Scientific Committee. Invited speakers

Transkript

1 Scientific Committee Vladimír Beneš Ivan Bízik Andrej Džubera Miroslav Galanda Robert Illéš Jiří Náhlovský Juraj Šteňo Petr Suchomel Igor Šulla Invited speakers Vladimír Beneš, Prague, Czech Republic Peter M. Black, Boston, Massachusetts, USA Jacques Brotchi, Brussels, Belgium Miroslav Galanda, Banská Bystrica, Slovak Republic Engelbert Knosp, Vienna, Austria Chris Loftus, Philadelphia, Pensylvania, USA L. Dade Lunsford, Pittsburgh, Pensylvania, USA István Nyáry, Budapest, Hungary Alexander A. Potapov, Moscow, Russia Bernd Richling, Salzburg, Austria Madjid Samii, Hannover, Germany Petr Suchomel, Liberec, Czech Republic Igor Šulla, Košice, Slovak Republic Karl Ungersböck, St. Pölten, Austria Geirmund Unsgard, Trondheim, Norway

2 GENERAL INFORMATION Venue Historical Building of the National Council of the Slovak Republic, Župné námestie 1, Bratislava 1 The official languages of the Congress: English, Slovak, Czech Date November 23 rd 25 th, 2008 Registration Sunday, November 23 rd, :00-18:00 Monday, November 24 th, :00-17:00 Tuesday, November 25 th, :00-14:00 Transportation Hotel CROWNE PLAZA - five minutes by walk to Conference venue Hotel DRUŽBA - tram No. 1, 9 get in Botanická záhrada, get out Kapucínska about ten minutes drive to Conference venue Hotel IBIS BRATISLAVA CENTRUM - five minutes by walk to Conference venue Hotel SÚZA - trolley bus No. 207 get in Búdková get out Hodžovo námestie or by taxi about twenty minutes drive to Conference venue Hotel TATRA - ten minutes by walk to Conference venue (More information on

3 PROGRAM AT A GLANCE Sunday, November 23 rd, Welcome reception Monday, November 24 th, Opening Tumour Coffee break Welcome of the Chairman of the National Council of the Slovak Republic Bestowing of Honorary Membership of the Slovak Neurosurgical Society Tumour Lunch Vascular Coffee break Tumour Reception Tuesday, November 25 th, Trauma Coffee break Degenerative spine Lunch Tumour Coffee break Vascular Closing remarks

4 SCIENTIFIC PROGRAM Monday, November 24 th, J. Šteňo (Bratislava, Slovakia): Department of Neurosurgery of Comenius University Medical School in Bratislava, 40 years history. (Time allocated for presentation includes discussion) Tumour I minutes Chairmen: J. Brotchi, M. Samii 1. M. Samii (Hannover, Germany): New trends in skull base tumour surgery 2. P. Black (Boston, MA, USA): Management of low grade gliomas 3. J. Brotchi (Brussels, Belgium): Intramedullary tumors surgery. Personal experience on more then 400 cases Coffee break 30" 30" 30" Welcome of the Chairman of the National Council of Slovak Republic Bestowing of Honorary Membership of the Slovak Neurosurgical Society Tumour II Chairmen: P. Black, E. Knosp 4. G. Unsgard (Oslo, Norway): Intraoperative 3D ultrasound navigation 5. D. Lunsford (Pittsburgh, PA, USA): The role of radiosurgery during multimodality management og glial neoplasms 6. E. Knosp (Vienna, Austria): Endoscopic surgery of sellar region tumours 20" 30" 20"

5 7. V. Masopust, D. Netuka (Prague, Czech Republic): Uzávěr tvrdé plény rozšířená endoskopická endonasální chirurgie (Closure of the dura enlarged endoscopic endonasal surgery) M. Vaverka, J. Macháč, D. Krahulík, L. Hrabálek (Olomouc, Czech Republic): Meningiomas involving optic nerve is there still place for surgical therapy? I. Nyáry (Budapest, Hungary): Surgical treatment of large peripheral and spinal nerve schwannomas 15" 10. M. Galanda (Banská Bystrica, Slovakia): The role of electrostimulating methods in neurosurgery - our experience 15" Lunch Lunch Symposium, Electa Vascular I Chairmen: B. Richling, C. Loftus, V. Beneš 11. B. Richling (Salzburg, Austria): The role of endovascular interventions in the management of brain AVMs? 12. V. Beneš (Prague, Czech Republic): AVM treatment Own series and metaanalysis 13. G. Unsgard (Trondheim, Norway): Surgery of brain AVM using navigation and stereoscopic display of both MRA and US angiography 14. C. Loftus (Philadelphia, PA, USA): Advanced techniques for carotid surgery 15. V. Přibáň, M. Bombic, J. Fiedler (České Budějovice, Czech Republic): Eversion techniques of carotid endarterectomy. 16. A. Csókay, A. Viola (Budapest, Hungary): Novel non-occlusive by pass technique in the course of cerebral revascularization by robot hand technique 20" 15" 15" 20" 10 10

