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DOI: http://dx.doi.org/10.20534/ESR-16-9.10-70-73
Asadullaev Ulugbek Maksudovich, Republican Scientific Center of Neurosurgery of Uzbekistan E-mail: [email protected] Kariev Gayrat Maratovich, Tashkent Medical Pediatric Institute Republican Scientific Center of Neurosurgery of Uzbekistan
E-mail: [email protected] Mamadaliev Dilshod Muhammadvalievich, Republican Scientific Center of Neurosurgery of Uzbekistan
E-mail: [email protected]
Staged surgery of deep midline tumors. Comparative analysis and literature review
Abstract: This article analyzes the results of clinical observation of255 patients with deep midline tumors accompanied by secondary obstructive hydrocephalus. Of them75 (29.41%) patients underwent endoscopic third ventriculostomy (ETV) as a first step, followed a week later by tumor resection as a second step of treatment. In 85 (33.33%) patients ETV and tumor resection was performed simultaneously, and 95 (37.25%) patients tumor resection with ventriculocisternostomy by Torkildsen's method was done. In ETV group condition of the patients is significantly improved after adequate correction of CSF circulation. All patients complained of headaches, symptoms of raised intracranial pressure or visual disturbances and vomiting or cerebellar ataxia. Complete tumor removal was achieved in 190 cases and partial removal or biopsy in the remaining 65. ETV was successful in 177 (87.50%) cases but failed in one. Two patients experienced intraoperative transitory bradycardia. Two postoperative complications occurred (one meningitis and one CSF leak). No death related to procedures occurred. Hospital stay ranged from 9 to 21 days (mean, 12.71 days). Follow up range was 4 months to 10 months. Keywords: posterior fossa tumors, third ventricular tumors, ETV, staged surgery.
The posterior cranial fossa considered not only the largest and deepest fossa, it is the fossa that containing most complex anatomical structures. All the vital pathways regulating consciousness, motor, sensory and balance functions. Only 2 of the 12 pairs of cranial nerves are located entirely outside of posterior cranial fossa, the 10 other pairs have a segment within posterior fossa [1].
The surgery of posterior cranial fossa tumors are still remaining one of the challenging cases of practical neurosurgery [1; 2; 5;
13]. The features of brain tumors associated with hydrocephalus, requires the solution of two important issues. Firstly, elimination of a progression of the hydrocephalic syndrome; secondly, resection of brain tumor itself [2-4]. Conventional methods of surgical correction of hydrocephalic syndrome are ventriculocisternostomy (VCS) by Torkildsen, ventriculoperitoneal shunting, ventriculoatriostomy have a number of contraindications and are traumatic in some point. Most these interventions often contribute to the development of
Staged surgery of deep midline tumors. Comparative analysis and literature review
several complications, such as infection and occlusion of shunts, particularly in decompensated patients [1; 3; 5; 9; 10].
An alternative way of solving this problem is endoscopic ventriculocisternostomy of third ventricle (ETV), which creates new CSF pathway provides drainage of excessive CSF to subarachnoidal space via cisterns. [2; 5; 11; 12]. This surgery is should be performed by experienced neurosurgeons, it should be noted that removing of tumor has to be at the second stage after eliminating the hydrocephalus. However, if the patient's condition, cerebral symptoms are relatively compensated, this operations are performed significantly less.
Objective of the research is to make a comparison between results of one and two staged surgery after ETV and ventriculocisternostomy by Torkildsen's method in deep midline brain tumors.
Materials and methods. We have analyzed 255 patients, with midline brain tumors associated hydrocephalus in Republican Scientific Center of Neurosurgery. Most of our patients admitted to hospital in a severe complicated stage of disease. Age group ranged from 1,5 to 50 years which is shown in Table № 1.
Table 1.
There are direct correlations of stage of papilledema to the extent ofventricular dilation on MRI. The results of treatment assessed by dynamic changes in clinical presentation, regress of hydrocephalic syndrome, positive changes in eye fundus, and data of neurovisualisation.
ETV was performed using neuroendoscopic complex of «Aes-culap» (Germany) with the set of microneurosurgical instruments
(Fig.1).
Age group Amount (%) Age group Amount (%)
1,5 -5y. 10 (3,92%) 20-25 20 (7,84%)
5 -10 53 (20,78%) 25-30 25 (9,81%)
10-15 57 (22,35%) 30-35 22 (8,62%)
15-20 43 (16,86%) 35-40 8 (3,15%)
40-50 17 (6,67%)
What is noticeable, 76,47% of patients were male and only 23,53% were female. It is remarkable that, close location of tumor to the CSF pathways, plays basic role in developing hydrocephalus, rather than size of a tumor. Clinical state of patients evaluated using standard neurological examination. The degree of common cerebral symptoms evaluated due to patients complaints. Ophthalmologi-cal examination includes detailed study of structures of eye fundus (arterioles, venules, optic disc). 3 stages of papilledema assessed.
