Ukrainian Neurosurgical Journal

Transparsinterarticularis approach for resection of a malignant melanotic nerve sheath tumour of the dorsal spine: A case report

2025-03-30T13:31:08+03:00

Introduction: Malignant melanotic nerve sheath tumours are extremely rare central nervous system neoplasms. Initially termed as Melanotic schwannoma the nomenclature was revised in 2020 WHO classification to malignant melanotic nerve sheath tumour (MMNST). They are rare aggressive peripheral nerve sheath tumours. In spine, they more commonly occur in the lumbosacral region (47.2%), followed by the thoracic (30.5%) and cervical (22.2%) segments. Most common age group affected is between 20-50 years. MMNSTs often tend to metastasize early and have poor prognosis. Surgical excision is the mainstay of treatment followed by radiotherapy and/or chemotherapy.

Case report: Here we present the case of a 54-year- old male who presented with gradually progressive lower limb weakness and hypertonia with bowel and bladder involvement. Magnetic resonance study of the spine suggested an intradural extramedullary melanoma at D4 level of spine. The rest of the physical examination and metastatic workup were unremarkable. The patient subsequently underwent tumour excision via trans-parsinterarticularis approach. Histopathological examination was suggestive of malignant melanotic nerve sheath tumour. Following surgery the patient’s lower limb weakness improved significantly. At six-month follow-up patient did not show any signs of recurrence.

Conclusion: Malignant melanotic nerve sheath tumours (MMNSTs) are extremely rare highly aggressive lesions that are often misdiagnosed on neuroimaging. When a spinal tumour arising from a nerve root demonstrating the characteristic of T1 hyperintensity and T2 hypointensity, MMNST should always be included in differential diagnosis and metastatic workup, Clinical and radiological evaluation should be done to rule out other associated syndromes. Complete surgical excision followed by vigilant follow-up for early detection of recurrence is recommended.

Intracranial mesenchymal tumor with FET::CREB fusion: diagnostic and therapeutic challenges in an adult patient: A case report

2025-05-05T08:40:30+03:00

Aims: To highlight the diagnostic and therapeutic challenges of intracranial mesenchymal tumors with FET::CREB fusion, emphasizing the role of molecular diagnostics and immunohistochemistry in accurate identification.

Case report: A 44-year-old male presented with seizures and chronic headaches. Brain MRI revealed a well-defined, enhancing lesion in the left frontal lobe with significant perilesional edema. Gross total resection was performed. Histopathological analysis showed round to oval, spindle, and epithelioid cells within a mucoid stroma, along with lymphoplasmacytic infiltration and prominent vasculature. Immunohistochemistry revealed positivity for EMA, CD99, and Desmin, while molecular testing confirmed the presence of EWSR1::CREB fusion. Adjuvant chemotherapy with temozolomide and irinotecan was administered.

Discussion: FET::CREB fusion-positive tumors, a molecular variant of angiomatoid fibrous histiocytoma, exhibit diverse morphological features resembling meningiomas or schwannomas. Accurate diagnosis relies on advanced molecular tools. Treatment primarily involves surgical resection, with adjuvant therapies tailored to the tumor’s molecular profile.

Conclusion: Early and precise diagnosis using molecular studies is critical for guiding treatment decisions. Further research is needed to refine therapeutic strategies and explore targeted therapies for these rare tumors.

Neuro-ophthalmological symptoms of compressive optic neuropathy depending on chiasmal position and pituitary adenoma extension

2025-04-17T22:59:15+03:00

Objective: to analyze the characteristics of compressive optic neuropathy depending on the anatomical position of the optic chiasm.

Materials and methods: The study was conducted at the A.P. Romodanov Institute of Neurosurgery of the National Academy of Medical Sciences of Ukraine between 2018 and 2024, within the Departments of Endonasal Skull Base Neurosurgery and Neuro-ophthalmology. We retrospectively analyzed data from a consecutive surgical series involving 212 patients (424 eyes) diagnosed with pituitary adenoma (PA) and compressive optic neuropathy manifested by decreased visual acuity and/or visual field defects. The cohort included 116 women (54.7%) and 96 men (45.3%) aged 18 to 76 years (mean age 52.3 ± 11.8 years). Based on the direction of PA growth and the anatomical position of the optic chiasm, patients were classified into three groups:

Group I – anterior growth and/or posterior chiasmal position (34 patients, 16.1%; 68 eyes); Group II – suprasellar growth and/or central chiasmal position (147 patients, 69.3%; 294 eyes); Group III – posterior growth and/or anterior chiasmal position (31 patients, 14.6%; 62 eyes).