6 17. S. Řehák, A. Krajina, J. Náhlovský(Hradec Králové, Czech Republic): Mozková Aneuryzmata dětského věku (Cerebral aneurysms in pediatric age) Coffee break Tumour III Chairmen: G. Unsgard, D. Lunsford, M. Galanda 18. J. Šteňo, I. Bízik, V. Matejčík, J. Šurkala (Bratislava, Slovakia): Gliomas of the third ventricle 19. Z. Novák, J. Chrastina, J. Hemza, R. Jančálek, I. Říha (Brno, Czech Republic): The role of neuroendoscopy in the treatment of intraventricular tumors 10" 20. J. Chrastina, Z. Novák, R. Kuba, M. Brázdil, R. Jančálek, I. Říha (Brno, Czech Republic): Brain tumor as a cause of pharmacoresistant epilepsy 10" 21. M. Tichý, P. Kršek, J. Zámečník, V. Komárek (Prague,Czech Republic): Epileptochirurgický přístup k benigním nádorum mozku (Epilepsy surgery attitude to low grade gliomas) 10" 22. A. Šteňo, J. Šurkala, G. Timárová, V. Ostatníková, P. Mendel, V. Hollý, J. Šteňo (Bratislava, Slovakia): Pitfalls of brainmapping and the use of awake craniotomy in low grade glioma surgery 10" 23. V. Hollý, P. Mendel, M. Liška (Bratislava, Slovakia): Awake craniotomy z pohľadu anesteziologa - target controlled infusion (Awake craniotomy from the anesthesiologist s point of view TCI) 10" Reception

7 Tuesday, November 25 th, Trauma Chairmen: A. Potapov, K. Ungersboeck, P. Haninec 24. A. Potapov (Moscow, Russia): Neuroimaging in TBI 25. K. Ungersboeck (St. Poelten, Austria): Clinical experience with head injury 26. P. Lavička, R. Pikner, S. Kormunda, O. Topočan, I. Chytra, R. Bosman, L. Holubec, M. Choc (Pilsen, Czech Republic): Development of the S 100 B protein levels in patients with polytrauma and positive or negative CT scan of the head 27. M. Novotný, M. Liška, M. Kľoc, J. Šteňo (Bratislava, Slovakia): Chronický subdurálny hematóm (Chronic subdural haematoma) M. Kľoc, A. Džubera, R. Illéš, V. Matejčík, J. Šteňo (Bratislava, Slovakia): The role of craniectomy in management of severe brain trauma our experience 10" 29. J. Mišovič, M. Rattaj, P. Moják, O. Šedivý (Nitra, Slovakia): Kontúzie mozgu (Brain contusions) 10" 30. P. Haninec, L. Houšťava, R. Tomáš, R. Kaiser (Prague, Czech Republic): Comparison of various methods of brachial plexus reconstruction 15" Coffee break Degenerative Spine Chairmen: P. Suchomel, A. Džubera P. Suchomel (Liberec, Czech Republic): Cervical spine arthroplasty critical update 32. M. Benčo, J. De Riggo, B. Kolarovszki, Y. Mellová, H. Poláček (Martin, Slovakia): Anatomy of the roots of cauda equina 30" 10

