Search

We present the results of the Romanian team for the multi-center grant “Paediatric Brain Monitoring with Information Technology (KidsBrainIT). Using IT Innovations to Improve Childhood Traumatic Brain Injury Intensive Care Management, Outcome, and Patient Safety”, acronym KidsBrainIT. Children aged 2 to 16 years who require intensive care management after sustaining traumatic severe brain injury are included in this study in three neurosurgical hospital: "Prof. Dr. N. Oblu" Clinical Emergency Hospital Iasi, "Sf. Maria" Children Clinical Emergency Hospital Iasi and "Bagdasar-Arseni" Clinical Emergency Hospital Bucharest. Continuous real-time intracranial pressure monitoring became a "gold standard" in TBI intensive-care management and ICP-lowering therapy is recommended when ICP is elevated above 20 mmHg or more. Continuous ICP and mean arterial blood pressure (MAP) monitoring allow calculation of cerebral perfusion pressure (CPP) and to establish of an optimal CPP. This study aims to improve the treatments and the outcomes in severe traumatic brain injury in children.

This article presents the mid-term results of the multi-center grant “Paediatric Brain Monitoring with Information Technology (KidsBrainIT). Using IT Innovations to Improve Childhood Traumatic Brain Injury Intensive Care Management, Outcome, and Patient Safety”, acronym KidsBrainIT, of the Romanian team. Continuous real-time intracranial pressure monitoring is a standard in TBI intensive-care management and ICP-lowering therapy is recommended when ICP is elevated above 20 mmHg or more. Paediatric TBI patients requiring intensive care are recruited from more contributing centres in 4 different countries and the Romanian team includes doctors CA Apetrei, C Gheorghita and A Tascu as principal investigators. Children aged 2 to 16 years who require intensive care management after sustaining traumatic severe brain injury are included in this study in three neurosurgical hospital: "Prof. Dr. N. Oblu" Clinical Emergency Hospital Iasi, "Sf. Maria" Children Clinical Emergency Hospital Iasi and "Bagdasar-Arseni" Clinical Emergency Hospital Bucharest. Continuous ICP and mean arterial blood pressure (MAP) monitoring allow calculation of cerebral perfusion pressure (CPP) and establish of an optimal CPP. The aim of this study is to improve the treatments in severe traumatic brain injury in children.

The complete name of this ERA-NET NEURON Grant is “Paediatric Brain Monitoring with Information Technology (KidsBrainIT). Using IT Innovations to Improve Childhood Traumatic Brain Injury Intensive Care Management, Outcome, and Patient Safety”. The Project Coordinators are Ms. Dr. Tsz-Yan Milly Lo (Consultant Paediatric Intensivist and Research Lead in Paediatric Critical Care Medicine ) and Ian Piper from University of Edinburgh, UK and the partners are: Prof. Bart Depreitere and his team from Neurosurgery & Intensive Care Research Group, University Hospitals Leuven, Belgium; Prof. Juan Sahuquillo and his team from Department of Neurosurgery, Vall d’Hebron University Hospital, Barcelona, Spain and the Romanian team with doctors CA Apetrei, C Gheorghita and A Tascu as principal investigators in three different hospitals. This material is based on the scientific project proposal with the basic project data. The aim of this grant is to test two clinically relevant hypotheses: after sustaining traumatic brain injury (TBI), paediatric patients with a longer period of measured cerebral perfusion pressure (CPP) maintained within the calculated optimal CPP (CPPopt) have an improved global clinical outcome and better tolerance against raised intracranial pressure (ICP). Paediatric TBI patients requiring intensive care are recruited from more contributing centres in 4 different countries. Their anonymised routinely collected bedside physiological monitoring data in minute-resolutions linking with anonmyised clinical and outcome data are exported and archived in the central KidsBrainIT data-bank. CPPopt is calculated and ICP dose-response analyses are performed on the KidsBrainIT dataset and their correlations with global outcome at 6 months are determined. The final aim of this study is to improve the treatments of the abnormal physiology insults: increase pressure from brain swelling (raised ICP) and brain perfusion pressure (CPP).