Results: No statistically significant difference in mean age was observed among the groups (p > 0.05). The mean duration of visual impairment was (14.8 ± 3.9) months in Group I, (8.80 ± 0.95) months in Group II, and (9.1 ± 2.5) months in Group III (p > 0.05). Mean visual acuity was 0.60 ± 0.05, 0.60 ± 0.03, and 0.60 ± 0.04, respectively (p > 0.05). Mean cumulative loss of light sensitivity was (10.39 ± 0.80) dB, (11.2 ± 0.3) dB, and (10.25 ± 0.80) dB in Groups I, II, and III, respectively (p > 0.05). The mean tumor volume of PA was significantly larger in Groups I ((20.4 ± 6.7) cm³) and III ((24.9 ± 5.9) cm³) compared to Group II ((9.02 ± 0.59) cm³) (p < 0.05).

Regarding visual field patterns: posterior chiasmal position was associated with superior temporal quadrantanopia (32.4%), central chiasmal position with temporal hemianopia and central scotoma (30.6%), anterior chiasmal position with homonymous hemianopia (35.5%).

Conclusions. In patients with pituitary macroadenomas, visual disturbances may be delayed or absent when the chiasm is located in anterior or posterior positions. This is likely due to reduced compressive impact on the opto-chiasmal complex in these anatomical configurations.

Features of peripheral and intrathecal content of immunological markers of inflammation in combatants with mild TBI depending on the chronicity of its course

2025-05-06T14:33:02+03:00

Aim: To investigate the levels of inflammatory mediators of the immune system in blood serum and cerebrospinal fluid (CSF) in combatants with mild traumatic brain injury (mTBI) at different time periods after its acquisition.

Materials and methods: IL-6, TNFα, IL-10 and TGFβ1 concentrations were measured according to the instructions of the «Human ELISA Kit» (Elabscience Bionovation Inc., USA) in 53 paired serum and CSF samples from patients with combat mTBI.

Results: In the general group of patients with mTBI, a significant increase in the peripheral content of IL-6, IL-10, TGFβ1 was found, compared with healthy donors (control). When studying these indicators depending on the duration of the post-traumatic period, a persistent increase in the level of IL-6 was shown in combination with significantly increased TGFβ1 concentration indicators and a tendency to an increased level of IL-10. At the same time, the analysis of the central content of inflammatory biomarkers did not reveal their significant changes at different times after TBI, with the exception of a tendency to a decrease in the presence of IL-6, the presence of which in paired analytes prevailed in CSF along with the prevalence of peripheral finding of TNFα, IL-10, TGFβ1.

Conclusions: Thus, the increased content of circulating pro-inflammatory IL-6 and TNFα in the intermediate and remote periods of the course of TBI and a significantly (approximately 6 times) increased level of pleiotropic TGFβ1 in combination with anti-inflammatory IL-10 indicate the persistent nature of inflammation, which indicates the possibility of induction of neurodegenerative processes in combatants with TBI. Such results confirm the feasibility of comprehensive monitoring of immunological markers of inflammation to identify potential directions for adequate pathogenetic therapy even in the context of significantly distant consequences of TBI.

Invasive monitoring of arterial blood pressure in cerebral arteries during thrombectomy

2025-05-26T22:58:07+03:00

Objective: to assess the arterial blood pressure measured invasively in the internal carotid artery and distal to the site of thrombotic occlusion (in the middle cerebral artery) during mechanical thrombectomy in patients with acute ischemic stroke.

Materials and methods: In 2024, a total of 90 patients with acute cerebrovascular occlusion who underwent thrombectomy were examined. Data from 23 patients in whom intraoperative arterial pressure (AP) was measured invasively were analyzed. Patient age ranged from 44 to 81 years, with a mean age of 66.3±10.4 years. The majority of patients were male (61%). Stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS), and functional outcomes were evaluated using the modified Rankin Scale (mRS) at discharge (0–3 points – favorable outcome, 4–6 points – unfavorable outcome). Ischemic changes were graded according to the Alberta Stroke Program Early CT Score (ASPECTS), with ≤7 points indicating extensive changes and ≥8 points indicating moderate changes.

Results: No statistically significant differences were found in AP levels in the internal carotid artery before and after thrombectomy depending on the degree of neurological deficit, volume of ischemic changes, or functional outcome (p>0.1). The mean AP measured distal to the site of occlusion was significantly higher in patients with NIHSS scores ≤15 compared to those with NIHSS scores>15 ((59.7±4.7) vs. (51.0±10.9) mm Hg, p=0.02), in patients with moderate ischemic changes ((58.5±5.4) vs. (44.3±11.9) mm Hg, p=0.03), and in those with a favorable functional outcome ((59.2±5.5) vs. (49.0±11.1) mm Hg, p=0.02). The mean AP in the internal carotid artery after thrombectomy was significantly higher in patients with hemorrhagic transformation ((114.4±9.0) vs. (100.4±13.4) mm Hg, p=0.01).

Conclusions: A correlation was found between the mean AP levels, measured invasively in intracranial arteries at various stages of mechanical thrombectomy for acute ischemic stroke, and stroke severity, infarct volume, development of hemorrhagic transformation, and functional outcome. These findings highlight the importance of investigating local hemodynamics to predict treatment outcomes in acute ischemic stroke and to explore personalized AP management strategies during thrombectomy and in the early postoperative period.

