The importance of the blood levels of homocysteine, folate and vitamin B12 in patients with primary malignant brain tumors.

PURPOSE: Glioblastoma multiforme and anaplastic astrocytoma represent one of the most frequently occurring primary brain tumors with dismal survival rates. The aim of our study was to investigate whether values of homocysteine, folates and vitamin B12 can be prognostic markers in relapse diagnosis, treatment and monitoring of adult patients with malignant brain tumors. METHODS: Twenty-seven patients from the Neurosurgical Clinic, Clinical Center of Serbia with diagnosed malignant brain tumors (anaplastic astrocytoma GR III and glioblastoma multiforme GR IV), were included in the study. The patients were divided in two groups according to the progression of disease, 15 with and 12 without progression. RESULTS: Mean values of homocysteine were significantly higher in the group with progression compared to the group without malignant tumor progression, at the baseline point and after six months. Mean values of folate were similar across groups in all measurements, except in the 3rd month after surgery. Results regarding vitamin B12 were similar to folate, without any significance in group comparisons in the examined time points, as well as in vitamin B12 values change. CONCLUSIONS: Our results pointed out that total homocysteine in blood circulation appears to be a tumor marker for monitoring primary malignant brain tumor patients before and after surgery. The association of hyperhomocysteinemia with folate deficiency, also provides strong support for viewing hyperhomocysteinemia as a predictive marker for carcinogenesis. It is hoped that future research will continue to explore the clinical relevance of homocysteine as a tumor marker and a risk factor for astrocytoma and glioblastoma.

Nerve Grafting versus Common Infraclavicular Intraplexal Nerve Transfer in Elbow Flexion Restoration.

AIM: To compare the results of nerve grafting versus common infraclavicular intraplexal nerve transfer in elbow flexion restoration. MATERIAL AND METHODS: The study included 39 patients with upper brachial plexus palsy who were operated using common intraplexal nerve transfer (Oberlin procedure) and the thoracodorsal and medial pectoral nerve transfer to the musculocutaneous nerve or grafting of C5 to the musculocutaneous nerve, for elbow flexion restoration. All patients underwent detailed preoperative evaluation, which included clinical and neurological examinations, electrophysiological investigation and neuroradiological studies. The final evaluation of achieved recovery of elbow flexion was done two years after surgery, using the British Medical Council scale. RESULTS: We achieved functional satisfactory recovery (M3, M4, M5) in 29 of 30 patients (96.7%) in the common intraplexal nerve transfer group, and in 4 of 9 patients in the nerve grafting group (44.4.%). There was a significant statistical difference between these two groups in favor of common intraplexal nerve transfers over C5 grafting to the musculocutaneous nerve regarding functional recovery. CONCLUSION: The results of our study concur with the findings of previous studies favoring intraplexal nerve transfers over nerve grafting in the restoration of elbow flexion in upper brachial plexus palsy. They reveal that intraplexal nerve transfers are clearly the primary treatment modality in cases of upper brachial plexus palsy without any sign of viable proximal C5 stump presence, while in cases of upper brachial plexus palsy with signs of viable proximal C5 stump the choice of the best treatment modality is still controversial.

Comparative analysis of the animal model and results of the clinical research of the aneurysm inclination angle as the predisposing factor for the occurrence of rupture.

INTRODUCTION: Natural course of aneurysms that occur on blood vessels of the brain singles out the need for understanding the mechanism of the occurrence of aneurysm wall rupture and identification of anatomic characteristics as predictive factors for hemorrhage to occur. OBJECTIVE: In this study we comparatively present results of our researches and experimental models on animals. METHODS: We made a comparative analysis of anatomical characteristics of blood vessels of the brain and aneurysms obtained on the basis of digital subtraction angiography and intraoperative finding. In this article we review recent research in the anatomic characteristics of intracranial aneurysms and parent blood vessels. We present a series of 185 aneurysms (ruptured and unruptured) dissected at the Neurosurgical Clinic of Clinical Center of Serbia in Belgrade. RESULTS: Inclination angle may be considered as the vital predesposing factor for intracranial aneurysm rupture. In aneurysms that ruptured it was 139.748+/-27.242 degrees, while in unruptured aneurysms it was considerably smaller and amounted to 100.882+/-22.001 degrees (p<0.01). CONCLUSION: Inclination angle may be regarded as the vital predisposing factor since it differs considerably in unruptured and ruptured aneurysms. Aneurysms with blood stream angle smaller than 115 degrees have very small probability of rupture, while blood stream angle bigger than 150 degrees presents a high risk of rupture.