8 33. R. Jančálek, P. Dubový, Z. Novák (Brno, Czech Republic): Dynamika morfologických změn u experimentální komprese spinálnich kořenu v korelaci s klinickou praxi (Dynamics of morphological changes in experimental compression of the roots in correlation with clinical practice) I. Šulla, V. Balik, F. Lacko, I. Lukáč, P. Levkuš (Košice, Slovakia): Cauda equine syndrome due to intervertebral disc disease T. Paleček, M. Mruzek, T. Posolda (Ostrava, Czech Republic): Funkční náhrada disku bederní páteře hodnocení po 5-ti letech (Functional lumbar disc replacement, follow-up 5 years) J. Steindler, L. Pekař, M. Tichý (Prague, Czech Republic): Minimálně invazivní operace páteře nový trend ve spondylochirurgii (Minimally invasive operations of the spinal column new trend in spinal surgery) M. Choc, S. Zidek, D. Bludovsky (Pilsen, Czech Republic): Diagnosis and surgical treatment of foraminal-extraforaminal intervertebral disc herniation 15" 38. A. Džubera (Bratislava, Slovakia): Laminoplasty in multilevel spondylosis of cervical spine 10" Lunch Tumours IV Chairmen: I. Nyáry, M. Tichý 39. V. Belan, Ľ. Pružincová, M. Srbecký, B. Rychlý, P. Kalina, M. Fabian, M. Novotný, J. Šteňo (Bratislava, Slovakia): Cerebral blood volume, MR spectroscopy and diffusion weighted imaging in grading of glial brain tumour 10" 40. Ľ. Pružincová, V. Belan, P. Kalina, M. Novotný, B. Rychlý, M. Chorváth, E. Bolješíková, V. Pročka, I. Makaiová, J. Šteňo (Bratislava, Slovakia): Advanced MRI techniques in the follow-up of treated gliomas 10"

9 41. V. Pročka, I. Makaiová, J. Šteňo, M. Novotný, P. Kalina, V. Belan, Ľ. Pružincová, B. Rychlý, V. Lehotská, A. Ďurkovský, P. Bánki, S. Kováčová, S. Šenkeriová (Bratislava, Slovakia): Value of 18FDG/PET in preoperative diagnostics of glioblastoma multiforme T. Galanda, J. Bullová, M. Kluzová, M. Galanda (Banská Bystrica, Slovakia): Our experience in determining of optimal stimulation parameters during surgery in eloquent areas of brain A. Viola, T. Major, Z. Kolonban, M. Šramka, J. Julow (Budapest, Hungary, Bratislava, Slovakia): Tumor target volume determination for stereotactic radiosurgery using PET, CT and MRI image fusion O. Kalita, M. Vaverka, L. Hrabálek, M. Zlevorová, R. Trojanec, M. Hajdúch, J. Drábek, A. Hlobílková, M. Houdek (Olomouc, Czech Republic): Management of glioblastoma multiforme recurrences M. Chorváth, E. Bolješíková, Ľ. Pružincová, V. Pročka, B. Rychlý, M. Novotný, P. Kalina, V. Belan, I. Makaiová, J. Šteňo (Bratislava, Slovakia): Post-therapeutic changes in the brain: Novel trends in imaging and their influence on external beam radiotherapy 10" 46. P. Kalina, V. Belan, I. Makaiová, B. Rychlý, E. Bolješíková, J. Šteňo (Bratislava, Slovakia): The impact of follow-up of novel MRI and PET techniques on the management of patients with low-grade gliomas 10" 47. M. Smrčka, P. Šlampa (Brno, Czech Republic): Týmová spolurpáce v léčbě maligních gliomu mozku (Team approach to treatment of malignant cerebral gliomas) 10" 48. Z. Mackerle (Brno, Czech Republic): Role neurochirurga v komplexní onkologické léčbě tumoru mozku u malých dětí (The role of the neurosurgeon in complex oncology treatment of brain tumours in infants) 10" 49. T. Hosszú, I. Látr, J. Náhlovský (Hradec Králové, Czech Republic): Malignity lební baze od extenzivní chirurgie k endoskopickým výkonům (Malignancies of the skull base from extensive surgery to endoscopic interventions) 10"

