 
no correlation with malignant 
transformation could be established. 
Radical surgery must be the goal in 
multimodal treatment of cerebral gliomas.  

Risk versus benefit criteria of the 
microsurgical treatment for recurrent 
glioblastomas  
Mircea Gorgan, Felix Brehar  

“Carol Davila” University of Medicine and Pharmacy 
Bucharest, Faculty of Medicine, Department of 
Neurosurgery; “Clinic Emergency Hospital Bagdasar- 
Arseni Bucharest, First neurosurgical Clinic  

 
Glioblastoma is the most common 

primary intra-axial tumor of the central 
nervous system with a poor outcome, 
despite the multidisciplinary approach 
which consists in surgery, radio- and 
chemotherapy. The rule is recurrence, 
which usually occurs between 6 and 12 
months after primary treatment. There are 
divergent opinions regarding the 
management of the glioblastoma 
recurrence. While some authors support the 
surgical resection of tumor recurrences, 
others prefer the palliative oncological 
treatment.  

The authors of this study present a case 
series of glioblastoma recurrences – 185 
cases (143 patients), operated in our clinic 
between 1998 and 2012 by the senior 
author. The majority of patients (119 cases) 
underwent one operation for recurrences, 
18 patients have been operated for two 
times, 6 patients for three times and 3 



 
 
 
190         Abstracts         3rd National Conference of Neuro-Oncology (NCNO 2013)  

 
 
 

patients for four times. The surgical 
mortality in this series was 1,1 % (2 cases) 
and morbidity (new neurological deficits 
postoperatively) was 9,7% (18 cases). The 
medium survival time for recurrent 
glioblastoma was 6.5 months. The authors 
analyzed the risks and potential benefits of 
the microsurgical treatment for 
glioblastoma recurrences and tried to 
identify some preoperative criteria which 
predict a better postoperative outcome. 
Therefore, the authors correlated the 
postoperative results (mortality, morbidity 
and the medium survival time) with the 
following preoperative parameters: age, 
tumor location (dominant or nondominat 
hemisphere), tumor volume and extension 
(lobar, multilobar, and bilateral), mass 
effect with midline shift, Karnofsky 
preoperative score and associated diseases. 
Authors identify several preoperative 
criteria which were predictive for a better 
outcome in the microsurgical treatment of 
glioblastoma recurrence: age<70 years, 
location in non-dominant hemispheres, 
extension in one lobe, Karnofsky 
preoperative score>70.  

In conclusion, tumor resection should 
be considered for the majority of the 
patients with glioblastoma recurrences 
especially in those cases with age<70 years, 
tumor location in non-dominant 
hemispheres, non-infiltrative growth 
pattern of reoccurrence and symptoms 
related to tumor mass-effect. The goals of 
surgery for glioblastoma recurrences are 
tumor debulking, prolonging survival and 
family and social reinsertion. Careful 
selection of the patients, based on analysis 
of several specific preoperative criteria (age, 
location, mass-effect, Karnofsky score), is 
important in order to obtain a better 
outcome and a good quality of life.  

Key words: Recurrent glioblastoma, 
prognostic criteria, mortality, morbidity  

Paraneoplastic sensory neuronopathy – 
and the cochrane study results  
Wolfgang Grisold, Bruno Giometto, Roberta 
Vitaliani  

Department of Neurology KFJ Hospital, Vienna, 
Austria Neurologic department Treviso, Italy  

 
The classic paraneoplastic neuropathy is 

subacute sensory neuropathy (SSN). Other 
types of peripheral neuropathy in cancer 
occur but are less well characterized This 
review is based on cancer related PNS, and 
deliberately omits paraproteinemic 
neuropathies, as they are conventionally 
discussed as a separate entity.  

A Cochrane review discussed the 
therapeutic options in paraneoplastic 
neuropathy (Cochrane reviews:Treatment 
for paraneoplastic neuropathies - 2012) and 
came to the conclusion that presently no 
convincing therapies are available.  

Objectives: Paraneoplastic neuropathies 
occur in different types and tumor 
associations. The most characteristic 
syndrome is subacute sensory 
neuronopathy, which is usually a sensory 
ataxic neuropathy. Motor involvement is 
discussed , and has been found in about 30 
% in the EUROPNS study. Other types of 
neuropathies as sensory neuropathy, 
sensorimotor neuropathy, infl ammatory 
neuropathies have been reported in singular 
cases, but have not been consistently 
reported.  

Aims of study: The aim of the Cochrane 
review was the effect of tumor treatment or 
therapy of paraneoplastic neuropathy.  

Case report: The Cochrane 
Neuromuscular Disease Group Specialized 



 
 
 

 Romanian Neurosurgery (2013) XX 2: 180 – 213          191 

 
 
 

Register, CENTRAL (2012, issue 1), 
Medline January 1966-2013), EMBASE 
(January 1980- 2013) and LILIACS 
(January 1982- 2013) was searched for 
„paraneoplastic neuropathy“ and 
“treatment”. The following key words were 
used in conjunction with “treatment” and 
“therapy”: paraneoplastic neuropathy, 
paraneoplastic subacute sensory 
neuronopathy, paraneoplastic sensory 
ganglionopathy, paraneoplastic sensory 
neuropathy, paraneoplastic sensory motor 
neuropathy, paraneoplastic motor 
neuropathy, paraneoplastic immune-
mediated neuropathy, paraneoplastic 
polyradiculoneuropathy, paraneoplastic 
multiplex mononeuropathy, paraneoplastic 
autonomic neuropathies.  

Studies were accepted when other causes 
of cancer associated neuropathy had been 
ruled out and the diagnosis was based on 
symptoms, signs and NCV studies. All 
types of interventions as surgery, 
radiotherapy, chemotherapy, immune-
modulating (corticosteroids, IVIg, 
plasmapheresis, immunosuppressants), 
supportive care and physiotherapy were 
considered. The treatments could be use 
alone or in combination. We evaluated 
stabilization or improvement versus 
worsening of disability after treatment. The 
data were analyzed according to two 
categories of treatments: tumor and 
immunemodulating treatment.  

Results: Paraneoplastic neuropathies are 
rare and for this reason quality controlled 
studies on their treatment are diffcult to 
conduct. Most of the evidences is based on 
uncontrolled studies, case reports or expert 
opinion. In our search we found suffcient 
information on treatment of paraneoplastic 
neuropathy in 70 case reports, 12 case series 
(defined as a study with more than 3 

patients), and 17 papers based on expert 
opinion. Two categories of treatment were 
distinguished: tumor treatment and 
immunemodulatory treatment.  

Tumor treatment: In the case series a total 
number of 315 patients with peripheral 
neuropathies were reported. The total 
number of treated patients is not known, 
but we found that 26 patients improved 
with tumor therapy among eight of whom 
also received immunotherapy. From the 
analysis of cases reports we found that 49 
out of 70 patients received cancer treatment 
and 36 patients improved of whom 6 had 
also immunomodulatory treatment. In the 
case reports patients who improved after 
tumor treatment had heterogeneous tumors 
and neuropathy. The types neuropathies 
were: subacute sensory neuropathy (SSN), 
sensory motor neuropathy, sensory 
neuropathy, infl ammatory demyelinating 
neuropathy, and other entities in single 
cases.  

IVIG: From the analysis of the studies, 
cases series and case reports we identified 
43 patients who improved or stabilized with 
IVIG. This hast to be considered with care 
as the duration of the IVIG treatment, the 
ranking of improvement and detailed 
information on concomitant tumor 
treatment was soften missing.  

Plasmapheresis (PE): directly removes 
antineuronal antibodies of other factors 
from the circulation. Concerns in the use of 
PE in cancer patients involves the 
possibility that it will increase 
chemotherapeutic drugs clearance, once 
tumor treatment has been initiated. PE is 
not often used as a therapeutic approach for 
paraneoplastic neuropathy. We found 8 
patients with paraneoplastic neuropathy 
which seemed to be responsive to PE 
treatment.  



 
 
 
192         Abstracts         3rd National Conference of Neuro-Oncology (NCNO 2013)  

 
 
 

Steroids: are generally recommended for 
their effects on immune mediated 
disorders. We found 18 patients which had 
improved or stabilized after steroids. 
Limitations in understanding their efficacy 
comes from the fact that steroids were 
given at different dosage and schedules.  

Immunosuppressants: There is concern 
that the use of immunosuppressants in 
cancer patients favors tumor growth or 
enhances toxicity of cancer therapies. To 
date, however, this hypothetical concern 
has not been properly evaluated. 
Cyclophosphamide, azothiaprine, often in 
combination with steroids have been used, 
but no recommendations can be given 
based on our analysis.  

Conclusions: In conclusion the most 
promising treatment option is the 
identification and treatment oft he 
underlying tumor. The impact of the 
immunotherapy on paraneoplastic 
peripheral neuropathy is still unclear The 
reasons are the low number of patients 
treated, the combination of several 
interventions, and the concomitant cancer 
treatment. Moreover treatment experience 
is based mainly on case report, small case 
series or open labeled studies while 
randomized prospective studies are missing.  

Cancer around the brain  
Wolfgang Grisold  

Department of Neurology KFJ hospital, Vienna, Austria  
 
Objectives: Neurooncology is concerned 

with direct and indirect effects of cancer on 
the nervous system. The main clinical focus 
is intraparenchymatose diseases as primary 
brain tumors and brain metastasis. In 
addition meningeal involvement by cancer 
and extraparenchymatous tumors as 

meningioma. In addition to metastasis also 
toxic, metabolic, infectious and 
paraneoplastic have to be considered.  