Long-term implant-related complications following anterior-only stabilization of thoracolumbar junction injuries: a radiological and clinical analysis

2025-05-20T06:57:03+03:00

Objective: To evaluate the long-term implant-related complications following anterior-only stabilization of traumatic thoracolumbar injuries and to identify structural and radiological patterns associated with construct failure.

Materials and methods: A retrospective multicenter study was conducted at two neurosurgical institutions (Kyiv, Ukraine; Lahore, Pakistan) between 2000 and 2023. Sixteen patients who underwent anterior stabilization at T11–L2 and developed mechanical complications ≥5 years postoperatively were included. Radiographic analysis (CT, X-ray) assessed signs of construct instability, segmental kyphosis (modified Cobb method), global sagittal balance (SVA), and bone mineral density (Hounsfield units, HU). Neurological status was graded using the ASIA scale; pain was assessed via VAS. A complication severity score was developed based on the type of implant failure. Statistical analysis was performed using R version 4.0.5.

Results: The most frequent complications were screw-related failures (87.5%), plate migration (68.8%), and cage subsidence/displacement (31.3%). A direct correlation was observed between the severity of structural failure and kyphotic deformity: the median Cobb angles for high-severity cases reached 57°. Global sagittal imbalance (SVA>50 mm) was present in 31.3% of patients, primarily among those with the most severe failures. Neurological decline occurred in 25% of cases, exclusively in the presence of marked kyphosis or implant migration. A bone density < 135 HU was associated with a higher risk of earlier complication onset (HR = 2.83; p = 0.068). Pain intensity showed only a weak correlation with structural deformity.

Conclusions: Anterior-only stabilization at the thoracolumbar junction provides effective decompression and anterior column support but carries a risk of delayed mechanical complications, particularly in the absence of posterior reinforcement. The cantilever effect remains a key biomechanical vulnerability. Patients with HU < 135 should be considered at an elevated risk. A tailored surgical strategy, meticulous implant positioning, and long-term radiological surveillance are critical. In cases with poor bone quality or suspected PLC injury, posterior stabilization may offer superior long-term outcomes.

A personalized approach to the treatment of traumatic spinal injuries: rationale, basic concept, and potential methods of implementation

2025-03-30T11:54:44+03:00

Traumatic spinal injuries (TSIs) are a leading cause of disability and represent a significant socio-economic burden. Despite advancements in diagnostic and surgical techniques, treatment outcomes remain inconsistent. Standardized protocols often fail to account for individual patient characteristics, which can reduce the effectiveness of interventions and increase the risk of complications. This highlights the growing relevance of adopting individualized approaches in the treatment of TSIs.

Objective: To comprehensively analyze the economic, legal, clinical, and deontological aspects of implementing individualized approaches to the treatment of TSIs.

Materials and methods: An analytical literature review was conducted in accordance with the PRISMA protocol. Sources were selected from international scientific databases over the past 10 years using relevant MeSH terms.

Results: The literature review revealed that, despite technological advances, treatment outcomes in TSIs do not always improve proportionally with increased healthcare spending, illustrating the phenomenon of diminishing returns. The use of the QALY metric in several countries enables the evaluation of the cost-effectiveness of medical interventions; however, it has ethical limitations and is not yet implemented in Ukraine. The domestic Health Technology Assessment (HTA) system, introduced in 2020, does not currently include mandatory protocols for managing TSIs due to clinical heterogeneity, resource constraints, and legal risks. Standardized, diagnosis-driven protocols focused on the “average patient” often disregard individual variability, potentially leading to both overtreatment and undertreatment. Simplified injury classification systems enhance standardization but may reduce clinical decision-making accuracy in atypical cases. Furthermore, limited public understanding of evidence-based medicine contributes to ethical and communicative challenges. These findings underscore the importance of individualized approaches in TSI management.

Conclusions: Individualization of TSI treatment represents a logical extension of evidence-based medicine and promotes optimization of outcomes. It allows for flexible, patient-specific therapeutic strategies, improves the efficiency of healthcare resource utilization, and reduces complication rates. The ongoing development of analytical tools offers promising prospects for constructing personalized algorithms for managing highly heterogeneous patient populations.

Neurosurgical anatomy of the insula and Sylvian fissure: Literature review and personal experience. The third report. Anatomy of sylvian fissure, sylvian cistern, gyri and fissures of the insula

2025-04-29T17:37:10+03:00

Despite being a region where numerous pathological processes may develop, the insula remains one of the least studied anatomical structures of the human brain. The clinical course of insular glioma is accompanied by a severe morbidity, caused by the proximity of the central core, important projection and associative pathways, main arteries and large venous collectors. For a long time, surgery of patients with insular gliomas, which would involve the total volume tumor removal while ensuring high quality of post-surgery life, was considered impossible.

Understanding the surgical anatomy of the insula is key to successful transsylvian-transinsular, transopercular approaches to insular gliomas and their radical removal.

The article provides a detailed surgical anatomy of the sylvian fissure, the operculum and the insula.