10 Coffee break Vascular II and Miscellaneous Chairmen: M. Vaverka, M. Choc 50. V. Přibáň, J. Fiedler, V. Chlouba, M. Bombic (České Budějovice, Czech Republic): Occlusion of contralateral carotid artery risk of carotid endarterectomy? 51. J. Šteňo, I. Bízik, J. Šurkala, V. Matejčik, R. Illeš (Bratislava, Slovakia): The role of surgery in the management of cerebral cavernous malformation and venous anomalies. 52. M. Rattaj, J. Mišovič, P. Moják (Nitra, Slovakia): Surgical treatment of spontaneous intracerebral haemorrhage 53. K. Koleják, B. Rudinský, P. Harangozó (Nové Zámky, Slovakia): Technika a indikácie mikrovaskulárnej dekompresie pri neuralgii trojklaného nervu a faciálnom hemispazme (Technique and indications for microvascular decompression in trigeminal neuralgia and facial hemispasm) 54. J. Šurkala, R. Illéš, Ľ. Sidorová, J. Šteňo (Bratislava, Slovakia): Raritná neuralgia n. glossopharyngei spôsobená schwanomom a súčasne kompresiou a. vertebralis (Rare case of glossopharyngeal neuralgia caused by schwannoma and compression by vertebral artery) 55. B. Kolarovszki (Martin, Slovakia): Hodnotenie mozgovej cirkulácie u novorodencov a dojčiat s hydrocefalom pomocou transkraniálnej dopplerovskej sonografie (Evaluation of CBF in the newborns and infants with hydrocephalus by means of TCD) Closing remarks " 10" 10"

11 POSTERS 1. V. Balik, I. Šulla Jr, M. Sarissky, P. Gáll, J. Šulla (Košice, Slovakia): Immunophenotypic characteristics of stem cells derived from adult rat bone marrow 2. M. Choc, V. Rohan, M. Michal (Pilsen, Czech Republic): Chordoid glioma of the third ventricle. A case report and review of the literature 3. M. Líška, V. Hollý, A. Džubera, R. Illéš, P. Kukumberg, J. Šteňo (Bratislava, Slovakia): The possibilities and limitations of transcranial dopller monitoring after subarachnoid haemorrhage 4. M. Novotný, V. Matejčík, V. Belan, Ľ. Pružincová, I. Makaiová, V. Pročka, P. Kalina, B. Rychlý, E. Bolješíková, M. Chorváth, J. Šteňo (Bratislava, Slovakia): Gliomatosis cerebri 5. F. Pataky, M. Gajdoš, P. Levkuš, V. Kaťuch (Košice, Slovakia): Prehľad náhrad medzistavcových platničiek v cervikálnej spondylochirurgii (Overview of the intervertebral disc replacement implants in cervical spinal surgery) 6. M. Smrčka (Brno, Czech Republic): Spektrum a koncepce neurotraumatologie ve FN Brno 7. I. Šulla, Jr, I. Vanický, V. Balik, J. Orendáčová, I. Šulla (Košice, Slovakia): A canine experimental study of cauda equine syndrome 8. J. Vyrostko, I. Šulla, M. Gajdoš, P. Levkuš, J. Leško, J. Kafka, V. Balik, T. Cicholesová (Košice, Slovakia): Has the outcome of patients reoperated for lumbar disc hernia changed?

12 ABSTRACTS 7. Uzávěr tvrdé pleny - rozšířená endoskopická endonasální chirurgie V. Masopust, D. Netuka Neurochirurgická klinika, Lekárska fakulta UK, Praha, Česká republika Od roku 1914, kdy Cushing provedl hypofyzektomii z gingivolabiální incize uplynulo 93 let a během této doby se chirurgický přístup k adenomům hypofýzy neustále zdokonolaval. Od začátku roku 2007 bylo na neurochirurgické klinice ÚVN provedeno 90 endoskopických operací technikou z obou nosních dírek bez použití retraktorů. Použit byl endoskop Storz s 0 nebo 30st. optikou s proplachem, který byl zaváděn do levé nosní dírky a nástroje byly zaváděny z pravé nosní dírky. Začátkem roku 2008 jsme po zkušenostech z předchozích operací přistoupili k průniku nad diafragma a otevřeli strop sfenoidální dutiny nad a napříč interkavernózního splavu za účelem resekce kraniofaryngeomů a meningeomů v této oblasti. Nejsložitější fází těchto operací je uzávěr přístupové cesty. Klasický uzávěr svalem případně tukem je neúčinný. Dalším krok v uzávěru je vytvoření živého laloku z dolní konchy po odstranění střední konchy. Dolní koncha je zbavena kostěné části a sliznice je evertována. Dle naší zkušenosti se jedná o dobrou možnost záplaty na mnohočetné drobné netěsnosti, ale větší komunikaci neuzavře a dochází k obtékání likvoru. V současnosti je používána vícevrstvou technika, kdy je do otvoru vložena Tissudura (Baxter), která je protlačena intrakraniálně pomocí CranioFixu přesně vystřiženého do kostěného defektu. Další vrstvou je pak Tissudura extrakraniálně fixovaná na okrajích Surgicelem. Nejmodernější, ale zároveň nejsložitější technikou určenou pro velké defekty je živý slizniční lalok vytvořený ze septa. Tento je přenesen do oblasti defektu a fixován balónkem do jeho přihojení. S vývojem nových materiálů bude jistě docházet ke zlepšování možností jak uzavřít vzniklý defekt a tím se rozšíří i možnosti endoskopické operativy na bazi lební.

