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Clinical Oncology

FEBRUARY 10, 2015

[Treatments of brain tumors in adults – an up-date]

BAGÓ Attila György

[Maximal safe resection is the fi rst step in the complex neurooncological therapy of adult brain tumors. Surgical management of brain tumors, including the surgical innovations (neuronavigation, intraoperative imaging, awake craniotomy, intraoperative electrophysiology) providing more radical resection with the safe preservation of neurological functions will be presented. In case of malignancy the surgery is followed by radiation and chemotherapy. In this review we describe the postoperative adjuvant therapeutical modatilites available for primary and metastatic tumors, emphasizing the modern chemotherapy of high grade gliomas and stereotactic radiosurgery of brain metastases. As a conclusion we summerize the guidelines and modalities for the most common adult brain tumors, according to histological type and grade.]

Clinical Neuroscience

SEPTEMBER 30, 2012

[Role of the intraoperative electrical brain stimulation in conserving the speech and language function in neurosurgical operations of awake patients]

ERÕSS Loránd, FEKETE Gábor, ENTZ László, FABÓ Dániel, BORBÉLY Csaba, KOZÁK Lajos Rudolf, ANDREJKOVICS Mónika, CZIRJÁK Sándor, FEDORCSÁK Imre, NOVÁK László, BOGNÁR László

[Aim of the study - To summarize the results gained with awake craniotomies, which were performed in either low grade glioma patients or epilepsy surgical patients whose tumor or epileptogenic zone, was in the vicinity of eloquent, mostly language, cortices. Patient selection and methods - In our retrospective study we selected 16 patients who were operated awake between 1999-2011 at the Neurosurgical Department of MÁV Kórház Budapest, or at the National Institute of Neurosciences in Budapest, or at the Neurosurgical Department of the University of Debrecen in Debrecen. In the presurgical evaluation if it was possible we performed functional magnetic resonance imaging, tractography and detailed neuropsychological testing. At the National Institute of Neurosciences all patients were operated with the aid of MR guided neuronavigation. Results - Anesthesia was carried out without complications in all of the 16 cases. Monitoring of sleep deepness has significantly contributed to the safety of anesthesia during the superficial anesthezied states of the operation. The intraoperative neuropsychological tasks used for testing language were sensitive enough to judge the little disturbances in speech during stimulation. Stimulation evoked seizures could be adequately managed during surgery and did not influence the outcome of the procedures. The use of neuronavigation helped significantly by planning the optimal place for the craniotomy and by intraoperative orientation. Conclusions - Awake craniotomies require well practiced surgical teams, which requires the cooperation of neuro-anesthesiologits, neurosurgeons, neuropsychologist and electrophysiologists. It has two goals, first to reduce the time of surgery to minimize surgical complications, secondly the detailed intraoperative mapping of cognitive and motor functions to avoid any neurological deficit. The intraoperative anatomical data provided by the neuronavigation and the functional data provided by awake intraoperative stimulation of the patient together serve the safety of the patient which is essential in the neurologically minimal invasive neurosurgical approach of the 21st century.]

Clinical Neuroscience

MAY 30, 2012

[New minimal invasive surgical techniques in spine surgery]