Predictable morphometric parameters for rupture of intracranial aneurysms - a series of 142 operated aneurysms.

AIM: Intracranial aneurysm rupture is followed by high mortality and morbidity. In order to understand the aneurysm's natural course, it is necessary to recognize the predisposing factors for the rupture. MATERIAL AND METHODS: Analysis included 142 operated aneurysms (94 hemorrhaging and 48 unruptured) in the period from 2008 to 2010. RESULTS: The ratio between the width of the aneurysm neck and diameter of the carrying blood vessel - artery in ruptured aneurysms (OR) was 1.58 ± 0.61, and in unruptured aneurysms 1.14 ± 0.52 (p < 0.01). Aspect ratio of ruptured aneurysm was 1.89 ± 0.59, and in unruptured 1:33 ± 0.17. The angle of inclination of ruptured aneurysms was 139.22 ± 21.53, while in unruptured aneurysms it was 101.73 ± 21.26. CONCLUSION: Based on the results of our research, a predictive model of morphometric characteristics of the vessel bearing the aneurysm to rupture can be identified: an irregular shape of the aneurysm, AR > 1.6, OR > 1.5 and inclination angle > 135 deg.

Natural course of the arteriovenous malformations of the brain initially presented by hemorrhage: analysis of a clinical series of 39 patients.

AIM: AVM because of outstanding tendency toward bleeding, even though 20 times more rare then aneurysm on the blood vessels of the brain and her own specific anatomical structure even today represents big neurosurgical challenge. MATERIAL AND METHODS: Series which is shown here consists of 39 patients which were hospitalized in the institute for neurosurgery of the Clinical Center of Serbia in the period between 1995 and 2004. This group was exposed to symptomatic therapy or it was estimated that surgery, embolization and radio surgery. RESULTS: Combined type of venous drainage brings a high risk (p < 0.001) from repeated bleeding. Combined artery bringing from different flows (p < 0.05) contributes to genesis of 'steal phenomenon', in combination with deep venous drainage it presents predisposing anatomical characteristics for repeated bleeding (p < 0.001) according to our results should present AVM with dimensions 2.5 to 5 cm localized in eloquent zone of big brain with combined type of venous drainage and cobined artery bringing from vertebro-basilar flow and carotid flow. CONCLUSION: Perception of natural course of AVM point to certainly more benign pathology in regard to other vascular malformations. Specific anatomical structure requires planning of treatment from case to case, most often combination of embolization, radio surgery and surgical treatment.

[Comparative results of operative and endovascular treatment of intracranial aneurysms].

Therapeutic protoclol for intracranial aneurysm treatment is very complex. In depand od patient status and anviografic founding we determinate modality and time of treatment. Analysis included 137 patients who were treated in Neurosurgical clinic CCS because sponatenus subarachnoid haemorrhage rigine from aneurysm belading. We performed direct surgery (microsurgery) in 109 patients. In early termine we operated 28 patients (25.69%), in first 24 hours 5 of them. In interemdiate period we performed surgery in 9, and other 72 patient we operated in postpone period. Embolisation was performed in 22 patinet. GOS form embolised patient was 4.636 +/- 0.581 and in operated 4.113 +/- 1.106 (p < 0.05). Cumulative experient of Neurisurgical Clinic CCS and summation of international experience impose as the best treatment is the treatment which is best known for the physician.

Neuroendocrine dysfunction in patients recovering from subarachnoid hemorrhage.

