Krzysztof Majchrzak

Rare primary tumours of the hypothalamus in adults: clinical course and surgical treatment

BACKGROUND AND PURPOSE The paper presents the operative technique and the results of treatment of adult patients with primary tumours of the hypothalamus, including rare ones. The aim of the study was to show the possibility of safe surgical treatment of rare tumours of the hypothalamus through a bifrontal basal interhemispheric trans-lamina terminalis approach. MATERIAL AND METHODS Five patients with tumours of the hypothalamus were operated on in the Neurosurgical Clinic in Sosnowiec between 1990 and 2008. There were 2 patients with craniopharyngiomas located exclusively in the third ventricle, and single patients with gemistocytic astrocytoma, Langerhans cell histiocytosis X and hamartoma of the hypothalamus each. The patients were treated surgically with a bi-frontal basal interhemispheric trans-lamina terminalis approach. In two cases, the neuronavigation system with the use of tractography (DTI) was used to determine the location of the lamina terminalis, the posterior surface of the optic chiasm and the optic tracts. RESULTS All lesions were resected totally, except for partially resected hamartoma of the hypothalamus. The most common postoperative complication was diabetes insipidus, which was transient in two cases. A long-lasting follow-up of all the patients operated on did not reveal regrowth of the lesion. CONCLUSIONS The bifrontal basal interhemispheric trans-lamina terminalis approach allows for radical resection of primary tumours of the hypothalamus while avoiding serious post-operative deficits. This approach enabled the preservation of the olfactory bulb and tract and prevented damage of the frontal lobes. The use of DTI helped to establish the location and borders of the lamina terminalis, to establish the posterior surface of the optic chiasm and the optic tracts, and to save the anterior and lateral wall of the hypothalamus.

Medial sphenoid ridge meningiomas: early and long-term results of surgical removal using the fronto-temporo-orbito-zygomatic approach

BACKGROUND AND PURPOSE The fronto-temporo-orbito-zygomatic approach (FTOZA) is an alternative to the pte-rional approach in surgical resection of meningiomas of the medial part of the lesser wing of the sphenoid bone. The purpose of this study is to present our results of treatment of these meningiomas using the FTOZA. MATERIAL AND METHODS Thirty patients (19 women, 11 men) with a central skull base tumour were included in the study. The neurological status of the patients was assessed before and after surgery as well as at the conclusion of treatment. The approximate volume of the operated tumour, its relation to large blood vessels, cranial nerves and brainstem, as well as consistency and vascularisation were assessed. RESULTS The symptom duration ranged from 1 to 36 months (median: 6 months). Impaired visual acuity was the predominant symptom in 27.5% of patients. Less frequent symptoms included paresis/paralysis of the third cranial nerve, headache, psychoorganic syndrome and epilepsy. Approximate volume of the tumours ranged from 5 to 212 mL (median: 63 mL). Total or subtotal resection was achieved in 77% of patients. The postoperative performance status improved in 16.5%, did not change in 52.8% and deteriorated in 26.4% of patients. One (3.3%) patient died after the surgery. CONCLUSION The FTOZA is a useful technique for removal of tumours expanding superiorly to the middle cranial fossa base without significant compression of the brain. Ability to remove tumours through the described approach decreases as the degree of infiltration of the clivus increases.

Mucocoele and mucopyocoele of the frontal sinus penetrating to the cranial cavity and the orbit

BACKGROUND AND PURPOSE Mucocoele of the paranasal sinuses falls within the scope of interest for neurosurgery when erosion of the sinus wall and the osseous structures of the skull base develops and the lesion extends towards the cranial cavity, the orbit, the cavernous sinus or the sella turcica. The pa-per aims to present the method of treatment of extensive mucocoele which is used in our clinic. MATERIAL AND METHODS We treated 7 patients (2 women and 5 men; age range: 27-68 years). Mucopyocoele was diagnosed in two cases, and mucocoele in the other five. In 5 cases, extension of the mucocoele to the cranial cavity and the orbit or to the ethmoid sinus and the orbit was observed. In the remaining 2 cases, mucopyocoele extended to the ethmoid sinus, the sphenoid and maxillary sinuses, cranial cavity and the orbit. The purpose of surgery was to remove the mucocoele or the mucopyocoele and to prevent recurrence. RESULTS The postoperative course in all 7 patients was uneventful. All symptoms gradually receded. No relapse was observed in any patient during a follow-up period that varied from 10 months to 8 years; nor did incidents of inflammation of collateral sinuses occur. CONCLUSIONS The treatment of mucocoele or mucopyocoele of the frontal sinus penetrating to the cranial cavity and the orbit consists of the following stages: cranialization of the frontal sinus, complete resection of the mucosa, tight closing of the frontal-nasal duct, and separating the air space of the opened collateral nasal sinuses from the cranial cavity with a large pedicled periosteal flap.