Types of tumor spread: Cancer can 
metastasize into the cavernous sinus, dura, 
calvaria, the base of the skull, cavities as 
nasal sinus, orbit and also into tissues as the 
skin, and the soft tissue of the neck, where 
nerves can be affected by compression, 
invasion and rarely solid nerve metastasis.  

The complications of cancer in and 
around the skull are more heterogeneous 
then the well defined intraparenchymatouse 
metastasis and are usually a diagnostic, as 
well as a therapeutic challenge.  

Aims of study: The aim of this review is to 
define the mechanisms, sites and treatment 
of cancer metastasis occurring in the 
adjacent structures of the skull, and neck. 

Material and methods: The review is based 
on a selected literature research aiming at 
the key words of the surrounding structures 
of the brain, skull , in particular the base of 
the skull and neck. Own experience, based 
on observations and practical experience is 
added.  

Mechanisms: Nerves are can be damaged 
by cancer via compression, invasion and 
also by effects of treatment as surgery and 
radiotherapy. The particular mechanisms of 
nerve invasion have been classified into 
invasion, intranerval metastasis and antero- 
and retrograde spread. In solid tumors, the 
invasion of peritumoral nerves is 
considered as a bad prognostic factor.  

Results: Primary brain tumors: Usually 
primary brain tumors as glioma do not 
metastasize outside of the brain. The 
observations in the past years have shown, 
that metastasis, either to the lung or spinal 
seeding may be more often than previously 
expected. The invasion of adjacent 
structures as the meninges, the cavernous 



 
 
 

 Romanian Neurosurgery (2013) XX 2: 180 – 213          193 

 
 
 

sinus and the cranial nerves have been 
observed. Interventions as biopsies can seed 
the tumor and induce skin metastases.  

Brain metastases: several studies are 
ongoing to identify the best treatment of 
intracerebral metastasis. Recent years have 
shown, that due to improved systemic 
tumor treatment also cerebral metastases 
occur in cancer types as prostate or 
intestinal cancers, which previously had 
been considered unlikely.  

Meningeal involvement as meningeal 
carcinomatosis occurs in several cancer 
types and several studies have elaborated 
treatment, depending on the tumor type. 
The invasion or isolated metastasis into the 
dura, with or without osseous involvement 
occurs in several cancer types.  

Although meningioma is often 
considered as typical in neuroimaging, 
rarely also metastasis can appear as a 
meningioma mimick. Local extracerebral 
tumors can also compress the venous sinus.  

The base of skull metastasis can appear 
at several sites, and are usually classified 
according to the topography into orbital, 
parasellar, middle fossa, jugular foramen 
and occipital. They can be local or 
infiltrating invasive. Local pain, often in 
combination with cranial nerve 
involvement are the typical presentations.  

Within the skull not only the cavities as 
the orbits and sinus can be the side of 
cancer, but also mucous membranes and 
the skin. Propagation of cancer via 
retrograde spread has been demonstrated.  

The spread of cancer outside of the 
skull, in particular of ENT tumors, or 
metastasis can present with local pain 
syndromes, often projecting to the skull, 
cranial nerve lesions, and also compression 
and invasion of blood vessels.  

Conslusion: The spread of cancer in 

structures around the brain, in the skull and 
neck is important in clinical neurooncology 
and usually no standardized treatment 
schedule is available. The lesion of nerves 
and nerve plexus is often associated by a 
combination of local pain and peripheral 
nerve damage. Although the morphological 
patterns of nerve invasion have been 
described the pathophysiologic mechanisms 
need to be further elucidated.  

Molecular targeting of glioblastoma: 
new experimental perspectives  
Marc-Eric Halatsch, Georg Karpel-Massler  

Neurosurgery, University of Ulm School of Medicine, 
Ulm, BW, Germany  

 
Several candidate genes for resistance of 

human glioblastoma cell lines towards 
erlotinib, an epidermal growth factor 
receptor tyrosine kinase inhibitor, have 
recently been proposed. In the current 
study, we sought to examine the 
antiproliferative effect of additionally 
inhibiting two of these candidate resistance 
gene products, i.e., RAC1 and SMO, on 
glioblastoma cell lines with erlotinib-
sensitive, somewhat responsive and 
resistant phenotypes. Glioblastoma cell 
lines selected to represent the 
erlotinibsensitive, somewhat responsive and 
resistant phenotypes, respectively, were 
grown in 96-well plates and exposed to 
erlotinib, HhAntag (an inhibitor of SMO) 
and NSC23766 (an inhibitor of RAC1) in 
various combinations and concentrations. 
After 10 days of continuous exposure, 
inhibitory concentration 50 (IC50) values 
were determined using a cytotoxicity assay, 
and drug combination effects (i.e., 
synergism, additivity, or antagonism) were 
calculated using the Bliss equation. 



 
 
 
194         Abstracts         3rd National Conference of Neuro-Oncology (NCNO 2013)  

 
 
 

Antiproliferative synergism among 
erlotinib, HhAntag and NSC23766 was 
observed for the combination of erlotinib 
with either HhAntag or NSC23766 as well 
as for the combination of all three agents in 
both the erlotinb-sensitive and – to a lesser 
extent – in the somewhat responsive cell 
line. Importantly, in the erlotinib-resistant 
cell line, combinations of erlotinib plus 
HhAntag or NSC23766 or both acted 
antagonistically. In a system of human 
glioblastoma cell lines with sensitive, 
somewhat responsive and resistant 
phenotypes, this study is the first to identify 
erlotinib combined with inhibitors of 
RAC1 and SMO to synergistically inhibit 
proliferation in a priori erlotinib-sensitive 
and somewhat responsive cell lines. These 
results strengthen the role of multi-
targeting approaches in the development of 
more effective therapies for glioblastoma. 
The antagonistic action of erlotinib, 
HhAntag and NSC23766 in the erlotinib-
resistant cell line is counterintuitive and 
requires further clarification. Taken 
together, combinations of targeted agents 
may act differentially depending on the 
glioblastoma cell phenotype.  

Cerebral metastases  
Bogdan Iliescu, Ziyad Faiyad, Sergiu 
Gaivas, Daniel Rotariu, Ion Poeata  

3rd Neurosurgery “Prof. Dr. N. Oblu“ Clinical 
Emergency Hospital, Iasi, Romania  

 
Objectives: Brain metastases are common, 

occurring in 20-40% of cancer patients and 
contributing to 20% of annual cancer 
deaths. Brain metastases are particularly 
common among patients with non-small 
cell lung cancer (NSCLC), even at the time 
of diagnosis, accounting for approximately 

18-64% of all brain metastasis diagnoses. 
Overall prognosis of patients with brain 
metastases is limited, but has been shown to 
vary significantly, based on factors such as 
tumor histology, number of lesions, patient 
age and performance status.  

Material and methods: We present our 
experience in brain metastases treatment. 
We analyzed retrospectively a series of 70 
patients with cerebral metastatic 
involvement admitted to our department 
during 2011-2012. We present the 
particularities of our series in terms of 
demographics, attitude at admission, 
therapeutic options, surgical results, and 
subsequent management.  

Results: 32 patients underwent surgery, 
the rest being submitted to oncology for 
systemic treatment. Reasons for surgery 
included: solitary lesion with good general 
status, diagnosis, lesions that posed a vital 
risk. We discuss particular cases with rare 
localization or with atypical presentation 
and pathology findings  

Conslusion: Our review of the recent 
experience in the management of cerebral 
metastasis suggests, in accordance with the 
other published reports, that patients with 
neurometastatic disease represent a very 
polymorphic group. The decision making 
process has to be highly individualized for 
each case and should be a team effort, 
including neuroradiologists and 
oncologists.  



 
 
 

 Romanian Neurosurgery (2013) XX 2: 180 – 213          195 

 
 
 

Gliadel and MGMT methylation: is 
there a correlation with patient’s 
prognosis?  
Ralf Ketter1, Joachim Oertel1, Christoph 
Tschan1, Kai Kammers2, Steffi Urbschat1  

1Department of Neurosurgery, Saarland University, 
Homburg/ Saar, Germany; 2Faculty of Statistics, TU 
Dortmund University, Dortmund, Germany 

 
Clinical protocols combining local 

chemotherapy and concomitant 
radiochemotherapy have shown 
improvement of survival for patients with 
newly diagnosed malignant glioma. 
Histomorphological diagnosis is the most 
valuable tool for the classification of human 
tumors, but provides insufficient 
information concerning of therapy 
response. On the other hand, genetic data 
becomes more and more important. Our 
aim is to determine chromosomal 
alterations as well as the methylation status 
of MGMT, p15 (CDKN2B) and p16 
(CDKN2A) in order to analyse their infl 
uence on survival time, radioand 
chemotherapy response.  

In our trail 72 Glioblastoma patients 
were included, divided in two treatment 
groups: group A (36 patients) treated 
according the EORTC-Study and group B 
(36 patients) treated also according the 
EORTC-Study but receive additional local 
chemotherapy with Gliadel.  

Promoter hypermethylation of MGMT, 
p15 and p16 and CGH analysis were 
performed as described in standard 
protocols.  

Univariate cox regression showed 
prolonged survival time of patients with 
tumors harbouring deletions on 
chromosome 9p and 10q under 
chemotherapy treatment (p=0.0042). No 

significant effect was observed for gains on 
chromosome 7p.  

Promotor methylation MGMT in tumor 
tissue was not associated with prolonged 
overall survival (p=0.46). Promotor 
hypermethylation of p16 was also not 
correlated with prolonged overall survival 
(p=0.821), whereas p15 showed significant 
differences between both groups 
(p=0.0684).  