The phosphorylated form of the high-molecular-weight neurofilament subunit NF-H (pNF-H) in serum or in cerebro-spinal fluid (CSF) is a specific lesional biomarker for spinal cord injury. The lesional biomarkers and the reaction biomarkers are both presented after several hours post-injury. The specific predictive patterns of lesional biomarkers could be used to aid clinicians with making a diagnosis and establishing a prognosis, and evaluating therapeutic interventions. Diagnosis, prognosis, and treatment guidance based on biomarker used as a predictive indicator can determine ethical difficulties by differentiated therapies in patients with spinal cord compression. At this point based on studies until today we cannot take a decision based on biomarker limiting the treatment of neurological recovery in patients with complete spinal cord injury because we do not know the complexity of the biological response to spinal cord compression.

Spinal cord injury (SCI) is one of the most devastating traumas for an individual because the complete traumatic spinal cord injury leads to paraplegia or tetraplegia. The mechanical injuries directly cause axonal destruction in fiber tracts, destruction of the neurons and of the glial cells, and their destruction releases substances whose presence, quantity and dynamics can be lesional biomarkers. The reactions of partially injured cells simultaneously start and the occurring substances and their quantity may be reaction biomarkers. The lesional biomarkers appear immediately post-injury and after several hours there are both lesional biomarkers and reaction biomarkers. The most important lesional biomarkers are the phosphorylated neurofilament subunits resulting from the axonal neurofilament destruction. The heavy phosphorylated neurofilament subunit (pNF-H) is a predictive lesional biomarker because its values pattern can show the reducing or stopping of the secondary lesions and the favorable outcome. The complete SCI patients with a favorable development had a specific pattern of daily values of pNF-H: a sudden increase up to a maximum value then a progressive decrease to normal. The patients with unfavorable outcome or neurological stabilisation had two patterns: an increase to a plateau of pNF-H values or a progressive increase up to a peak followed by a progressive decrease to quasi-normal values.

From the first to use of “pseudotumor cerebri” by Nonne in 1904, the historic evolution of the knowledge on pseudotumor cerebri has been marked by several periods (the otologic stage, the neurosurgical stage, the neuro-ophthalmologic stage); today there are clear diagnosis criteria for the idiopathic intracranial hypertension, there is a clear differentiation between idiopathic intracranial hypertension and vascular intracranial hypertension, also the comprehension of the illness pathogeny is based on the dynamics of the intracranial fluids, which allows the auto-regulation of the cerebral circulation within quasi-normal limits, despite the very high intracranial pressure.

We present a case of a patient with a ruptured temporo-occipital arteriovenous malformation, grade 3 on Spetzler-Martin scale, with an unpredictable evolution. A spontaneous occlusion of the malformation was found at 4 months after the initial partial endovascular embolization. We reviewed and discuss some aspects concerning clinical and angiographic finding, the angioarchitectural remodelling and evolution of the AVMs after partial occlusion treatment.

Early therapies for acute traumatic spinal cord injury has some key points: 1. Immediately or soon after the injury is recommended a hemodynamic support to maintain mean arterial pressure at 85 – 90 mmHg and monitoring in an intensive care unit for the first week after spinal cord injury. 2. Immediate surgery for spinal cord decompression is of high importance for the prognosis and evolution of spinal cord injury. 3. The recommendation is to treat all patients with spinal cord injury according to the local protocol, methylprednisolone is not standard of care anymore, it is a treatment option that should only be undertaken with knowledge of the potential complications.