Dostęp podskroniowy rozszerzony do dołu podskroniowego i jego otoczenia – analiza techniki operacyjnej na podstawie symulacji na zwłokach

Streszczenie Celem pracy jest przedstawienie poszczegolnych etapow dostepu podskroniowego rozszerzonego (DPR). Przeprowadzono 7 symulacji dostepu na nieutrwalonych zwlokach ludzkich, u ktorych nie podejrzewano procesow patologicznych w zakresie glowy i szyi. Kolejne fazy symulacji byly dokumentowane fotograficznie oraz schematami. Punktem wyjścia dla DPR jest osteotomia luku jarzmowego i kraniektomia obejmująca dolne partie cześci luskowej kości skroniowej i skrzydlo wieksze kości klinowej. Przemieszczenie lub usuniecie zawartości dolu podskroniowego pozwala na penetracje jego wnetrza i otoczenia. Dodatkowe poszerzenie wglądu daje osteotomia wyrostka klykciowego zuchwy. Dostep podskroniowy rozszerzony stanowi powtarzalną metode penetracji dolu podskroniowego i jego otoczenia. Dostep ten jest szczegolnie przydatny w leczeniu operacyjnym guzow nowotworowych rozrastających sie w oczodole, zatoce szczekowej, dole skrzydlowo-podniebiennym, nosogardle, zatoce klinowej, zatoce jamistej, przestrzeni przygardlowej, dole zazuchwowym i otoczeniu odcinka skalistego tetnicy szyjnej wewnetrznej.The aim of the study was to present consecutive stages of the extended subtemporal approach (ESA). Seven simulations of ESA were performed on non-fixed human cadavers without any known pathologies in the head and neck. The consecutive stages of the procedure were documented with photographs and schemes. The starting point for ESA is osteotomy of the zygomatic arch and craniectomy including the greater wing of the sphenoid bone. Dislocation or removal of subtemporal fossa contents allows one to penetrate its inside and related structures. Additional widening of inspection allows osteotomy of the condyloid process of the mandible. ESA is a reproducible technique which provides surgical penetration of the subtemporal fossa and related structures. This approach is particularly useful in the surgical treatment of tumours expanding in the orbit, maxillary sinus, pterygopalatine fossa, nasopharynx, sphenoid sinus, cavernous sinus, parapharyngeal space, retromandibular fossa and surroundings of the petrosal part of the internal carotid artery.

Dostęp do otworu szyjnego i jego otoczenia – analiza techniki operacyjnej w oparciu o symulacje na zwłokach

Streszczenie Celem pracy jest przedstawienie poszczegolnych etapow dostepu do otworu szyjnego i jego otoczenia. Przeprowadzono 11 symulacji dostepu na nieutrwalonych zwlokach ludzkich, u ktorych nie podejrzewano procesow patologicznych w zakresie glowy i szyi. Kolejne fazy symulacji byly dokumentowane fotograficznie oraz schematami. Punktem wyjścia dla omawianego dostepu jest resekcja cześci sutkowej i tylnych partii cześci skalistej kości skroniowej, jak rowniez wyrostka i guzka szyjnego. Pozwala to na penetracje otworu szyjnego od tylu. Poszerzanie dostepu umozliwia penetracje otworu szyjnego od gory i od przodu. Dostep do otworu szyjnego stanowi powtarzalną metode penetracji tego otworu i jego otoczenia. Dostep ten jest szczegolnie przydatny w leczeniu operacyjnym guzow nowotworowych rozrastających sie w piramidzie kości skroniowej, otoczeniu odcinka skalistego tetnicy szyjnej wewnetrznej, kącie mostowo-mozdzkowym, dole podskroniowym i peczku naczyniowo-nerwowym szyi.