Although these results needs to be 
confirmed in larger series and under 
different treatment conditions, our 
retrospective study underlines that the 
tumor suppressor gene p15, involved in cell 
cycle control, can act as an attractive 
candidate for therapeutic approaches in 
glioblastomas.  

Prognosis of meningiomas in the 1970s 
and today  
Stefan Linsler, Jörg Rahnenführer, Urbschat 
Steffi, Ketter Ralf, Oertel Joachim  

Neurosurgery Saarland University Homburg Gemany  
 
Objectives: The benefit of the current 

strategy for diagnosis (computer 
tomography and magnetic resonance 
imagine) and treatment (microsurgery, 
microscope, endoscope) of meningiomas, 
in contrast to the standard treatment in use 
before CT- and MR-imaging and the 
microsurgical era, has not yet been 
determined.  

Aims of study: Our new 
planning/navigation system has been 
designed with practical necessity for easy 
modification with minimum cost. 
Accordingly, the support for new ideas 
from surgical side is possible with a simple 
but accurate realization.  

Material and methods: A retrospective 



 
 
 
196         Abstracts         3rd National Conference of Neuro-Oncology (NCNO 2013)  

 
 
 

statistical analysis was performed for 1349 
patients with meningiomas who underwent 
surgery at the Neurosurgical Department of 
the Saarland University between 1965 and 
2011.  

Results: There were no major differences 
in symptomatology, tumor localization, and 
number of surgical procedures. The mean 
time until tumor diagnosis was significantly 
shorter after 1985. A significant better 
prognosis for patients operated after 1980 
with regard to the postoperative duration of 
recurrence free survival could be revealed.  

Conslusion: Based on the results of this 
study, the time from diagnosis to treatment 
have been remarkably reduced within the 
last 30 years. Also the overall prognosis for 
patients with meningiomas has changed 
from the 1960s until today. Thus, the 
introduction of modern diagnostic 
modalities and surgical procedures has 
improved the outcome in patients with 
meningiomas signicifantly.  

Management of neurologic 
manifestations of primary brain 
tumors: the role of the neurologist  
Ioan Marginean  

Neurological Clinic II University of Medicine and 
Pharmacy “Iuliu Hatieganu” Cluj-Napoca, Romania 

 
The comprehensive care of patients with 

brain tumors involves a multidisciplinary 
team of specialists. Neurologists serve as 
valuable members of this team and bring a 
unique perspective to this 
approach.Complications in patients with 
brain tumors can result from the tumor 
itself (e.g., seizures), from treatment 
directed at controlling tumor growth (e.g., 
fatigue), or from treatments directed at 
controlling symptoms (e.g., 

corticosteroids). Seizures are the presenting 
sign in roughly 15-50% of patients 
diagnosed with gliomas. Levetiracetam is 
beneficial in patients with brain tumors 
with >50% reduction in seizure number in 
20/25 brain tumor patients, but there is no 
role for seizure prophylaxis in patients with 
newly diagnosed brain tumors. The risk of 
deep venous thrombosis (VTE) and 
pulmonary embolus is high for patients 
with brain tumors, especially gliomas. In 
general, pharmacologic anti-coagulation 
after the peri-operative period has not been 
recommended for cancer patients. 
Therapeutic anticoagulation for patients 
with VTE is widely accepted for at least 3 
months after first thrombosis, and can be 
considered for longer periods in patients 
who are good medical 
candidates.Thrombolytic therapy for VTE, 
is contraindicated in patients with 
intracranial malignancies. Improvements in 
MRI over the past two decades have 
increased awareness of spontaneous 
intratumoral hemorrhage within malignant 
gliomas. The risk of symptomatic 
intracranial hemorrhage during treatment 
has become an area of interest as anti-
angiogenic treatments have become 
available. Glucocorticoids are a mainstay of 
therapy for the cerebral edema associated 
with brain tumors. Decadron is the 
preferred glucocorticoid due to its long 
half-life and low mineralocorticoid activity, 
but other corticosteroids may also be used. 
Although these drugs are often required to 
treat increased intracranial pressure in 
patients with brain tumors, these drugs 
should be weaned as soon as possible to 
minimize side events. Hydrocephalus can 
develop as a late complication of treatment. 
The development of new headaches or a 
significant worsening of baseline headaches 



 
 
 

 Romanian Neurosurgery (2013) XX 2: 180 – 213          197 

 
 
 

should prompt an evaluation for 
hydrocephalus. Diversion of CSF is the 
standard treatment for hydrocephalus. 
While some superficial infections can be 
treated with antibiotics alone, many will 
require surgical drainage with intensive 
post-operative antibiotics. Pneumocystic 
jiroveci (PCP) pneumonia is a well-
recognized complication of patients with 
brain tumors. Prophylactic bactrim is safe 
and effective; alternatively dapsone or 
pentamidine. Fatigue directly affects quality 
of life by diminishing a patient’s ability to 
fully participate in personal, social, 
educational, and work related activities. 
Exercise remains the most reliable 
treatment for this common problem. 
Cognitive decline predicts tumor 
progression and may precede tumor 
progression by months.Behavioral 
interventions, such as cognitive behavioral 
therapy and compensatory strategies (e.g., 
keeping lists), are important tools . In 
addition, stimulants such as 
methylphenidate may improve cognitive 
dysfunction related to subcortical white 
matter changes. Palliative care focuses on 
supporting the patient’s physical, 
psychological, and social needs and is aimed 
at maximizing quality of life for patient’s 
and their families.  

Spinal ependymoma up to date  
Roxana Mittler-Matica  

Neurosurgery Department Klinikum Braunschweig 
Braunschweig Lower Saxony Germany  

 
Ependymomas are lesions with a 

moderate cell density, originating from the 
ependymal lining of the central canal of the 
spinal cord, ependymal cell clusters in the 
terminal filum, or from ependymal rests 

left during embryonic development. The 
pathophysiologycal mechanism it is 
traditionally thought to be an oncogenetic 
event that transforms the ependymal cells 
phenotype. There are studies that suggest 
that epigenetic silencing of tumor 
suppressor genes, through DNA 
methylation, is an important mechanism in 
the pathogenesis of ependymomas. The 
benign pathological nature of these 
tumours poses great difficulty in their early 
diagnoses and management. However, their 
compressive rather than infiltrative nature 
makes them amenable to surgical resection 
and the role of adjuvant radiotherapy and 
chemotherapy is still debated. Despite 
previous research, prognostic factors for 
ependymoma remain relatively 
controversial. Given the variety of 
localisation for this rare disease, the 
establishment of protocols for diagnostic or 
management is still a challenge. This paper 
proposes an updated overview regarding 
this challenging pathological entity.  

Introduction / Objective / Objectives: 
Ependymoma represent a relatively broad 
group of glial tumours which share a 
common origin from differentiated 
ependymal cells lining the ventricles of the 
brain or the central canal of the spinal cord. 
There are only about 230 spinal 
ependymomas diagnosed each year in the 
United States, yet they constitute the most 
common type of primary spinal cord 
tumors. Owing to the rarity of the disease, 
the literature regarding ependymomas in 
adults is scarce and limited to retrospective 
series. Thus, the level of evidence regarding 
therapeutic strategies is low and universally 
accepted guidelines are lacking. This broad 
group of glial tumors pose special problems 
regarding diagnostic and in many cases 
diagnostic is delayed. The patients with 



 
 
 
198         Abstracts         3rd National Conference of Neuro-Oncology (NCNO 2013)  

 
 
 

ependymoma of the filum terminale due to 
the difficulty of diagnosis are occasionally 
wrong labeled as psychosomatic or 
hypochondriac. Given the rarity of the 
disease there are no generally established 
management protocols, for operative 
treatment the general principles of surgery 
of the spinal cord tumors apply. After 
operative management 50% of patients with 
ependymomas experience immediate 
postop worsening in terms of sensory 
disturbances due to posterior column 
retraction. The benign pathological nature 
of these tumours poses great difficulty in 
their early diagnoses and management. 
However, their compressive rather than 
infiltrative nature makes them amenable to 
surgical resection and the role of adjuvant 
radiotherapy and chemotherapy is still 
debated. Despite previous research, 
prognostic factors for ependymoma remain 
relatively controversial.  

Aim / Aims / Aims of study: The objectives 
of this paper are to present the actual 
knowledge level about the subject, offer an 
integrative update based on the newest 
studies, draw common lines for possible 
future protocols and identify new research 
directions.  

Case report / Design / Background and aims: 
Ependymomas are classified based on the 
morphologic phenotype (cellular, papillary, 
tanycytic, clear cell, pigmented and 
epithelioid, giant cell ependymoma) or on 
the WHO tumour grading as it follows: low 
grade (grade 1 or 2), or high grade (grade 3 
or anaplastic). Compared with intracranial 
ependymomas, spinal ependymomas are 
less prevalent, occur in a younger 
population, and exhibit a better prognosis. 
The fourth decade of age seems at most risk 
and the sex distribution is equal although 
some studies report a slight male 

prevalence. In the lumbosacral region, 
ependymomas are most commonly 
associated with the conus medullaris and 
cauda equina, but can also occur 
extradurally in the sacrum, presacral tissues, 
or subcutaneous tissues over the sacrum, 
extradural epedymomas are extremely rare 
entities. The clinical presentation can 
broadly vary according to location. Diffuse 
dull pain constantly increasing due regional 
impediment of venous outfl ow is worse at 
night or upon awakening. When contact 
with nerve roots the pain becomes of a 
burning or fulgurant character and may 
irradiate radicularly. Tactile and pain 
sensation are usually affected first because 
of the central topography of these tumors. 
Motor deficits and pathological refl exes are 
also depending on the tumor location. MRI 
is the radiological exam of choice, either for 
surgical planning or to rule out differential 
diagnosis. Current efforts being made to 
identify the pathophysiology of this disease 
suggest that epigenetic silencing of tumor 
suppressor genes, through DNA 
methylation, is an important mechanism in 
the pathogenesis of supratentorial and 
spinal ependymomas. There appears to be a 
consensus for radiation therapy in cases of 
subtotal resections of intradural tumors 
although the role of adjuvant therapy in 
subtotal resection is controversial.  