13 8. Meningiomas involving optic nerve is there still place for surgical therapy? M. Vaverka, J. Macháč, D. Krahulík, L. Hrabálek FNO Olomouc, Czech Republic Introduction As the safety and efficacy of stereotactic radiosurgery has been widely approved in the treatment of complex cranial base lesions, an increasing number of meningiomas have been treated with this modern technology. Meningiomas involving optic nerve - however primary tumors of the optic nerve sheath or secondary extended tumors from cavernous sinus, planum sphenoideale, tuberculum or diaphragma sellae and spheno-orbital localization can be considered as some special group. Methods In the group of 185 intracranial meningiomas surgicaly treated in period of last four years data of 33 patients with meningiomas involving the optic nerves were reviewed, by using operative notes, pre -, intra a postoperative imaging and ophtalmological examination findings.in all patient was performed preoperative CT and MR imaging. Results and discussion Authors find involved optic nerve in surprisingly high number of patients and degree of involvement varied of truly encased nerve to the tiny surface of tumor, which cannot be identified in MR imaging. Fragility and vulnerability of the optic nerve is based on the disturbances of vessels supplying the nerve, which tolerated only minimally surgical manipulation. Intact arachnoid membrane in intradural portion of the nerve and extradural unroofing bone optic canal and fissura orbitalis superior according Dolenc with opening optic nerve sheath in beginning of procedure permitted authors safety identification of nerve and complete dissection of tumor from nerve in all cases. In cases with large tumor the procedure was continuing in the conventional microsurgical technique with the splitting of Sylvian fissure. The limited factor for outcome are preoperative visual changes patients with minimally preoperative compromised vision had better results. It means, that treatment can be indicated as soon as possible especially in cases with the blindness in the opposite site.

14 It is still under discussion the difference between approximately 8 Gy, witch tolerated normal optic nerve and radiosurgical marginal dose around 14 Gy for tumor control. Sequential usage both method microsurgery and radiosurgery in staged procedures in various patients is part of the paradigm shift in now days Conclusion Meningiomas that involve optic nerves require special considerations and surgical techniques. The tumor could be completely resected from the optic nerve in most cases. Extradural unroofing of the bony optic canal is crucial for many reasons: additionally extradural decompression allows the surgeon interrupt a substantial portion of the tumor blood supply a and anterior clinoidectomy also adds more surgical space for manipulation. In cases involving large tumor facilitates locating and identification the optic nerve in normal area and following in into the tumor. When tumor recurs or regrows,the optic nerve has room to be displaced, without compromising vision. In cases requiring postoperative radiotherapy an optic nerve free of disease is spared the deleterious effects of radiotherapy and tumor can safely receive the radiation dose required for tumor control. Histological examination of tumor also brings important information, if radiosurgery is needed in staging procedures in high grade meningiomas in early postoperative period.

15 10. Role of electrostimulating methods in neurosurgery our experience M. Galanda Department of Neurosurgery, Roosevelt University Hospital, Banska Bystrica, Slovakia G. Fritsch and E. Hitzing (1870) were the first to demonstrate in experiment that the electrical stimulation of brain cortex of dogs produces contralateral limb movements. In humans, V.Horsley was the pioneer who systematically examined the motor cortex during neurosurgical procedures applying electrical stimulation. By stimulating of motor and somatosensory cortex he evoked motor response and paresthesias in contralateral extremities. In the middle of the last century the electrical activation of the cerebral functions has got a wide application in stereotactic neurosurgery, where it increased the accuracy of targeting from merely morphological to functional localization. Verification of the position of the electrode by stimulation caused a strong improvement of its efficacy and reduction of the side effects. The same principle is also used in contemporary neurosurgery. When performing surgery in eloquent areas of the brain or in their vicinity on cortical even subcortical level, often as awake craniotomy, utilizing close cooperation with anesthesiology, speech therapist, psychology and neurophysiology, with stimulation it is possible to detect functionally important areas, which are crucial and must be preserved during surgery. Neuronavigation and application of anatomical or functional MR, CT images, in conjunction with intraoperative neurophysiology, has really improved the possibilities of neurosurgeons for effective but safe treatment of diseases in these important territories of the CNS. In functional and stereotactic surgery long-term application of precisely defined stimulation program into a selected structures of the brain can positively influence central movement disorders, epilepsy, psychiatric diseases, pain, which remarkably worsen living standard of patients. Neurostimulation is a part of neuromodulating methods. Further development of cooperation of biomedical and technological experts will move forward the potential of neuromodulation into the horizons which were previously unreachable. Our experience with application of the electrostimulating methods in neurosurgery will be presented.