Early and long-term results of the treatment of jugular paragangliomas using different ranges of surgical approach

BACKGROUND AND PURPOSE The applied approach to the jugular foramen is a combination of the juxtacondylar approach with the subtemporal fossa approach type A. The purpose of this study is to present our results of treatment of jugular paragangliomas using the aforementioned approach. MATERIAL AND METHODS Twenty-one patients (15 women, 6 men) with jugular paragangliomas were included in the study. The neurological status of the patients was assessed before and after surgery as well as at the conclusion of treatment. The approximate volume of the tumour, its relation to large blood vessels, cranial nerves and brainstem, as well as consistency and vascularity were also assessed. RESULTS The duration of symptoms ranged from 3 to 74 months. In 86% of patients hearing loss was the predominant symptom. The less frequent symptoms included pulsatile tinnitus in the head, dysphagia and dizziness. Approximate volume of the tumours ranged from 2 to 109 cm3. A gross total resection was achieved in 71.5% of patients. The postoperative performance status improved in 38% of patients, did not change in 38% and deteriorated in 24% of patients. CONCLUSIONS A proper selection of the range of the approach to jugular foramen paragangliomas based on their topography and volume reduces perioperative injury without negative consequences for the radicality of the resection.

ARTYKUŁ POGLĄDOWY/REVIEW PAPERDostęp podskroniowy rozszerzony do dołu podskroniowego i jego otoczenia – analiza techniki operacyjnej na podstawie symulacji na zwłokachExtended subtemporal approach to the subtemporal fossa and related structures – analysis of the surgical technique based on cadaver simulation

Streszczenie Celem pracy jest przedstawienie poszczegolnych etapow dostepu podskroniowego rozszerzonego (DPR). Przeprowadzono 7 symulacji dostepu na nieutrwalonych zwlokach ludzkich, u ktorych nie podejrzewano procesow patologicznych w zakresie glowy i szyi. Kolejne fazy symulacji byly dokumentowane fotograficznie oraz schematami. Punktem wyjścia dla DPR jest osteotomia luku jarzmowego i kraniektomia obejmująca dolne partie cześci luskowej kości skroniowej i skrzydlo wieksze kości klinowej. Przemieszczenie lub usuniecie zawartości dolu podskroniowego pozwala na penetracje jego wnetrza i otoczenia. Dodatkowe poszerzenie wglądu daje osteotomia wyrostka klykciowego zuchwy. Dostep podskroniowy rozszerzony stanowi powtarzalną metode penetracji dolu podskroniowego i jego otoczenia. Dostep ten jest szczegolnie przydatny w leczeniu operacyjnym guzow nowotworowych rozrastających sie w oczodole, zatoce szczekowej, dole skrzydlowo-podniebiennym, nosogardle, zatoce klinowej, zatoce jamistej, przestrzeni przygardlowej, dole zazuchwowym i otoczeniu odcinka skalistego tetnicy szyjnej wewnetrznej.The aim of the study was to present consecutive stages of the extended subtemporal approach (ESA). Seven simulations of ESA were performed on non-fixed human cadavers without any known pathologies in the head and neck. The consecutive stages of the procedure were documented with photographs and schemes. The starting point for ESA is osteotomy of the zygomatic arch and craniectomy including the greater wing of the sphenoid bone. Dislocation or removal of subtemporal fossa contents allows one to penetrate its inside and related structures. Additional widening of inspection allows osteotomy of the condyloid process of the mandible. ESA is a reproducible technique which provides surgical penetration of the subtemporal fossa and related structures. This approach is particularly useful in the surgical treatment of tumours expanding in the orbit, maxillary sinus, pterygopalatine fossa, nasopharynx, sphenoid sinus, cavernous sinus, parapharyngeal space, retromandibular fossa and surroundings of the petrosal part of the internal carotid artery.

Dostęp czołowo-skroniowo-oczodołowo-jarzmowy – analiza techniki operacyjnej na podstawie symulacji na zwłokach