Patient and methods / Material and methods / 
Methods / Purpose: This paper is based on the 
review of relevant literature on spinal 
ependymoma. The latest studies converge 
to some key points usefull in helping the 
clinician to establish the best therapy option 
for each case.  

Results / Result: One interesting aspect of 
ependymoma is the pathophysiological 
mechanism; one theory assumes that 
ependymal cell rests arise from the 



 
 
 

 Romanian Neurosurgery (2013) XX 2: 180 – 213          199 

 
 
 

coccygeal medullary vestige, a remnant of 
the dural part of the terminal filum that 
involutes during embryonic development. 
Others authors assume that these 
ependymal rests occur as a result of 
incomplete closure of the neural arch. 
Ependymoma has been characterized at the 
DNA copy number and mRNA expression 
levels and was associated with an increase in 
expression of genes encoding for proteins 
involved in methylating DNA. Genes 
involved in the control of cell growth and 
death and the immune system including 
members of the JNK pathway seem to play 
an important role. Genetic and 
transcriptional differences between tumors 
arising in different locations have been 
described. Studies report that members of 
the c-Jun N-terminal kinase (JNK) 
signaling pathway; MAPK10 and MAP3K1 
display hypermethylation in spinal 
ependymoma but they are not specific. 
CD99 monoclonal antibody could 
differentiate between ependymomas and 
nonependymal tumors, and so act as a 
marker but was of no consequence in 
determining the variant type or degree of 
histologic aggressiveness. In some studies is 
reported that over two thirds of the patients 
had experienced symptoms for more than 6 
months before diagnosis. Also patients who 
had tumors involving the spine had 
symptoms for a significantly longer time 
than patients who had ependymomas 
involving the brain. Dissemination 
evidence of ependymoma cells into the 
cerebrospinal fl uid CSF fl uid examination 
is a key factor in staging, prognosis, and 
treatment and allthough intradural 
ependymomas can spread throughout the 
CNS they are not likely to metastasize 
outside it. A neuro-axis MRT study is 
recommended to rule out tumor 

dissemination. The optimal treatment for 
intramedullary spinal tumors is 
controversial. Current therapeutic options 
include surgery, radiation therapy, 
chemotherapy, or a combination of these 
modalities. Stereotactic radiosurgery for 
intramedullary spinal tumors is feasible and 
safe in selected cases. Resection and 
conventional radiation therapy are 
associated with potential morbidity and so 
there is no optimal treatment established. 
Some studies suggest that radiation therapy 
among adults might be somewhat 
deleterious to survival. Age at diagnosis 
appears to be a strong predictor of the 
outcome of those patients according to 
some authors, tumor histology was more 
infl uential in adults than children, and 
complete resection was the most effective 
treatment option, regardless of age.  

Conclusion / Conclusions: Multicentric 
studies could be a solution for getting a 
better insight on the spinal ependymoma 
complex problematic. For small tumors 
with no or little neurological deficit there is 
a tendency for conservative management 
with multiple follow up imaging studies. 
Even if the diagnostic is not histologically 
established the conservative strategy is more 
often adopted in clinical practice due to the 
high risks correlated with the operation. 
For high cervical lesions the indication for 
surgery is even more difficult given the 
possible complications of spinal injury 
caused by the operation. Adequate 
knowledge of anatomy and the correct use 
of microsurgical techniques allow total 
resection of some tumors with minimal 
morbidity and maximum functional 
recovery. There are no studies focused on fl 
uorescence assisted microsurgical 
extirpation for spinal ependymoma. Cranial 
ependymomas are often being 



 
 
 
200         Abstracts         3rd National Conference of Neuro-Oncology (NCNO 2013)  

 
 
 

administrated a fl uorescent substance 
preceding the operation in order to allow a 
better demarcation of the tumor 
intraoperatively. A possible practical study 
direction can be establishing if fl uorescence 
is an efficient means to improve 
postoperative outcome for extended 
intraspinal ependymomas.  

Clinical behavior and outcome of optic 
pathway gliomas in children  
Emilia Mihut, Rodica Cosnarovici, Stefania 
Neamtu, Popita V., Anca Dumitrovici, 
Dana Cernea  

Oncological Institute “Prof. Dr. I.Chiricuta” Cluj-
Napoca, Romania 

 
Background: Tumorsof the optic 

pathways comprise 4-6% of pediatric 
intracranial tumors and may have a more 
aggressive course in younger children.  

Methods: In the present study we 
retrospectively reviewed the clinical 
characteristics, treatment and outcomes of 
15 children diagnosed with optic pathway 
gliomas (OPG) between 2000 and 2010.  

Results: The age range of the children at 
diagnosis was 11 months to 17 years (mean 
8.1 years). The male/female ratio was 8/7. 
Presentation included: decline in visual 
acuity (53%), headache (27%), proptosis 
(13%) and seizures (7%).Forty per cent of 
the children with OPG had 
neurofibromatosis type 1 (NF1). 
Treatments included various combinations 
of surgery, chemotherapy and radiation. 
Biopsy was not performed in two cases. 
Five children were treated with 
chemotherapy alone, three with 
radiotherapy, threewith combined 
treatment, while four children were 
observed. After a median follow-up of 6 

years, 12 patients are alive with stable 
disease.  

Conslusion: Despite the benign histology 
of optic pathway gliomas, its biological 
behavior is unpredictable. Because of 
difficulties in defining progression and 
generally variable natural history the most 
favorable management of optical pathway 
gliomas is still controversial. Association of 
NF1 is a favorable prognostic factor, these 
tumors tended to be less aggressive in NF1 
patients.  

Aspects of microsurgical treatment of 
craniospinal, cervico-medullary and 
cervical intramedullary tumors  
István Nyáry, Péter Banczerowski  

Semmelweis University Medical School, Department of 
Neurosurgery Budapest, Hungary 

 
Surgical removal of intrinsic medullary 

tumors still make a challenge at any level of 
the spinal cord including the cauda equina, 
because of the risk inherent with surgical 
manipulation. This risk is even more 
enhanced within the cervical, 
cervicomedullary region.  

Patient material: In the period between 
1985 – 2005 we operated 216 cases of 
intramedullary lesion with different 
pathologies (108 ependymomas, 58 
astrocytomas, 14 hemangioblastomas, 15 
cavernomas, the others less frequently 
occurring pathologies), and 50%, 108 
affected the cervical spinal cord, as well. 
Within the cervical group two subgroups 
could be differentiated: cervico-medullary 
and high cervical, and low cervical, cervico-
thoracic group, roughly in two third-one 
third proportion, considering the frequency 
of occurrence.  

Surgical strategy and techniques: Only well 



 
 
 

 Romanian Neurosurgery (2013) XX 2: 180 – 213          201 

 
 
 

delineated, circumscribed tumors could be 
operated radically, and with good success. 
Contrast enhanced MRI was the most 
important factor in predicting operability. 
Radical removal was avoided in cases of 
diffuse, infiltrative tumors, instead 
decompression, biopsy, and radiotherapy 
was done. At surgery bony exposure was 
kept at minimum, using a wide spectrum of 
minimally invasive approaches and standard 
microsurgical techniques were applied. In 
the high cervical group special 
postoperative intensive care was needed due 
to respiratory and lower cranial nerve 
problems. Rehabilitation was also necessary 
in most of the cases.  

Results: Outcomes were measured 
according to the McCormick classification. 
According to our follow-up survey, most of 
our patients are still alive, if the underlying 
pathology permitted. The longest survival is 
20 years, 18 had died on various reasons.  

Conclusion: Surgery should be done as 
soon as possible, in spite of the risks, since 
quality of life depends on the preoperative 
state. Therefore, we adopted an aggressive 
surgical strategy, and gros total removal was 
the goal to be achieved. Radiotherapy was 
applied depending on histology, and 
rehabilitation was followed after radical 
surgery.  

The brain tumour patient and 
caregiver: what is important for the 
journey?  
Kathy Oliver  

International Brain Tumour Alliance (IBTA) 
Tadworth, Surrey United Kingdom  

 
Brain tumours are one of the most 

devastating of diagnoses. Whether benign or 
malignant, primary or secondary, they strike 

at the very core of who a person is, affecting 
not only physical abilities, but an 
individual’s cognitive and psychosocial 
aspects as well.  

One of the most notable things about 
brain tumours is that they intersect three 
major disease areas: cancer, neurological 
disease and rare disease.  

Brain tumours are no respecter of race, 
religion, sex, age or geography. They strike 
people around the globe indiscriminately, 
and present a formidable enemy in any 
language.  

Brain tumour patients and their 
caregivers face many medical, social and 
psychological challenges.  

But there are also other challenges for 
brain tumour patients and their caregivers 
beyond the medical ramifications – political 
and financial challenges which impact on 
each and every person on this journey.  