Normal pressure hydrocephalus (NPH) is characterized by normal CSF pressure, less than 18 cm H2O, classical clinical triad: gait disturbance, dementia and incontinence in patients with communicating hydrocephalus on CT or MRI. We analyzed retrospectively the NPH hospitalized patients in three neurosurgical departments between July 2007 and December 2012. Only the cases who met all diagnostic criteria were selected for this study. There were 47 selected cases of patients with NPH, including 24 patients with secondary NPH and 23 patients with idiopathic NPH. Ventriculo-peritoneal shunt was performed in all 24 patients with secondary NPH and at 11 patients with IdNPH. The short-term and long-term results were good and very good for cases of secondary NPH and good in 60% and poor in 40% in cases of IdNPH. The MR imaging showed the absence of CSF passage through the ventricular wall and the ventricular wall in cases of IdNPH with poor results after shunting: ependyma and glia limitans interna represents a fluid - parenchymal barrier between the brain parenchyma and the ventricles as a glial-ependymal barrier. We can consider that secondary NPH and some cases of idiopathic NPH with repeated small increases of ICP, with transependymal migration of CSF and hydrocephalus causing clinical triad because of the open glial-ependymal barrier, as an Active Normal Pressure Hydrocephalus and the shunt has good results. Other cases of IdNPH have not increases of intracranial pressure, no transependymal migration of CSF and there are periventricular deep lesions, without brain atrophy, causing clinical triad, as a passive hydrocephalus, it is a Passive Normal Pressure Hydrocephalus.

Several studies showed that the phosphorylated form of the neurofilament subunit NF-H (pNF-H) are related to neuronal injuries and its detection provide information about the presence and degree of neuronal loss. Neurofilaments are three subunits, namely NF-L, NF-M and NF-H. The phosphorylated neurofilament subunit NF-H (pNF-H) is present into serum and CSF in significant amounts following neuronal injury and may be detected. The pNF-H can be a biomarker of the neuronal injuries and its detection allows the monitoring neuronal pathology and may provide diagnosis and prognosis in humans. We are interested in pNF-H as biomarker of neuronal injury in spinal cord injury and we used a pNF-H ELISA test capable of detecting the levels of phosphorylated NF-H (pNF-H) to patients with spinal cord injury. We studied the pNF-H levels in CSF in two patients with spinal cord injury (SCI) and for normal values of pNF-H we determined the CSF pNF-H level from individuals without neurological damage. The pNF-H values of CSF from the two patients with SCI were 5-10 times higher than the normal and its higher values were related to an unfavorable outcome. In conclusion, although the number of cases is very low - only two, in the context of experimental studies in animals with SCI, we can say that pNF-H is marker in SCI in humans and its increased values are consistent with an unfavorable outcome.

Objectives: Pituitary adenoma represents the most frequent tumour encountered in the sellar region. We have proposed to review the principles of diagnosis and treatments and to analyze their standard protocol of approaching pituitary lesions. Material and method: We have retrospectively analyzed the cases of pituitary adenoma between Jan 2006 and Dec 2010, we studied presenting symptoms, hormonal status, local extension, surgical approach, tumor histology, type of resection, tumor volume, cavernous sinus invasion, surgical corridors, recurrence rate, intra operative and postoperative complications Results: 72 patients were included in the study, with no significant difference between sexes, the pathology was dominated by pituitary macro adenomas in 47 cases, regarding the hormonal status 51.3% were non secreting pituitary adenomas, the rate of operability in our series was 65.2%, the surgical indication has been given mainly by the hormonal status and involvement of the optic apparatus which in our series was 51%, the invasion of the cavernous sinus has been appreciated according the Knosp criteria (7) and grade 3 and 4 was present in 44% of the cases. The most used surgical approach was the pterional approach in 83% and the remaining 17% by the transsphenoidal approach. The most frequent surgical corridor was represented by the prechiasmatic route in 54%, gross total resection was achieved in 51%. The most frequent postoperative complication encountered in our series was represented from systemic complication the meningitis 13%, as for endocrine complication it was represented by transitory diabetes insipidus in 23.4% and SIADH in 4.2% (2 cases). The follow up at 3 months showed no cases of early recurrence, from the group of patient with STR 6 were sent to radiotherapy. The follow up at 1 year has comprised 3 deaths, 3 cases of hydrocephalus treated with ventriculoperitoneal derivation, 19 cases were with no imagistic or clinical symptoms of tumour and 22 presented with imagistic evidence of stable residual tumour with no clinical symptoms. Conclusions: The main surgical indication in pituitary adenomas is represented by the secreting hormonal status of the patient (excepting prolactin secreting tumours) and the impairment of the vision. The most frequent surgical approach was represented by the transcranial (pterional) approach due to the large dimensions and invasiveness of the tumours presented in our series but also the surgical team preference (in the absence of intracranial endoscopy at those times).