Streszczenie Celem pracy bylo przedstawienie poszczegolnych etapow dostepu czolowo-skroniowo-oczodolowo-jarzmowego (DCSOJ). Przeprowadzono dwie symulacje dostepu na nieutrwalonych zwlokach ludzkich, u ktorych nie podejrzewano procesow patologicznych w zakresie glowy i szyi. Kolejne fazy symulacji byly dokumentowane fotograficznie oraz za pomocą schematow. Punktem wyjścia dla DCSOJ jest kraniotomia pterionalna i osteotomia obejmująca obramowanie oczodolu, trzon kości jarzmowej i luk jarzmowy. Plat pterionalny i wymienione wyzej struktury stanowią jeden blok kostny. W uzasadnionych przypadkach mozliwe jest tez czasowe usuniecie gornej i bocznej ściany oczodolu. Wazne uzupelnienie dostepu stanowi szerokie rozchylenie szczeliny bocznej mozgu. Dostep czolowo-skroniowo-oczodolowo-jarzmowy stanowi powtarzalną metode penetracji środkowego dolu czaszki i obszarow z nim graniczących. Jest szczegolnie przydatny w leczeniu operacyjnym guzow nowotworowych wyzej wymienionych okolic anatomicznych, jak rowniez wad naczyniowych tylnej cześci kola tetniczego mozgu.This paper presents consecutive stages of the fronto-temporo-orbito-zygomatic approach (FTOZA). Two simulations of FTOZA were performed on non-fixed human cadavers without any known pathologies in the head and neck. The consecutive stages of the procedure were documented with photographs and schematic diagrams. The starting point for FTOZA is a pterional craniotomy and osteotomy including the orbital rim, body of the zygomatic bone and zygomatic arch. In justified cases it is also possible to temporarily remove the upper and lateral walls of the orbit. Wide drawing apart of the Sylvian fissure is an important supplement of the approach. The fronto-temporo-orbito-zygomatic approach is a reproducible technique, which provides surgical penetration of the middle cranial fossa and related regions. This approach is particularly useful in the treatment of tumours of the above-mentioned anatomical areas as well as vascular malformation of the posterior part of the arterial circle of the brain.

Direct and remote outcome after treatment of tumours involving the subtemporal fossa and related structures with the extended subtemporal approach

BACKGROUND AND PURPOSE The aim of the study was to present our results of the surgical treatment of subtemporal fossa tumours and surrounding regions using the extended subtemporal approach. MATERIAL AND METHODS Twenty-five patients (10 women, 15 men) with subtemporal fossa tumours were included in the study. The neurological and performance status of the patients were assessed before and after surgery as well as at the conclu-sion of treatment. The approximate volume of the operated tumour, its relation to large blood vessels and cranial nerves, as well as consistency and vascularisation were assessed. RESULTS The symptom duration ranged from 2 to 80 months (mean: 14 months). In 44% of patients, headache was the predominant symptom. Less frequent symptoms were: paralysis of the abducent nerve and disturbances of the trigeminal nerve. Approximate volume of the tumours ranged from 13 to 169 cm3 (mean: 66 cm3). The most frequent histological diagnosis was meningioma (16%), followed by angiofibroma, neurinoma and adenocystic carcinoma (12%). Total or subtotal resection was achieved in 80% of patients. CONCLUSIONS The extended subtemporal approach allows for the removal of tumours of the subtemporal fossa and surrounding regions. This approach also allows one to remove tumours expanding in the regions surrounding the subtemporal fossa only. In such cases the subtemporal fossa constitutes the way of the surgical approach.

Surgical treatment and prognosis of adult patients with brainstem gliomas

The paper presents 47 adult patients who were surgically treated due to brainstem gliomas. Thirteen patients presented with contrast-enhancing Grades III and IV gliomas, according to the WHO classification, 13 patients with contrast-enhancing tumours originating from the glial cells (Grade I; WHO classification), 9 patients with diffuse gliomas, 5 patients with tectal brainstem gliomas and 7 patients with exophytic brainstem gliomas. During the surgical procedure, neuronavigation and the diffusion tensor tractography (DTI) of the corticospinal tract were used with the examination of motor evoked potentials (MEPs) and somatosensory evoked potentials (SSEPs) with direct stimulation of the fundus of the fourth brain ventricle in order to define the localization of the nuclei of nerves VII, IX, X and XII. Cerebellar dysfunction, damage to cranial nerves and dysphagia were the most frequent postoperative sequelae which were also the most difficult to resolve. The Karnofsky score established preoperatively and the extent of tumour resection were the factors affecting the prognosis. The mean time of progression-free survival (14 months) and the mean survival time after surgery (20 months) were the shortest for malignant brainstem gliomas. In the group with tectal brainstem gliomas, no cases of progression were found and none of the patients died during the follow-up. Some patients were professionally active. Partial resection of diffuse brainstem gliomas did not prolong the mean survival above 5 years. However, some patients survived over 5 years in good condition.