This presentation will include a 
discussion of these challenges as well as 
observations from the “coalface” as the 
speaker brings to the topic her own 
personal experiences as a caregiver to her 
young adult son Colin who was diagnosed 
with a grade two astrocytoma in 2004 at age 
24 and passed away seven years later, in 
2011, at age 32 from a glioblastoma 
multiforme. This presentation will also 
focus on the role of brain tumour patient 
support organisations and the brain tumour 
caregiver.  

Intracranial hemangiopericytomas lack 
typical cytogenetic and epigenetic 
features of meningiomas and gliomas  
Samuel Ige Orie, Dennis Kraemer, Ralf 
Ketter, Joachim Oertel, Steffi Urbschat  

Department of Neurosurgery, Saarland University, 
Homburg/ Saar, Germany 



 
 
 
202         Abstracts         3rd National Conference of Neuro-Oncology (NCNO 2013)  

 
 
 

Objective: Intracranial hemangioperi-
cytomas (cHPC) are rare tumors of 
mesenchymal origin with a high proclivity 
towards recurrence and extraneural 
metastasis. Total tumor resection is the 
main treatment of choice due to its 
radiochemical resistant nature. Considering 
the paucity of reports dealing with the 
tumor genetics and epigenetics of cHPC 
and the still ongoing debate over their 
histological standing, we examined a series 
of 9 cHPC for known important 
meningioma and glioma specific 
cytogenetic and epigenetic aberrations.  

Methods: In a total of nine 
histopathologically confirmed cHPC, this 
study evaluated the promoter methylation 
status of MGMT, p15(CDKN2B), 
p16INK4A, TIMP3 and NDRG2 genes 
which have been shown to be epigenetically 
altered in gliomas and meningiomas, 
respectively. Typical numerical 
chromosomal aberrations reported in 
gliomas and meningiomas were investigated 
using two-color fl uorescent in situ 
hybridization (FISH) on touch-
preparations with locus specific probe pairs 
detecting 1p36/22q11, 14q24/18q21, and 
9p21/10q23. Additionally, conventional 
comparative genomic hybridization (CGH) 
was performed to access genomic 
imbalances.  

Results: All studied cases presented with 
an unmethylated status of the MGMT, p15 
and TIMP3 promoters. One specimen was 
encountered with positive methylation 
signal for p16 in methylation specific PCR 
analysis. Direct bisulfite sequencing for 
NDRG2 revealed only in 1 of 6 cases a 
moderately elevated average methylation 
degree. In FISH analyses, disomy for all 
targeted chromosomal regions was found in 
5 of 9 studied cHPC specimens; in two 

tumors an oligocellular clone with 
hemizygous loss of 10q23 was detected. In 
one other specimen, virtually all nuclei 
harbored a hemizygous deletion of 9p21. 
One further cranial hemangiopericytoma 
was characterized by a tetraploid mainline 
with slight sidelines that contained 
trisomies of 9p21 and 10q23. CGH analysis 
showed a chromosomal imbalance in all 
nine specimens involving loss and or gains 
of partial or complete chromosome 
segments. The one cHPC specimen that 
presented with positive methylation for p16 
harbored the hemizygous deletion of 9p21 
with corresponding loss of chromosome 9p 
in CGH.  

Conclusions: This work shows that cHPC 
obviously lack glioma and meningioma 
specific epigenetic and molecular 
cytogenetic lesions, further providing 
evidence that cHPC represent a distinct 
tumor entity with different genetic features. 
These present findings prompt one to 
speculate on the possible role of the 
inactivation of p16INK4a, and deletions on 
chromosome 9p in the underlying 
tumorigenesis of a subgroup of cranial 
hemangiopericytomas.  

Controversies in pathological bone 
fracture of the spine  
Stanca Ples  

Neurosurgery Department County Hospital Timisoara 
Romania  

 
New imaging technologies offer for 

neurosurgeons important preoperative and 
postoperative data for spinal fractures. It is 
possible now to make the differential 
diagnosis for pathological bone fracture, to 
distinguish the tumoral from osteoporotic 
fractures. The new MRI techniques we 



 
 
 

 Romanian Neurosurgery (2013) XX 2: 180 – 213          203 

 
 
 

currently use in Neurosurgical Clinic, 
County Hospital Timisoara are: diffusion 
weighted image(DWI) and spectroscopy 
(H-MRS) MRI SPECTROSCOPY – can 
evaluate intra-lesional components 
(metabolites). Offers the opportunity for 
establishing differential diagnosis (infl 
ammatory, tumoral, osteoporosis) 
DIFFUSION WEIGHTED IMAGING 
(DWI)-is using the water diffusivity 
properties; the ADC coeffcient is very 
different in osteoporotic comparing with 
tumoral fractures, helping in differential 
diagnosis. Acquisitions are made with 1,5 T 
MRI, SIEMENS, Avanto. We have 
examined 15 pacients with pathological 
bone fracture of spine: 10 osteoporotic and 
5 neoplasic fractures. 13 pacient needed 
surgery and we have anatomo-pathological 
examination for this patients.. Conclusions: 
Using new imaging technologies we can , 
with 86% sensitivity of this methods, to 
establish the metabolic lesional 
components. Our study make the 
differential diagnosis in pathological bone 
fractures using diffusion and MR 
spectroscopy.  

Introduction: New imaging technologies 
offer for neurosurgeons important 
preoperative and postoperative data for 
spinal fractures. It is possible now to make 
the differential diagnosis for pathological 
bone fracture, to distinguish the tumoral 
from osteoporotic fractures. The new MRI 
techniques we currently use in 
Neurosurgical Clinic, County Hospital 
Timisoara are: diffusion weighted 
image(DWI) and spectroscopy (H-MRS)  

Aim: To evaluate if it is possible now to 
make the differential diagnosis for 
pathological bone fracture, to distinguish 
the tumoral from osteoporotic fractures.  

Case report: We have examined 15 

patients with pathological bone fracture of 
spine: 10 osteoporotic and 5 neoplasic 
fractures. 13 patient needed surgery and we 
have anatomo-pathological examination for 
this patients.  

Material and methods: MRI 
SPECTROSCOPY – can evaluate intra-
lesional components (metabolites). Offers 
the opportunity for establishing differential 
diagnosis (infl ammatory, tumoral, 
osteoporosis) DIFFUSION WEIGHTED 
IMAGING (DWI)-is using the water 
diffusivity properties; the ADC coefficient 
is very different as value in osteoporotic 
comparing with tumoral fractures, helping 
in differential diagnosis.  

Results: Using new imaging technologies 
we can, with 86% sensitivity of this 
methods, to establish the metabolic lesional 
components of bone fractures of spine.  

Conclusion: Our study succeed to make 
the differential diagnosis in pathological 
bone fractures using diffusion (DWI) and 
MR spectroscopy MR techniques.  

Cerebral metastases-preoperative 
diagnostic, possible or not?  
Stanca Ples  

Neurosurgery Department County Hospital Timisoara 
Romania  

 
New development in imaging 

technologies brings for neurosurgeons 
important preoperative and postoperative 
prospects for intracranial lesions and 
especially for cerebral metastatic disease 
evaluation. The new MRI techniques we 
currently use in Neurosurgical Clinic, 
County Hospital Timisoara are: DTI 
(diffusion tensor imaging), DWI(diffusion 
weighted imaging ), cerebral spectroscopy, 
SWI (susceptibility weighted imaging), 



 
 
 
204         Abstracts         3rd National Conference of Neuro-Oncology (NCNO 2013)  

 
 
 

cerebral perfusion(PWI) DTI (diffusion 
tensor imaging)- MRI techniqueapplication 
is useful for localizing white mater tracts in 
relation with intracranial lesions, MRI 
SPECTROSCOPY – can evaluate intra-
lesional components (metabolites). Offers 
the opportunity for establishing differential 
diagnosis (ischemic, infl ammatory, 
tumoral). In tumor pathology it is used to 
establish tumoral grading, and to 
differentiate the metastatic from primary 
cerebral tumors. SWI (susceptibility 
weighted imaging) - a very new sequence in 
MRI which evaluates magnetic properties 
of blood, iron and other structures. Now it 
is used for diffuse axonal injuries, micro 
bleeds, angiogenesis in tumors, venous 
angiomas (slow fl ow vessels). Acquisitions 
are made with 1,5 T MRI, Avanto in 
â€oeNeuromed â€oe Diagnostic Image 
Center Timisoara. Conclusions: Using new 
imaging technologies we can , with 95% 
sensitivity and 91% sensibility of this 
methods, to establish the metabolic lesional 
components. Our study tries to make the 
difference in cerebral lesional evaluation of 
primary cerebral tumors from metastatic 
cerebral lesions.  

Introduction: New development in 
imaging technologies brings for 
neurosurgeons important preoperative and 
postoperative prospects for intracranial 
lesions and especially for cerebral metastatic 
disease evaluation. The new MRI 
techniques we currently use in 
Neurosurgical Clinic, County Hospital 
Timisoara are: DTI (diffusion tensor 
imaging), DWI (diffusion weighted 
imaging), cerebral spectroscopy, SWI 
(susceptibility weighted imaging), cerebral 
perfusion (PWI).  

Aim: Our study tries to make the 
difference in cerebral lesional evaluation of 

primary cerebral tumors from metastatic 
cerebral lesions.  

Case report: Our study is made for 30 
patients with secondary cerebral tumors.  