Figure 1. Neuroendoscopic complex of «Aesculap»
Figure 2. Stages of ETV of patient with severe hydrocephalus: а) view from anterior horn of right lateral ventricle. (foramen
of Monroe, tela chorioida, septal vein) b) a view of third ventricle through foramen of Monroe. (mammillary bodies and premammillary membrane is visible). c) before fenestration (the membrane distorted and fixed to the wall of basilar artery.). d, e) preliminary coagulation of membrane. f) ETV is performed, basilar artery is visible within interpeduncular cistern
In figure 2 on the right side, we can see the fenestration process. The first anatomic landmark that we should evaluate is foramen of Monroe (Fig.2., a). Perforation was done using Fogarti's catheter, passing it through external surgical sheath of endoscope. Considering all detailed MRI visualization of tumor localization the approach was planned. In case of foramen of Monroe occlusion by the tumors located at the anterior or middle part of the 3rd ventricle ETV was not feasible, therefore, planned ventriculocisternostomy by Torkild-sen. A direct indication for ETV was enough space into 3rd ventricle. (usually occlusion caused by aqueductal stenosis or mass lesions in posterior cranial fossa).
All 255 patients were divided into 3 group regarding method of surgery:
1st group — patients who underwent surgery resection of tumor along with ventriculocisternostomy by Torkildsen; 2nd group underwent surgery simultaneously ETV with tumor resection; 3rd group who underwent 2 staged surgery -ETV followed by tumor removal after 5-35 days, after regression of symptoms of hydrocephalus. The
Table 2. - Distribution of patients
criteria for appointing second stage of treatment were elimination of common cerebral symptoms and regress of papilledema. Papilledema was evaluated according to Tron E. D. gradation I to V stage ofpapilledema. Statistical analysis was done using Students criteria. Difference between 2 groups considered as trustworthy in case statistical significance was not less than 95% (p<0,05).
Results and discussion. Most of (22%) patients were admitted to our clinic in a severe state of disease with symptoms of secondary hydrocephalus. In 52 (20,39%) patients admitted with extremely high risk of brain herniation syndrome with bradycardia severe papilledema complicated with retinal hemorrhage. Most of patients experienced diffuse headaches 245 (96,07%), followed by vertigo 218 (85,49%), and nausea in 227 (89,02%) and vomiting in 192 (75,29%) patients. Ophtalmologically in 95 (37,25%) patients found papilledema of 1stdegree, in 107 (42,96%) patients 2nd degree, in 53 (20,78%) patients 3rd degree of papilledema. In 90 (76,59%) patients detected bradycardia. All the the patients by CT and MRI revealed signs of hydrocephalus- ventriculomegaly with periventricular edema.
by the site and cause of occlusion
Localization of brain tumors Site of occlusion
3rd ventricle, cerebral aqueduct 4th ventricle, cerebellar hemispheres Overall
Abs % Abs % Abs %
Pineal and quadrigeminal plate 15 28,30 38 71,70 53 20,78
Posterior fossa tumors 25 12,38 177 87,62 202 79,22
Overall 40 15,68 215 84,31 255 100
The site of occlusion was one of the indications for surgery in brain tumors with secondary hydrocephalus, table1 depicts distribution of patients regarding site of occlusive process thereby chosen surgical procedure. All patients of 3rd group underwent ETV without any complications and postoperatively clearly seen regressed signs of hydrocephalus. Significantly decreased headaches in 55 patients (73,33%) and local occipital pains in 20patients (26,66%). Postoperative CT and MRI at the 2-3rd found decreased dilation of ven-
tricles and no periventricular edema 62 (82,66%) clear opening of subarachnoid spaces in 35 (46,66%) "Flow-void" phenomenon at the anterior third ventricular region.
85 patients underwent (33,33%) ETV with simultaneous tumor removal, 95patients (37,25%) ventriculocisternostomy by Torkildsen. The analysis of results of surgical treatment (table.2) considering morbidity, improving or deterioration state of patients let us to make a clear comparison of outcome of surgeries.