[The last decade has brought significant development in spine surgery. As in all field of surgery, introduction of the minimal invasive, atraumatic procedures characterized our activities. The number of short and long-time complications were significantly reduced and the effectiveness of operations were markedly improved by the new technical conditions, for example by the use of neuronavigation, surgical microscope, intraoperative fluoroscopy, high speed drill and the widespread of keyhole concept. The applied multislice CT imaging and the high resolution MRI enabled to improve the accuracy of the planned surgical procedures and to reduce the mortality and morbidity of operations. In our studies technical methods were investigated and new developments were established in the field of minimal invasive spine surgery. The National Institute of Neurosurgery's spinal surgical team pioneers further development and application of novel minimal invasive procedures. Applied methods of vanguard surgical procedures include split laminotomy, the “archbone” technique, the “over the top” decompression, the multilevel hemi-semi laminectomy, the supraforaminal “burr hole”, the facet joint sparing “open tunnel” techniques or parasplit minimal invasive approaches. The new innovative surgical techniques are applied in our daily routine and meet international trends by utilizing benefits of minimal invasive spinal surgery. Using our newly developed innovative techniques allow to decompress neural elements in case of spinal canal stenosis and to remove the intramedullary and extramedullary space-occupying lesions located in the spinal canal and spreading extraspinally through the neuroforamen. These techniques are specially tailored to preserve structural integrity and stability of the spinal column, and allow at the same time to minimize resection of and injury to tissues not directly involved in the pathologic processes. In our studies a classification system of spatial localization of pathological lesions and processes in spinal canal was developed by us. Using this classification system enables the surgeon to select and apply the appropriate minimal invasive technique from dorsal direction and to remove the space-occupying lesions located in the spinal canal. The minimal invasive techniques were characterized and summarized. This overview of the minimal invasive techniques can be applied and recommended in the daily routine of spine surgery. We proudly employ novel surgical techniques having been developed in our institution. These techniques are internationally recognized and applied in our practice on daily basis as well.]

Clinical Neuroscience

SEPTEMBER 23, 2011

[Magnetic resonance measuring and analitic methods in epilepsy]


[Neuroradiology and magnetic resonance imaging (MRI) as its leading tool play a basic role in the diagnostics of epilepsy. The result of the MRI examination is of utmost importance in patients with therapy resistent focal epilepsy possibly requiring neurosurgical intervention. Based on the continuously developing MRI techniques, we can use an optimal imaging protocol. Cerebral structures can be evaluated on a microanatomical level on high-resolution images with thin slices. The three-dimensional (3D) sequence has high spatial resolution, properly distinguishes cerebral grey and white matter, provides the possibility of surface rendering and volumetry, as well as an anatomical basis for other methods like tractography, functional MRI and neuronavigation. Diffusion weighted and diffusion tensor imaging (DWI, DTI) and tractography has an important role in differential diagnostics and tractography visualizes the main white matter tracts and their relation with brain pathologies. MR perfusion (MRP) provides help in differential diagnostics and may have a future role in the determination of the epileptogenic focus in multifocal pathologies. MR spectroscopy (MRS) is important in differential diagnostics, lateralization of focal epilepsy and in the confirmation of hippocampal sclerosis. Several of these methods need special hardware, software and expertise, but the basic MRI protocol for epilepsy can be implemented in all modern MR scanners of middle or high field strength.]

Clinical Neuroscience

SEPTEMBER 23, 2011

[The role of neuronavigation in the preoperative invasive evaluation and surgical treatment of drug resistant epilepsies]

ERÕSS Loránd

[For localizing the epileptogenic zone in cases of focal epilepsies detailed clinical investigations, imaging studies and electrophysiological methods are in use. In lesional epilepsies the intrapreoperatíve localization of the lesion and it’s location to the eloquent cortex is essential for the neurosurgeon. The development in image guided neurosurgery lead us to use neuronavigation systems to localize intracerebral lesions or functionally eloquent cortical areas or subcortical pathways during surgery. Neuronavigation brought changes in preoperatíve evaluation and in resective surgery in epilepsy as well. In this article we describe the basics of neuronavigation and enhance the advantages of the technique in epilepsy surgery during the presurgical evaluation with invasive electrodes, in resective surgery and DBS for epilepsy.]

Clinical Neuroscience

FEBRUARY 20, 2002

[Endo-sonographic anatomy of the ventricular system]


[A preclinical cadaver study was performed to test a transendoscopic sonographic probe for neurosurgery. In 25 fresh post-mortem adult human cadaver with a total of 39 endo-sonographic dissections in the ventricular system were carried out. A sonograph with an outer diameter of 6 F was used and radial sonograms were made by a realtime image technique. First results showed precise imaging, comparable to a CT in a neighbouring area of 3 cm. In this publication, the authors describe the endo-neurosonographic anatomy of the ventricular system. The sonographic probe was advanced through the working canal of a ventriculoscope, then the endoscopic and sonographic imaging were compared. Results were documented by paralell sonographic and endoscopic photo and video recordings. Based on the authors experience, it is revealed that the additional sonographic view could also be used as a navigation tool.]