Material and methods: Acquisition is made 
with 1,5 T MRI in â€oeNeuromed â€oe 
Diagnostic Image Center Timisoara. Used 
MRI techniques are: DTI (diffusion tensor 
imaging) - MRI technique-application is 
useful for localizing white mater tracts in 
relation with intracranial lesions, MRI 
SPECTROSCOPY – can evaluate intra-
lesional components (metabolites). Offers 
the opportunity for establishing differential 
diagnosis (ischemic, infl ammatory, 
tumoral). In tumor pathology it is used to 
establish tumoral grading, and to 
differentiate the metastatic from primary 
cerebral tumors. SWI (susceptibility 
weighted imaging ) - a very new sequence 
in MRI which evaluates magnetic 
properties of blood, iron and other 
structures. Now it is used for diffuse axonal 
injuries, micro bleeds, angiogenesis in 
tumors, venous angiomas (slow flow 
vessels).  

Results: Using new imaging technologies 
we can, with 95% sensitivity and 81% 
specificity of this methods, to establish the 
metabolic lesional components.  

Conclusion: Using new imaging 
technologies we can, with 95% sensitivity 
and 81% specificity of this methods, to 
establish the metabolic lesional 
components. Our study tries to make the 
difference in cerebral lesional evaluation of 
primary cerebral tumors from metastatic 
cerebral lesions.  



 
 
 

 Romanian Neurosurgery (2013) XX 2: 180 – 213          205 

 
 
 

Follow-up in operated and non-
operated low grade gliomas  
Stanca Ples 

Neurosurgery Department County Hospital Timisoara, 
Romania  

 
The follow-up in low grade gliomas can 

be accomplished in very good condition 
establishing protocols for each category of 
cases: operated and non -operated patients. 
In our clinic we have a 5 years followed -up 
150 low grade gliomas: 85 operated, 65 non 
-operated. The protocol in this moment is 
:in first year, every 3 months conventional 
cerebral MR, in 2-nd and 3-d year every 6 
month conventional MR, after that every 
year conventional cerebral MR. In every 
year we have a imaging neurodiagnose MRI 
made with spectroscopy, diffusion, 
perfusion and swi. Those protocols brings 
better results in this low grade gliomas 
follow-up. We can appreciate that by 
following this protocol. We can see the 
moment when this gliomas turn into high 
grade and we appreciate the moment of 
recurrence in post surgical cases.  

Introduction: The follow-up in low grade 
gliomas can be accomplished in very good 
condition establishing protocols for each 
category of cases: operated and non -
operated patients.  

Aim: The aim of our study was to share 
our experience in this diffcult follow -up of 
low grade gliomas.  

Case report: In our clinic we have in 5 
years followed-up 150 low grade gliomas: 
85 operated, 65 non-operated. The protocol 
in this moment is: in first year, every 3 
months conventional cerebral MR, in 2-nd 
and 3-rd year every 6 month conventional 
MR, after that every year conventional 
cerebral MR.  

Material and methods: In every year we 
have a neurodiagnostic imaging MRI made 
with spectroscopy, diffusion, perfusion and 
swi.  

Results: Our results were good, better 
than before this period of non protocoled 
follow up in low grade gliomas.  

Conclusion: We can appreciate that 
following this protocol we can see the 
moment when this gliomas turn in high 
grade, and to appreciate the moment of 
recurrence in post surgical cases.  

Common igs planning support for 
frame-based stereotaxy and frameless 
navigation  
Ferenc Pongracz, Istvan Valalik  

Department of Neurosurgery St. Johnas Hospital, 
Budapest Hungary  

 
Our Vister3D system is a new prototype 

of planning platform for frame-based and 
frameless stereotactic interventions which 
integrates most important elements of 
image guided navigation. According to 
general opinion, the frame-based systems 
have the advantage of proven clinical utility 
and instrument carriage with a high degree 
of mechanical stability and accuracy. 
Frameless methods are more complex, but 
also very fl exible, and have already many 
applications in general neurosurgery. In 
general, comparisons until now have been 
limited between different planning 
platforms and different surgical sessions, 
utilizing commercial neuronavigation 
systems. Vister3D planning platform 
integrates calculations for arc-based 
stereotactic frames (Riechert-Mundinger 
and MHT, Freiburg, Germany) into 
frameless neuronavigation environments. 
The system communicates with Polaris-



 
 
 
206         Abstracts         3rd National Conference of Neuro-Oncology (NCNO 2013)  

 
 
 

type cameras (Northern Digital Inc, 
Canada); registers surgical space to 
diagnostic images and visualizes tracked 
devices in volumetric and surface views. 
During frame-based stereotaxy, rigid 
reference system (marker plates) with 
recognizable landmarks in images, are used 
to align stereotactic space with imaging 
volume. The integrated platform is 
supported by detailed data parsing (for 
DICOM and NIFTI images, as well as 
archive studies), CT-MR fusion algorithm 
(with subvolume targeting) and different 
3D visualizations. The system is designed 
to determine the geometrical overlap of 
targeting, carried out, either in stereotactic 
space of the arc-based frame, or in moving 
reference space of the navigation platform. 
The main challenge in comparison is to 
have computations of identical rules for 
both environments. Therefore, Vister3D 
uses strictly 3D-based algorithms to get 
projection transform between any two 
coordinate spaces, that guarantees full 
transparency between frame-based and 
frameless techniques.  

Objectives: The main motivation of this 
work is to develop a common IGS (image-
guided surgical) platform which is suitable 
for sharing surgical planning data in frame-
based stereotaxy and frameless, navigated 
brain surgery. The comparison until now 
has been based on planning with different 
platforms and review of associated variables 
of both techniques. In biopsy the final 
outcomes are compared by pathology 
diagnostic accuracy and (in electrode 
placement as well) immediate post-
operative CT imaging. The eligibility of 
frameless technique depends on target size, 
anatomical location, with an ongoing debate 
on un-quantifiable variables which 
ultimately infl uence technique selection 

(anesthesia, size of craniostomy, diagnostic 
yield, etc).  

Aims of study: Our new 
planning/navigation system has been 
designed with practical necessity for easy 
modification with minimum cost. 
Accordingly, the support for new ideas 
from surgical side is possible with a simple 
but accurate realization.  

Case report: Vister3D is usable for 
planning target and entry positions for DBS 
electrodes and sampling parameters along 
the path of biopsy needle. After graphical 
planning the surgeon can proceed with 
frame-based stereotaxial intervention or 
frameless navigation technique. The 
frameless method can be turned into 
different tracking modes supporting 
diagnostic needs during surgeries (tumor 
resection support, 3D localization of 
features, etc).  

Material and methods: In our approach, 
common IGS platform integrates fusioned 
CT and MR images and standard 3D 
planning tools for target trajectory. The 
electrode placement or biopsy techniques 
include Riechert-Mundinger or MHT 
(Freiburg, Germany) stereotactic frames. 
The IGS platform is able to calculate 
parameter settings for these frames with a 
newly developed algorithm providing for 
3D transforms between diagnostic space, 
stereotactic space and patient local reference 
(AC-PC). Moreover, the platform 
communicates with Polaris Spectra and 
Vicra optical tracking devices (Northern 
Digital, Inc.) and registers surgical space to 
diagnostic data. Alignment tests of frame-
based and frameless geometries are 
possible: 1/ Static: calibration procedures 
have been used to find the origin and axes 
direction of the arc-based system within the 
frameless reference. By collecting samples 



 
 
 

 Romanian Neurosurgery (2013) XX 2: 180 – 213          207 

 
 
 

from the frame geometry (with the pointer 
of navigation system), statistical calculation 
gives an estimate for location/orientation of 
stereotactic space within the frameless 
environments. 2/ Dynamic: display/refresh 
polar coordinates for actual position of 
navigated device. The actual navigated 
position has been registered in CT volume 
and projected into stereotactic space using 
the registration transform of stereotactic 
space. After it, - if the tracked device 
crossed distance of planned entry from the 
arc-surface, the device tip has been set as 
target position, and the cross point used as 
entry point and the polar settings 
continuously updated with these points.  

Results: Vister3D now is routinely used 
in planning trajectories for DBS electrode 
placement and biopsy sampling. Number of 
frame-based stereotactic surgeries 
performed by the system now is close to 50. 
The planning procedure is very 
straightforward and easy to follow, thanks 
to the hierarchical workfl ow implemented 
in the system. The subvolume-targeted 
CT-MR fusion is found usable in finding 
the most accurate MR registration when 
compared to fusion with the whole 
volumes. Stereotactic planning of target 
trajectory can follow steps known in the 
frame-based technique (finding the polar 
settings for DBS electrode or biopsy needle 
in frame reference), or can use the interface 
for frameless neuronavigation system. 
These results have been compared, and in 
some cases the electrode movement was 
detected by optical tracker and displayed 
with frame-based, planned data. In this 
tracking mode, the system converted the 
actual location/orientation of device into 
polar coordinates and, in parallel, visualized 
the model in CT volume. The difference 
between the planned and actual polar 

settings was tested. This difference proved 
to be very sensitive to the device calibration 
accuracy (i.e. the transform from tool 
sensor space to device coordinate space).  

Conclusions: Novel 3D algorithm has 
been implemented for frame-based 
stereotactic planning, which follows the 
rules known in frameless neuronavigation. 
This approach could help in a unified 
treatment of both techniques and can make 
the interpretations (at least) 
computationally transparent. Direct 
comparison of surgeries using frame-based 
stereotaxy with sensor tracking approach is 
possible with this development. Critical 
issue is the device calibration i.e. the 
accuracy of transform between the DBS 
electrode or biopsy needle geometry and 
the attached sensor’s space. Further 
work is needed to explore more meaningful 
applications of the system.  