Table 3. - Outcome of surgical intervention first time operated patients using various methods of CSF diversion with tumor removal
Method of operation Improved Deteriorated Morbidity Overall
Abs % Abs % Abs % Abs %
VCS by Torkildsen 38 40,00 35 36,84 22 23,16 95 37,25
Simultaneous ETV 52 61,18** 20 23,53** 13 15,29** 85 33,33*
2 staged ETV 55 73,34*** 13 17,33*** 7 9,33*** 75 29,41*
Overall 145 56,86 68 26,67 42 16,47 255 100
Note: Credibility among groups assigned with asterisk: * - P < 0,05; ** - P< 0,01; *** - P< 0,001.
If when ETV was performed simultaneously 52 patients from 85 (61,18%) experienced significant improvement, 20 patients 23,53%) experienced deterioration and 13 (15,29%) exitus lethalis, while 2 staged operation gave 73,34% of improvement, 13 (17,33%) patients deteriorated, morbidity in 7 (9,33%) from 75 operated patients. In group of operated patients with ventriculocisternostomy by Torkildsen (95 patients) 38 (40,00%) patients experienced good outcome and 35 (36,84%) patients with deterioration, and rate of morbidity — 22 (23,16%).
In conclusion, the study of 3 group ofpatients whom performed 3 method of surgery, showed advantage of endoscopic minimally invasive intervention, preserving anatomical structures in contrast to
open surgery. Comparative study of one and two staged ETV procedures showed the advantage of two staged surgery, more smooth postoperative course ofrehabilitation and much easier surgery when hydrocephalic symptoms are eliminated.
Conclusion.
1. ETV considered as minimally invasive highly informative method of diagnostics and treatment helping neurosurgeon to do a surgery much easier.
2. In case of predominant occlusive hydrocephalus the method of choice is staged operation using ETV as a first stage and after stabilization of general state of patient, removing the brain tumor gives better outcome.
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Impact of diabetes mellitus compensation on pregnancy outcomes
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DOI: http://dx.doi.org/10.20534/ESR-16-9.10-73-75
Atadjanova Muborak Masharipovna, MD, PhD, researcher at the Thyroidology Department of Republican Specialized Scientific and Practical Medical Center of Endocrinology, Uzbekistan.
E- mail [email protected]
Impact of diabetes mellitus compensation on pregnancy outcomes
Abstract: 40 pregnant women with type 1 DM were recruited for the study and divided into two groups by terms of DM compensation. Pregnancy outcomes significantly improved with pregnancy planning and adequate and timely self-control over glycemia, and regular visits to a physician for examination.
Keywords: diabetes mellitus, pregnancy, compensation, complication.
High percent of complications both in pregnancy and delivery taken into account [3, 11], management of pregnant women with diabetes mellitus (DM) ever was and still is a challenging task. Leading experts in the sphere believe that among the most important issues to be determined prior to conception in every patient are the degree of DM compensation, presence and stage of microangiopathies, presence of arterial hypertension, and thyroid pathology as well as changes in lipid metabolism, and presence of anemia [1; 7].
DM compensation prior to conception is the most important issue of all above, since it contributes to reduction in the rate of congenital anomalies, stillbirths, neonatal mortality and premature deliveries. As compared with the patients who get antenatal consultation, incidence of fetal and neonatal mortality and congenital anomalies is four times higher in women who do not get it [2; 3]. Hyperglycemia is a teratogen, and it may result in cardiac defects, anomalies in the central nervous system, such as anencephaly and spina bifida, skeletal and urogenital anomalies [4; 11]. Ideally, any pregnancy should be the planned one. A woman should be capable of self-control, and she should have as few diabetic complications as possible. She should be informed that the risk of diabetic complications increases by duration of the disease. 3-4 months before con-
ception ideal DM compensation should be achieved. Changes in the targets of self-control, more frequent decompensation events due to changes in insulin requirements, and potential obstetric complications taken into account, patients who were trained in the "diabetes school" should be trained repeatedly when getting pregnant.
The work was initiated to compare pregnancy outcomes in patients with compensated and decompensated type 1 diabetes mellitus.
Materials and methods
We recruited 40 pregnant women aged 21 to 28 years with type 1 diabetes mellitus to divide them into two groups by terms of DM compensation. Thus, 20 women referred for medical care after 8 weeks of gestation (late term referral and, consequently, late compensation) were included into the 1st group, 20 women referred before conception or under 8 weeks of gestation (early term and, consequently, early carbohydrate metabolism compensation) comprised the 2nd group. The disease duration was 2-13 and 1-10 years in the 1st and 2nd group, respectively.
The fasting glucose and postprandial 1-hour glucose, urinary glucose, HbA1 c and lipid profiles were measured during the first visit and subsequently once in 1-3 months. All patients were capable of self-control. 17 of 40 patients (42.5%) had glucometers