16 12. Mozková aneuryzmata dětského věku S. Řehák, A. Krajina, J. Náhlovský Neurochirurgická klinika, FN Hradec Králové, Česká republika Rádiologická klinika, FN Hradec Královí, Česká republika Mozková aneuryzmata jsou vzácnými neurochirurgickými lézemi, jejich incidence je menší než o 5%. Aneuryzmata v dětském věku se významně odlišují od dospělé populace v klinické manifestaci, rentgenových nálezech, morfologií a výsledcích. Při jejich zniku hrají hemodynamické faktory jako hypertenze a arterioskleróza menší roli než u dospělých, významné jsou vrozené defekty cévní stěny a sdružené systémové onemocnění. Prezentujeme skupinu dětských aneuryzmat léčených na NCH klinice v Hradci Králové za posledních 10 let. Jedná se o 11 pacientů u kterých jsme prokázali 13 aneuryzmat, kde převážná většina byla lokalizovaná v oblasti cerebri media (46%) a přední cirkulaci (39%). Více než polovina aneuryzmat měla větší průměr než 1 cm. U 39% nemocných se klinicky manifestovaly jen útlakovými příznaky bez vzniku SAK. Chirurgicky jsme řešili 3 pacienty u 2 pacientů s dobrým výsledkem a u jednoho předoperačně ve špatném klinickém stavu s ICH přetrvá vigilní stav. Endovaskulárně jsme léčili 7 pacientů s dobrými výsledky. Jeden nemocný v těžkém stavu zemřel krátce po SAK ještě před zahájením léčby.

17 16. Eversion technique of carotid endarterectomy V. Přibáň, M. Bombic, J. Fiedler Department of Neurosurgery, Hospital České Budějovice, Czech Republic The authors describe their own modification of carotid endarterectomy by eversion technique which they use in the case of combined stenosis and kinking of internal carotid artery. Complete division of internal carotid artery from the common carotid artery at the bulb is performed in an oblique fashion, folowing by excision of redundant wall. Added longitudinal incision of common carotid artery enables perfect removal of the atherosclerotic plaque. Proper posterior wall anastomosis of common and internal carotid artery in the bulb is carried out by one-way-up technique.this is an alternative to parachute technique and gives perfect view of operating field, thus decreasing the risk of technical mistake. Eversion technique of carotid endarterectomy represents an ideal operative technique in the case of carotid stenosis combined with kinking. Presentation will be illustrated with short video presentation.

18 17. Novel non-occlusive by pass technique in the course of cerebral revascularization by robot hand technique András Csókay M.D. Ph.D. Árpád Vilola M.D. St. John s Hospital, Budapest, Hungary Introduction With,,ultra microsurgical operations one of the main risk factors is physiological tremor. The paper s purpose to show a new procedure in the course of cerebral revascularization by which the tangentional cliping as a nonocclusive by pass method available. Methods In the course of microsurgery to reduce the tremor, microsurgeons usually fix their forearms and hands up to the fingertips IV-V. on supporting desks (armrests), and on the skull.the new technique gives micro surgeons support for fingertips I.II. and III. due to the Bethlehem bridge that can be placed quite close to the site of operation. Results So an approximately tenfold reduction of tremor can be achived due to the fixation of the crucial I.II. and III. fingertips, which hold the operating instruments. Conclusions The I-III fingertip support (robot hand)method radically reduces physiological tremor enabling the microsurgeons to perform the operation at higher precision level. The well known tangentional clipping from macrovascular surgery could be available in microvascular revascularization as a non-occlusive by pass procedure protecting the brain against ischemia.