Two patients with chronic cervical spinal cord injury and quadriplegia underwent partial resection of the medular scar and implant of bone marrow tissue with a combination of drugs at the site of spinal cord injury. Post-operatively they received a similar treatment in the neuromotor rehabilitation centre and were treated additionally with cerebrolysin . Sensory improvements were noticed, but no significant motor improvements were observed twenty months afterwards.

A cervical spine model built by means of the finite element method was used to determine the risk of postoperative cervical instability in relation to the type of discectomy, in cervical disc herniation. Furthermore, this model was employed to check whether, at the adjacent levels of the fusion discectomy, the intervertebral translation during cervical movements will maintain the normal amplitude [normal ROM] or its amplitude will decrease. The intervertebral displacement and the tension arising from motion and weight in the cervical vertebral structure were thus determined through computer modelling using the above-mentioned method and the software Abaqus. It resulted in a cervical spine model consisting of 739666 finite elements interacting through 210530 nodes, with biomechanical properties following the vertebral anatomical structures modelled. Two movement situations were studied to determine the behaviour of this model. Firstly, the moment of force for flexion and extension of 1 Nm. Secondly, we aimed to establish the maximum flexion and extension for a normal cervical spine model in order to determine the momentum value of moving forces for each of them. It was showed that both anterior cervical microdiscectomy without fusion and cervical discectomy with cage fusion (used for the surgical treatment of cervical disc herniation at one level), ensure postoperative vertebral stability when performed properly. Both types of surgery reduce the mobility of the cervical spine, although more in the case of fusion discectomy. The intradiscal tension increases in movement in both models, with a higher intensification in the fusion discectomy model. The practical conclusion is that microdiscectomy without fusion is preferable in the case of a single-level cervical disc herniation occurred to a cervical spine without instability. [ABSTRACT FROM AUTHOR]

We present the results of the Romanian team for the multi-center grant "Paediatric Brain Monitoring with Information Technology (KidsBrainIT). Using IT Innovations to Improve Childhood Traumatic Brain Injury Intensive Care Management, Outcome, and Patient Safety", acronym KidsBrainIT. Children aged 2 to 16 years who require intensive care management after sustaining traumatic severe brain injury are included in this study in three neurosurgical hospital: "Prof. Dr. N. Oblu" Clinical Emergency Hospital Iasi, "Sf. Maria" Children Clinical Emergency Hospital Iasi and "Bagdasar-Arseni" Clinical Emergency Hospital Bucharest. Continuous real-time intracranial pressure monitoring became a "gold standard" in TBI intensive-care management and ICP-lowering therapy is recommended when ICP is elevated above 20 mmHg or more. Continuous ICP and mean arterial blood pressure (MAP) monitoring allow calculation of cerebral perfusion pressure (CPP) and to establish of an optimal CPP. This study aims to improve the treatments and the outcomes in severe traumatic brain injury in children. [ABSTRACT FROM AUTHOR]

