Branislav Antic

Ultrastructure and immunohistochemistry of the trigeminal peripheral myelinated axons in patients with neuralgia

OBJECTIVE Detailed ultrastructural and immunohistochemical examination of the trigeminal axons surrounded by the peripheral type of the myelin could add new information about the extent of the trigeminal nerve lesion in neuralgia. PATIENTS, MATERIALS AND METHODS The examination comprised, firstly, the 10 trigeminal nerve roots (TNRs) in which the neurovascular contact was found in 20% of the cases, and the 2 additional control TNRs. Secondly, the biopsy specimens were taken from 6 patients with trigeminal neuralgia and 2 patients with trigeminal neuropathy following a partial TNR rhizotomy. The specimens were examined under the electron microscope (EM) and/or using the immunohistochemical (IHC) methods. RESULTS In addition to the central zone of demyelination, the EM examination of the TNR also revealed alterations of the peripheral myelin, i.e. deformation, thickening, demyelination and remyelination, as well as changes of the peripheral axons, that is, atrophy or hypertrophy, neurofilaments increase, loss of the myelin and sprouting occasionally. Some Schwann cells were also damaged. The IHC examination usually showed a moderate immune reaction against neuron-specific enolase (NSE) and protein gene product 9.5 (PGP9.5), but sporadically weaker reaction against the S-100 protein, synaptophysin (SY), neurofilament protein (NFP) and glial fibrillary acidic protein (GFAP). The substance P (SP) and calcitonin gene-related peptide (CGRP) immunoreactivity was weak at some sites, but strong at some other places. CONCLUSIONS The pathological changes affect not only the central nerve fibers of the TNR, but also some of the peripheral axons, their myelin sheath and Schwann cells. These are signs of the retrograde ultrastructural and biochemical alterations, which could participate in the pathophysiological mechanism underlying the trigeminal neuralgia.

Posterior fossa exploration in treatment of trigeminal neuralgia associated with multiple sclerosis

BACKGROUND The possible surgical options during PFE in treatment of TN in patients with MS are MVD and PSR. Only sporadic cases of PSR in treatment of TN patients with MS have been reported. METHODS We retrospectively analyzed the outcome of surgical treatment in 8 patients with MS who underwent PFE due to surgical treatment of medically intractable TN. MVD was projected in severe neurovascular conflict, MVD + PSR in mild conflict, and PSR alone in cases without neurovascular conflict. RESULTS There were no patients with severe neurovascular contact. In 5 patients with mild neurovascular contact and in 3 without neurovascular contact, MVD + PSR and PSR alone were performed, respectively. An immediate BNI-score of I was achieved in all patients. There were 2 minor and 1 major recurrences. Nine years after surgery, 75% of the patients were free of pain. There was no immediate postoperative mortality. Postoperative cerebrospinal fluid rhinorrhea in 1 patient was resolved with spinal drainage. Two patients died during the follow-up period due to the complications of MS. CONCLUSION In our experience, MVD + PSR or PSR alone are safe and effective surgical procedures in the management of TN complicating MS. In MVD + PSR patients, PSR seems to play more significant role than MVD in pain relief. Since there were not severe neurovascular conflicts in our patients with MS, MVD alone was never justified.

Symptomatic idiopathic noncommunicating intradural arachnoid cyst of the S1 nerve root: a case report.

Study Design. A case report of a rare symptomatic, idiopathic, noncommunicating intradural arachnoid cyst (IAC) of the proximal part of the S1 nerve root (NR). Objective. To discuss the possible pathophysiology, clinical and magnetic resonance imaging (MRI) presentation, intraoperative findings, and follow-up of IAC of the proximal part of the S1 NR. Summary of Background Data. Rare variety of the Naborss Type 3 spinal IAC. The etiopathogenesis are uncertain. Surgical NR decompression with extirpation of the cyst is the treatment of choice. Methods. A 37-year-old woman clinically presented as monoradiculopathy with a 9-month history of progressive, posture-dependent radicular pain, paresthesia and hypoesthesia in the right S1 dermatome, and mild weakness of the ipsilateral plantar flexors. Magnetic resonance imaging (MRI) showed a noncommunicating IAC of the proximal part of the S1 NR on the right side. Surgical exploration through the ipsilateral L5-S1 hemilaminectomy was performed with microsurgical arachnolysis of the compressed and stretched S1 NR fascicles that surrounded the cyst, during which the cyst spontaneously collapsed. The remnant of the cyst wall was extirpated and histopathology confirmed the diagnosis. Results. After surgery an excellent clinical outcome was archived: the leg pain was no longer present and the paraesthesia, hypoesthesia, and motor weakness were resolved within 3 months. At 12 months of follow-up, the patient continues to be completely asymptomatic with no evidence of recurrence on MRI. Conclusion. A rare case of symptomatic, idiopathic, noncommunicating IAC of the proximal part of the S1 NR has been presented. Early recognition and treatment resulted in complete symptom resolution, with preservation of the full working capacity and good quality of life. Isolated monoradiculopathy with progressive, posture-dependent radicular pain seem to be typical clinical findings for such a lesion. Attending physicians should always be mindful of this fact in the total clinical evaluation of such cases.

Aneurysmal bone cyst of the frontal bone

BACKGROUND Aneurysmal bone cyst (ABC) is a benign, expansive, osteolytic lesion that mainly occurs in young people, and involves the skull bones only exceptionally. The origin of ABC is controversial: secondary reactive bone lesion, or primary disease that represents an independent nosological entity. Blunt head trauma was suggested as a possible etiological factor. CASE REPORT A case of a 19-year-old man with primary ABC of the right frontal bone was reported. The lesion was totally excised through frontal craniotomy, and the skull bone defect primarily reconstructed with an acrilate cranioplasty. Five years after the surgery, the patient was without signs of local recurrence. CONCLUSION Clinical and neuroradiological presentation of the skull ABC was not specific. Pathohistology confirmed the diagnosis. Total excision was the treatment of choice.