Cauda equina cavernoma:clinical case 
prezentation and rewieu of the genetic 
findings  
George Popescu1, Popescu Mihai2, Grigorean 
V.T.1, Strambu V.4, Popescu Irina6, Miclea 
Gabriela5, Mihalache George2, Popescu 
Georgeta Maria6  

1Spitalul Clinic de Urgenta “D. Bagdasar-Arseni”, 
Bucuresti; 2Spitalul Judetean de Urgenta Pitesti; 
3Spitalul Clinic de Urgenta “Sf. Pantelimon”; 4Spitalul 
Clinic “Carol Davila”; 5Spitalul Orasenesc Campeni; 
6Spitalul Clinic de Urgenta “Sf. Ioan”  

 
Objectives: To present an rarely 

encountered case, diagnosed and operated 
in the Neurosurgery Department of Pitesti 
of a patients with cauda equina cavernoma, 
which is the 15th worldwide case cited in 
the literature.  

Material and methods: We present 
differential diagnosis in terms of clinical 



 
 
 
208         Abstracts         3rd National Conference of Neuro-Oncology (NCNO 2013)  

 
 
 

and imaging, and surgical technique 
approached and post-operative results. It is 
about 60 years old patient hospitalized for it 
atrocious lumbar pain, paravertebral muscle 
contraction associated with bilateral 
lombosciatica, relatively poorly 
systematized, installed after a heavy lifting 
exercise. Simple X-ray orients us toward 
disc pain,highlighting a pinched L5-S1 disc 
space and posterior osteophytes at this level. 
We performed a lumbar spine CT 
highlighting an area of spontaneous 
hiperdensitay apparently intradural, at L4, 
followed by MRI showing a well defined 
formation in T1 hipersemnal with areas of 
hemosideria located at the cauda equina 
level. We intervened surgically, ablation 
being performed entirely under the 
operator microscope of a purplish tumor, 
well defined, with diameter about 1.5 cm, 
developed between ponytail roots at L4 
level Complete clinical remission after 
surgery.  

It is a benign hamatom with vascular 
origin, occurring forms involving sporadic 
or familial forms of vascular malformations 
with autosomal – dominant transmission. 
Etiology is unknown.In sporadic forms that 
implies a solitary cavernoma a contributinf 
factor that could induce cavernomas is 
radiotherapy. Family forms involving two 
or more cavernoame occur in 50% of 
Hispanic patients and 10-20% in the 
Caucasian population. We identified 
mutations in 3 genes, with diferent loci 15:  

1. CCM 1 on chromosome 7q 21.2, 
KRITI-1 gene increases endothelial 
proliferation;  

2. CCM2-15-p13 on chromosome 7p, 
MGC 4607 gene-role in the cellular 
response to osmolar insults. Togheter with 
gene located on p 38 MAPKs give signals 
for modeling and vascular maturation;  

3. CCM3 on chromosome 3q25.2- -q27, 
the gene that encodes 212 amino acids 10 
PDCD with role in apoptosis (a small 
muscle cells). In our case we didnt had the 
possibility to perform genetic studies.  

Conclusions: Cavernoimas found at the 
cauda equina lelvel is exceptional, this 
beeing only the 15th case publied in 
literature Clinical symptoms include 
sphincter disturbances, motor and 
sensitivity acusses, our case having a totally 
atypical symptomatology. In our opinion, 
acute symptoms of the disease were caused 
by intratumoral bleeding, confirmed by 
histopathological examination. In terms of 
surgery our approach is through 2-level 
laminectomy, opening dura mater and 
cavernoma dissection grom cauda equina 
roots.   

Treatment of peripheral nerve tumors 
- multidisciplinary approach  
Lukas g. Rasulik, Miroslav M. Samardzic, 
Vladimir Lj. Bascarevic, Mirko V. Micovic, 
Irena S. Cvrkota, Jelena D. Zivanovic, 
Bojana M. Zivkovic  

Department for peripheral nerve surgery, functional 
neurosurgery and pain management surgery 
Neurosurgical Clinic, Clinical Centre of Serbia Belgrade, 
Serbia 

 
Objectives: Peripheral nerve tumors are 

relatively rare lesions. Most of these tumors 
are benign lesions built from the neural 
sheath cells: Schwann cells, perineurial cells 
and fibroblasts.  

Aims of study: Aim of this paper is to 
present and analyze results of treatment of 
peripheral nerve tumors of all patients 
treated in our clinic during last ten years.  

Case study: In this study, we included all 
patients treated in our Clinic, during last 



 
 
 

 Romanian Neurosurgery (2013) XX 2: 180 – 213          209 

 
 
 

ten years, who have been admitted for 
surgical treatment of peripheral nerve 
tumor. Relevant data about every patient, 
diagnostic procedures, course of treatment 
and outcome, has been collected through 
detailed analysis of 39 patient histories.  

Material and methods: We analyzed 
demographic data, clinical presentation 
(occurrence of pain and paresthesia as 
symptoms, neurological deficit – quantified 
in six-grade system (M0-M5 and S0-S5 
respectably), localization, size of the lesion, 
used diagnostic procedures, 
pathohystological type of tumor, and 
finally, treatment of choice for each case.  

Results: Analysis showed that there was 
slight gender predominance (53.8% female, 
and 46.2% male). Over half of all patients 
(61.6%) were treated in six months to one 
year after first symptom occurred. Most 
common tumor of peripheral nerves is 
schwannoma (66.7%). Method of choice 
was microsurgical resection. In about 80% 
of all threated patients, after surgery, 
baseline function was preserved or 
improved.  

Conclusions: Clinical presentation, 
diagnosis, indication for specific type of 
treatment for peripheral nerve tumors are 
still actual debate topic. However, all 
collected data show that individual and 
multidisciplinary approach is necessary in 
treatment of these tumors.  

Low grade gliomas – how to deal with  
Daniel Rotariu, Bogdan Iliescu, Ziyad 
Fayad, Bogdan Secara, Ion Poeata  

3rd Neurosurgical Department Clinical Emergency 
Hospital “Prof. Dr. N. Oblu”, Iasi, Romania  

 
Introduction: Low grade gliomas represent 

a relative frequent part of the tumoral 

pathology of the CNS, with a highly 
potential to recurrence and progression. We 
wanted to determine the prognostic factors 
associated with these two possibilities of 
evolution.  

Material and methods: We have 
retrospectively analyzed the cases of low 
grade gliomas from the 3rd neurosurgical 
department at Clinical emergency hospital 
“Prof. Dr. N. Oblu” Iasi from the last 5 
years, 2008 -2012  

Results: Low grade gliomas represent 15 
to 20 % of CNS tumors and aff ects mostly 
the young adults, 50% of our patients 
having ages between 20 and 40 years, with a 
slightly male predominance M:F ration 
1,31:1. The most common presenting 
symptom was represented by seizures 70% 
of cases, the most frequent cerebral lobes 
were the frontal 46% and insular lobes 31%. 
3 or more lobes were involved in only 17% 
od cases. Contrast enhancement was 
observed in half of the cases comprised in 
our series and 31% presented a mixt 
structure of the tumor, solid and cystic 
component or solid with calcifications. 97% 
of the cases underwent surgical resection as 
a first line treatment with a rate of gross 
total resection of 41%. Adjuvant treatment 
after surgery was used in 8 cases, with equal 
distribution between combined 
RxT+CHT and RxT alone. The median 
follow up period was, and during this 
period we had 27% recurrences 11 cases 
from which 7 cases presented malignant 
transformation. The treatment of 
recurrences was represented by in 63% and 
RxT in 27% of the cases.  

Conclusions: LGG represent a relative 
frequent pathology, with a better prognostic 
compared with their counterparts (high 
grade gliomas), but with a real potential of 
recurrence and progression (gross total 



 
 
 
210         Abstracts         3rd National Conference of Neuro-Oncology (NCNO 2013)  

 
 
 

resection being often difficult to achieve) 
facts that emphases the need for a close and 
rigorous follow up which sometimes can be 
difficult and which sometimes puts the 
neurosurgeon in a difficult position with 
regard to further treatment decisions.  

 

Gamma-knife radiosurgery in brain 
metastases  
Fery Stoica Savu, Nicolae Mircea, Perin 
Radu, Rodica Stempurszki 

Gamma-Knife Department, “Bagdasar-Arseni” Clinical 
Hospital Bucharest Romania  

 
Introduction: At least 12-13% of cancer 

patients develop symptomatic brain 
metastases and this figure is likely to rise as 
diagnostic technologies improve, allowing 
additional occurrences to be identified. 
With no treatment, patients with 
symptomatic brain metastases usually die 
within two months of diagnosis. However, 
early diagnosis and vigorous treatment, 
while rarely curative, may lead to a useful 
remission of neurological symptoms and 
enhance the quality of a patient’s life, as 
well as, prolong survival. Given the number 
of cases, the question arises, how many of 
these cases are appropriate for Gamma-
Knife Radiosurgery?  

Material and methods: Indications for 
Gamma-Knife Radiosurgery in Brain 
Metastases are presented in relation with 
their location (deep seated or in eloquent 
areas) and their pathology. Comparisons to 
alternative treatments (radiosurgery versus 
surgical resection, radiosurgery versus 
whole brain radiotherapy) and various 
combined indications (surgery, whole brain 
radiotherapy and radiosurgery) are reviewed 

using well established predictive factors 
regarding the clinical benefit for the 
patients with brain metastases, as part of an 
evidence-based clinical practice guideline.  

Results: Brain metastases are excellent 
targets for Gamma-Knife Radiosurgery.  