The phosphorylated form of the high-molecular-weight neurofilament subunit NF-H (pNF-H) in serum or in cerebro-spinal fluid (CSF) is a specific lesional biomarker for spinal cord injury. The lesional biomarkers and the reaction biomarkers are both presented after several hours post-injury. The specific predictive patterns of lesional biomarkers could be used to aid clinicians with making a diagnosis and establishing a prognosis, and evaluating therapeutic interventions. Diagnosis, prognosis, and treatment guidance based on biomarker used as a predictive indicator can determine ethical difficulties by differentiated therapies in patients with spinal cord compression. At this point based on studies until today we cannot take a decision based on biomarker limiting the treatment of neurological recovery in patients with complete spinal cord injury because we do not know the complexity of the biological response to spinal cord compression. [ABSTRACT FROM AUTHOR]

Intracranial pressure monitoring seems to be an indispensable stage in management of severe traumatic brain injured patient. Since 2009, this technique completes our trauma protocol. The study has been carried out from 2011 to 2013 in Prof. Dr. N. Oblu hospital in Iasi. There have been included in the study patients with severe craniocerebral trauma, who had traumatic brain lesions CT detected and Glasgow score between 3 and 8. The age ranged from 16 to 60, an average of 35.5 years old. 50% of the studied cases had a favorable outcome. Diagrams associated to this category of patients showed increases in intracranial pressure above normal values but without repeated values above 50 mm Hg. Most of those patients had a good evolution under medical treatment. Monitoring intracranial pressure is an extremely useful stage in treating intracranial high pressure in traumatology and it should be included in the equipment of any intensive therapy section caring traumatic patients.

Spinal cord injury (SCI) due to trauma has major functional, medical, and financial effects on the injured person, as well as an important effect on the individual's psychosocial well-being. These patients have not any treatment for their or tetraplegia and any therapeutical attempt can bring hope and can improve their quality of life. Today methylprednisolone is a standard treatment option for an acute spinal cord injury but it is not a cure for a spinal cord injury. Surgery is often necessary for decompression, to realign and to stabilize the spine. The experimental treatments had yet not results. In case of acute complete traumatic SCI, steroid medication is insufficient and it is necessary to add new immediate procedures at the standard treatment performed today. Treatment should be started immediately and must stop cell death, control inflammation and promote nerve regeneration (action to primary and secondary damage).

Intracranial meningioma represent a quite frequent pathology but those located in the foramen magnum are quite rare. We have described a small number of cases with their singularities – FMM associated with vagal disorders and associated with multiple aneurysms - operated in a short period of time along with reviewing the literature concerning the topic – frequency, type of approach, clinic signs.

A cervical spine model built by means of the finite element method was used to determine the risk of postoperative cervical instability in relation to the type of discectomy, in cervical disc herniation. Furthermore, this model was employed to check whether, at the adjacent levels of the fusion discectomy, the intervertebral translation during cervical movements will maintain the normal amplitude [normal ROM] or its amplitude will decrease. The intervertebral displacement and the tension arising from motion and weight in the cervical vertebral structure were thus determined through computer modelling using the above-mentioned method and the software Abaqus. It resulted in a cervical spine model consisting of 739666 finite elements interacting through 210530 nodes, with biomechanical properties following the vertebral anatomical structures modelled. Two movement situations were studied to determine the behaviour of this model. Firstly, the moment of force for flexion and extension of 1 Nm. Secondly, we aimed to establish the maximum flexion and extension for a normal cervical spine model in order to determine the momentum value of moving forces for each of them. It was showed that both anterior cervical microdiscectomy without fusion and cervical discectomy with cage fusion (used for the surgical treatment of cervical disc herniation at one level), ensure postoperative vertebral stability when performed properly. Both types of surgery reduce the mobility of the cervical spine, although more in the case of fusion discectomy. The intradiscal tension increases in movement in both models, with a higher intensification in the fusion discectomy model. The practical conclusion is that microdiscectomy without fusion is preferable in the case of a single-level cervical disc herniation occurred to a cervical spine without instability.