Lege Artis Medicinae

SEPTEMBER 15, 2006



[The history of the treatment of pituitary adenomas that cause acromegaly is as long as that of neurosurgery. While in the first half of the past century the aim of surgery was to save the patient's life, later the radical removal of the tumour was coupled with an effort to decrease complications, morbidity and mortality to the minimum. Today, beside all these, the complete sparing of the remaining hypophyseal substance and restoration of normal pituitary function are also important goals. The achievement of these goals is efficiently served by recent advances in microscopy, the minimally invasive methods of craniotomy, the availability of endoscopy in neurosurgery, three-dimensional computerguided neuronavigation, intraoperative colour Doppler sonography, as well as intraoperative real-time MRI. Recent developments in pharmacological research have created new promising conservative treatment modalities that supplement surgery, including somatostatin analogues and growth hormone receptor agonists. Also as supplementary treatment to surgery, occasionally replacing it, new radiosurgical methods, such as stereotaxic radiation, gamma knife, and heavy particle irradiation have gained grounds in neurosurgical practice.]

Clinical Neuroscience

JANUARY 20, 2007



[Aim of the study - Presentation of functional MRI performed at low magnetic field (1 Tesla) for planning microsurgical operation in a patient suffering from tumor close to an eloquent brain area. Methods - Microsurgical removal navigated by frameless stereotaxy of an intrinsic tumor located in eloquent area is indicated if speech function is not damaged, i.e. exact localisation and relationship of the tumor and speech area can be defined. Before operation an optimized EPI based 2D sequence was applied to yield functional MR images. At the planning of the operation the paradigm used for the localization of the sensory language cortex contained passive listening to a text. Control investigations were performed one month postoperatively. A specific psychological test, as an additional investigation to estimate the accurate level of the sensory language function, was also conducted. Results - Low resolution (matrix of 64×64) functional MR images visualized sensory speech center and auditory cortex satisfactorily. The scans showed clearly that the Wernicke's region was situated just above the tumor (WHO grade II glioma), and this finding increased the safety of intraoperative localization and reduced the risk of morbidity. Control examinations revealed minimal decrease in sensory language function, however, it was not noticeable for either the patient or her surroundings. Conclusion - Optimized functional MR imaging performed at low magnetic field can support planning of neurosurgical operations and reduce the morbidity of microsurgical interventions.]

Clinical Neuroscience

JULY 30, 2006


KASÓ Gábor, HORVÁTH Zsolt, KÖVÉR Ferenc, EZER Erzsébet, DÓCZI Tamás

[Vertebroplasty is a therapeutic image-guided procedure, consisting of an injection of acrylic cement through a bone biopsy needle into a vertebral body. Main indication for vertebroplasty is painful vertebral body compression fracture due to osteoporosis. The procedure is an efficient mean with high succes in pain release and prevention of further collapse of the treated vertebrae; however, the technique does not allow to realign the spine. Kyphoplasty was designed to adress the kyphotic deformitiy. It involves the percutaneous placement of an inflatable bone tamp into a vertebral body (VB). Restoration of VB height and kyphosis correction is achieved by inflation of the tamp with contrast material liquid. After deflation a cavitiy is created that eases the cement application. The most modern way of guidance in spinal surgery is neuronavigation - the use of frameless stereotaxy. The system reformats patient-specific CT images acquired prior surgery, performs image fusion with intraoperative plain X-ray. Before the operation, the surgeon may create surgical plan and simulate advancement of a virtual instrument along one or more surgical trajectories. During surgery, the system tracks the position of specialized surgical instruments. All three modalities mentioned above have been applied in the treatment of our patient suffered from multiple osteoporotic vertebral body compression fractures. Using kyphoplasty an almost total VB height restoration could be achieved. The pain relief was more than 50% after both operation.]