19 18. Gliomas of the third ventricle J. Šteňo, I. Bízik, V. Matejčik, J. Šurkala Department of Neurosurgery, Comenius University, Bratislava, Slovakia Objective Involvement of the optic chiasm and the diencephalon by gliomas of the third ventricle makes surgical treatment difficult. These tumors, the majority of which are of low grade malignancy, are rare; surgical experience generally is limited. The purpose of the present study was to analyze our results with neurosurgical resection of these lesions. Methods Among 113 consecutive patients operated during for tumors of 3rd V 34 harbored gliomas (21 children and 13 adults). According to the predominant location of the tumor and its relation to the walls and to the floor of 3rd V they were subdivided into three groups: thetumors of the anteroinferior, of the anterosuperior and of the posterior part of 3rd V. Results Anteroinferior gliomas infiltrated the chiasm and the hypothalamus, their lowest part was left alone in 12 of 13 patients; upper part growing exophytically into the 3rd V could be removed. Anterosuperior tumors infiltrated lateral walls but not the floor of 3rd V; 11 of 18 were removed radically. All 3 posterior tumors could be removed radically. There was no early surgical mortality. The highest survival rate and the highest proportion of the patients in good condition at the end of the follow up (10-203, mean 104 months) were achieved after radical tumor removal. Conclusion Safe resectability of the third ventricular gliomas depended on the tumor location within basal, oral, or caudal portion of 3rd V. Radical removal of the tumor led to the best long-term outcome.

20 19. The role of neuroendoscopy in the treatment of intraventricular tumors Z. Novák, J. Chrastina, J. Hemza, R. Jančálek, I. Říha Department of Neurosurgery, Masaryk University, Brno, Czech Republic Even the contemporary imaging modalities are not able to replace the pathological verification of the tumorous lesion and this is particularly true in intra - and paraventricular tumors. These lesion may originate from any tissue, located para or intraventricularly. Endoscopic surgery enables precise biopsy taking from the predefined site under direct visual control. The possibility to use bipolar coagulation and hemostasis of the biopsy site under direct visual control means enhancement of procedure safety. When dealing with intraventricular tumors neuroendoscopy brings the possibility of diagnostic ventriculoscopy adding further informations to imaging techniques and facilitating the possibilities of tumor resection. During endoscopic surgery it is possible to perform interventions aimed at cerebrospinal fluid pathways maintaning patency, like septostomy, endoscopic third ventriculostomy, aqueductal orifice deliberation and tosolve intracranial hypertenzion, caused by the block of cerebrospinal fluid pathways. Neuroendoscopic interventions are supported by presurgical stereotactic navigation and the surgical approach itself is based on the pre - planned trajectory taking into consideration tumor location and growth, type of the planned surgery and eloquent areas location. Therefore it is also possible for instance to perform endoscopic biopsy of a tumor affecting the ventricular system of the dominant hemisphere from the non dominant side via previous septostomy. Transfrontal approach is the most frequently used, especially for tumors affecting third ventricle, frontal horn and ventricular body tumors. Occipital approach is suitable for trigonal tumors, temporal horn and cella media of the lateral ventricle. There are another possible alternative surgical approach - for instance transtemporal (most frequently through middle temporal gyrus incision), tailored to the given anatomical situation. The selected endoscopic approach should permit conversion into open microneurosurgical procedure either during the same time as endoscopic surgery, or after some time period depending on intracranial hypertenzion and biological features of the tumor.

21 The problems of surgical procedures for third ventricular tumors are dealt with in Apuzzo monography. Numerous microsurgical approaches were invented to treat the lesions in this delicate area, and they can be summarised in the following overview. Endoscopic view of the third ventricular area depends on the direction of the planned trajectory and the approach is different for anterior, middle and posterior part of the third ventricle. Surgical procedures for lesions located inside the the fourth ventricle employ neuroendoscopy as a part of endoscope controlled and assisted microsurgical interventions. It is possible to inspect the area of the fourth ventricle including aqueductal orifice and lateral recess areas from limited suboccipital craniectomy. For pineal region tumors the key point is histological verification of the lesion, cerebrospinal fluid patency maintenance, cytoreduction of the tumorand as a result treatment plan estrablishment. Another diagnostic possibility, especially when germ cell tumor is suspected, is cerebrospinal fluid sampling for tumor markers - AFP, HCG. Ventriculoscopic staging reveals the undiscovered tumor dissemination inside the ventricular system. Significant information are brought by neuroendoscopy in cancer patients with sudden onset of hydrocephalus. During the surgical treatment - endoscopic third ventriculostomy it is possible to identify tumorous dissemination on the ventricular walls, not identified on presurgical MRI.