This treatment has an important role in 
the management of patients with metastatic 
brain tumors. The authors present their 
experience, as well as studies from across 
the world, which have shown its eff 
ectiveness in treatment of brain metastases. 
Local control provided by radiosurgery for 
the management of metastatic brain tumors 
in any brain location exceeds 85% on 
average. There is also a cost-effectiveness 
analysis of the economic impact of 
stereotactic radiosurgery for patients 
harboring brain metastases and 
improvement of the quality of life for these 
patients.  

Conclusions: Brain metastases constitute a 
significant disease burden and have major 
impact on morbidity and mortality. This 
presentation reveals the relative merits of 
stereotactic radiosurgery, whole brain 
radiotherapy and open surgery, which have 
to be used alone or in combination for the 
treatment of patients with brain metastases. 
Treatment aims to provide disease control 
with a good quality of life, although 
prolonged survival may not be always be 
achieved.  

The effect of ferite nanoparticles on 
brain tumours in vitro  
Ligia Tataranu  

Neurosurgical Dept., “Bagdasar-Arseni” Clinical 
Hospital Bucharest, Romania  

 
One factor contributing to the poor 

response to the therapy of brain tumour 



 
 
 

 Romanian Neurosurgery (2013) XX 2: 180 – 213          211 

 
 
 

patients is the limitation of conventional 
drug delivery systems. Recently, magnetic 
nanoparticles received enormous attention 
as new tools for drug delivery in cancer 
treatment. The aim of this study was to 
analyse the toxic effect of ferite 
nanoparticles in vitro, in order to evaluate 
their biological compatibility as drug 
support in brain tumour tratment. For this 
reason, we used two brain tumour primary 
cell cultutes: glioblastoma GB3B cells and 
astrocytoma AC1B cells. As a normal 
control, we used human fibroblast HDF 
cells. The cells were exposed to 0,25 ug/ml, 
0,5Aμg/ml 1 ug/ml ferrite nanoparticles and 
the proliferation rates were evaluated 24, 48 
and 72 hours, after the treatment. Statistical 
analysis revealed that no significant effect of 
ferrite nanoparticles treatment was induced 
on malignant or normal cell lines used in 
this study (p0,05). In conclussion, our 
results showed that ferite nanoparticles, did 
not cause significant cytotoxicity in brain 
tumour cells and encourage the use of these 
compound as drug carrier in brain cancer 
treatment Grant support: 134/2011 
UEFISCDI Romania  

Multiple functional image-guided 
resection of cerebral low grade glioma  
Francesco Tomasello  

Department of Neurosurgery University of Messina 
Messina, Italy  

 
Objectives: Early and extensive resection 

of low-grade gliomas (LGGs) may lead to 
better patients survival. Nevertheless, 
resection of LGGs is often limited by 
extensive involvement of functional brain 
areas. We describe the surgical management 
of patients with tumors at risk due to their 
diffuse nature and relationships with 
functional neural tissue.  

Material and methods: The use of 
multimodal neuroimaging, including 
routine MRI for intraoperative 
neuronavigation, functional MRI with 
speech and motor mapping, diffusion 
tensor imaging and tractography, and 
CT/MR perfusion, is described in 
preoperative evaluation of LGGs.  

Navigated Transcranial Magnetic 
Stimulation (nTMS) was performed to map 
the motor cortex. Intraoperative motor 
mapping and monitoring were performed 
in a consecutive series of patients.  

Tumor removal was performed through 
a transsylvian approach for insular lesions, 
and through a trans-sulcal approach in 
stimulation-confirmed noneloquent areas 
for all other lesions. Resection was 
continued until neuronavigation-evidenced 
normal white matter or cortical or 
subcortical stimulation revealed functional 
areas.  

Results: Gross-total resection was 
achieved in 78% of cases, as assessed by 
postoperative MRI. Over the average 
follow-up duration of 24 months, no 
patient experienced tumor progression or 
recurrence. No patient experienced new 
deficits at the long-term follow up. 
Intraoperative mapping and clinical results 
demonstrated that pre-operative planning 
using multimodal neuroimaging and nTMS 
reliably identifies distribution of tumor, 
eloquent brain structures and their 
relationships.  

Conclusions: Significant resection of diff 
use LGGs is possible, even in presumed 
eloquent neural tissue, without necessarily 
causing permanent neurological deficits. 
Individualized preoperative neuroimaging 
evaluation, with pre- and intraoperative 
speech and motor mapping, is an essential 
tool in achieving a good outcome.  



 
 
 
212         Abstracts         3rd National Conference of Neuro-Oncology (NCNO 2013)  

 
 
 

Genetic heterogeneity in gliomas  
Steffi Urbschat, Ralf Ketter, Joachim Oertel  

Department of Neurosurgery, Saarland University, 
Homburg/ Saar, Germany  

 
Gliomas display a wide range of 

histopathological features and biological 
behavior, and an inherent tendency to 
progress to a highly malignant phenotype. 
Molecular- and cytogenetic studies revealed 
that different grades of gliomas correlate 
with specific genetic alterations. 
Glioblastomas, the most malignant form of 
gliomas, may develop de novo (primary 
glioblastomas) or through progression from 
low-grade or anaplastic astrocytomas 
(secondary glioblastomas).  

To analyze the genetic heterogeneity, we 
performed different cytogenetic methods 
considering their methodic limitations. Cell 
culture analysis may be biased by clonal 
selection artifacts. Homogenized tissue 
lacks control over the tissue composition 
and permits contamination of the tumor 
specimen with preexisting and reactive 
nonneoplastic tissue. Moreover, gliomas 
exhibit a diffuse infiltrating growth pattern 
into normal brain so that no tumor area 
contains a uniform cellular composition. In 
order to evaluate an intratumoral genetic 
heterogeneity we performed FISH 
investigations and microdissection analysis 
in paraffin-embedded glioma tissue and 
correlated the cytogenetic data with the 
histomorphology of the given tumor areas.  

Low-grade astrocytomas most often 
showed normal karyotypes, by conventional 
cytogenetic methods. However, we were 
able to identify numerous alterations in 
low-grade astrocytomas, especially in areas 
with a gemistocytic appearance. Primary 
glioblastomas and secondary glioblastomas 
showed consistant as well as different 
genetic findings, which correlate partial 

with the histomorphological features of the 
investigated areas. Our results provide clear 
evidence of inter- and intratumoral genetic 
heterogeneity in gliomas independent of 
the applied method. In order to develop 
genetic prognostic criteria, the distinct 
genetic heterogeneity of these tumors has to 
be considered.  

Preoperative surgical planning with 
probabilistic fibre tractography  
Istvan Valalik, Peter Szloboda,  
Gyorgy Szekely  

Department of Neurosurgery St. Johnas Hospital, 
Budapest Hungary  

 
Deterministic tractography are primarily 

based upon streamline algorithms where 
the local tract direction is defined by the 
major eigenvector of the diffusion tensor 
(white matter tractography). On the other 
hand the probabilistic tractrography uses 
the anisotropy of water to generate 
probabilistic maps of connectivity between 
brain regions and it may draw fibers into 
the grey matter. In the last decade 
numerous software was made to process 
Diffusion Tensor MRI data and the 
application of tractrography has become 
more and more widespread in the 
neurosurgery. In this paper, we present our 
experiences and future opportunities of 
preoperative planning of brain surgery with 
the aid of probabilistic fibre tractography. In 
the course of our work we used 3T 32 
directions diff usion-weighting and high 
resolution T1 MR Images, FMRIB 
Software Library (FSL 5.0) and 3D Slicer 
software. At the surgical planning of the 
brain tumours in the delicate regions we 
visualized eloquent intact tracts in vivo to 
avoid them. This method is widely used for 
visualization of corticospinal tract pathway 
in the surgery of central region tumours. In 



 
 
 

 Romanian Neurosurgery (2013) XX 2: 180 – 213          213 

 
 
 

addition, we used tractography maps for 
surgery of tumours in the vicinity of 
language-related regions and improving the 
stereotactic targets of Deep Brain 
Stimulations in movement disorders. The 
fibre tractography help to understand for 
the neurosurgeons the advantages and 
disadvantages of approaches in order to 
most benefit from pre-surgical mapping.  

Objectives: Deterministic tractography are 
primarily based upon streamline algorithms 
where the local tract direction is defined by 
the major eigenvector of the diffusion 
tensor (white matter tractography). On the 
other hand the probabilistic tractrography 
uses the anisotropy of water to generate 
probabilistic maps of connectivity between 
brain regions and it may draw fibers into 
the grey matter. In the last decade 
numerous software was made to process 
Diffusion Tensor MRI data and the 
application of tractrography has become 
more and more widespread in the 
neurosurgery.  

Aims of study: In this paper, we present 

our experiences and future opportunities of 
preoperative planning of brain surgery with 
the aid of probabilistic fibre tractography.  

Material and methods: In the course of our 
work we used 3T 32 directions 
diffusionweighting and high resolution T1 
MR Images, FMRIB Software Library (FSL 
5.0) and 3D Slicer software.  

Results: At the surgical planning of the 
brain tumours in the delicate regions we 
visualized eloquent intact tracts in vivo to 
avoid them. This method is widely used for 
visualization of corticospinal tract pathway 
in the surgery of central region tumours. In 
addition, we used tractography maps for 
surgery of tumours in the vicinity of 
language-related regions and improving the 
stereotactic targets of Deep Brain 
Stimulations in movement disorders.  

Conclusions: The fibre tractography help 
to understand for the neurosurgeons the 
advantages and disadvantages of approaches 
in order to most benefit from pre-surgical 
mapping.