OBJECTIVE: Subarachnoid hemorrhage (SAH) is a recently identified risk factor for hypopituitarism, particularly growth hormone (GH) and corticotrophins deficiencies. The aim of our study was to identify possible predictor(s) for neuroendocrine dysfunction in SAH survivors. DESIGN: Pituitary function was evaluated in 93 patients (30 males, 63 females), aged 48.0+/-1.1 years (mean+/-SE), and with a Glasgow Outcome Scale score of 4.6+/-0.6 (mean+/-SE) more than one year following SAH. In the acute phase, SAH was complicated by vasospasm (VS) in 18 and by hydrocephalus (HDC) in 9 patients. Baseline serum values of insulin growth factor 1 (IGF-I), cortisol, thyroxine (T4), thyroid stimulating hormone (TSH), follicle stimulating hormone (FSH), luteinizing hormone (LH), testosterone (in males), estradiol (in females) and prolactin were determined. RESULTS: According to the results of baseline hormonal evaluation, 47 patients (50.5%) had no hormonal abnormalities. Seven patients (7.5%) had multiple pituitary hormone deficiencies: Four patients (4.3%) had two (GH and cortisol), one patient had three (gonadal, adrenal and GH) and two patients had deficiency of all pituitary axes. Thirty-nine patients (42%) had one abnormal axis (13 adrenal, 2 thyroid, 4 gonadal and 20 GH). None of the subjects was treated with desmopressin or exhibited symptomatic polyuria. The VS and HDC during the acute phase of SAH were related to abnormal pituitary status (VS with low IGF-I levels and HDC with low cortisol levels). CONCLUSION: Through a screening procedure, neuroendocrine dysfunction was identified in a substantial number of asymptomatic patients with previous SAH. Cerebral VS and HDC at the time of SAH emerged as risk factors possibly predicting development of pituitary dysfunction. Low basal levels of IGF 1 and cortisol may help in selecting patients requiring further evaluation of pituitary function.

[Clinical characteristics and results of surgical treatment of petroclival meningioma].

INTRODUCTION: The size of meningioma and its relation with neurovascular structures in petroclival region stipulate the degree of surgical radicalism and determine an operation risk. In spite of progress of surgical technology, the rate of surgical morbidity in view of cranial nerves deficit is 30%-50%. OBJECTIVE: The objective of our study was to present the results of treatment of patients with petroclival meningiomas and to point to correlation of preoperative radiological findings and intraoperative results as well as neurological status of patients before and after surgical treatment. METHOD: Retrospective analysis of 35 operated petroclival meningiomas at the Institute of Neurosurgery, CCS, in the period from 1995 to 2004 was presented. The following parameters were analyzed: size of tumor, relation with bone and neurovascular structures, preoperative condition, degree of surgical radicalism and postoperative outcome. RESULTS: The size of tumor was classified in four groups. There were 20 tumors at the right, and 15 at the left side. At the time of diagnostic procedures (based on CT and MRI), 20 tumors were in contact with brainstem, 9 compressed the brainstem, and 6 obstructed the IV ventricle. Preoperative patient condition was evaluated by Karnofsky index. Mean value for group I was 90, II - 80, III - 70 and IV - 50. In 9 cases, liquor drainage was performed preoperatively. In 3 cases, external liquor drainage was carried out postoperatively, and in one case it was replaced by permanent liquor drainage. Radical operation was performed in 44%, and significant reduction was done in other cases. In the postoperative period, 11% patients died, 28% had cranial nerves deficit, and pyramid deficit was recorded in 14% of the patients. The tumor size (III-IV) and brainstem compression were found to be statistically significant (p<0.05) as predisposed factors of deficit prolongation. CONCLUSION: Petroclival meningoma surgery is required upon precise preoperative analysis. Radicalism of operation is reserved for small and medium tumors, younger patients, and patients in good preoperative condition

[Hydrocephalic risk factors after spontaneous subarachnoidal haemorrhaging of aneurysmal aetiology].

INTRODUCTION: Hydrocephalus is one of the most significant complications of spontaneous subarachnoidal haemorrhaging that can be treated surgically. OBJECTIVE: We analysed risk factors that caused spontaneous subarachnoidal haemorrhaging. Patients were divided into two groups: shunt-dependent and shunt-independent. METHOD: We retrospectively analysed 174 patients (63 men and 111 women), surgically treated at the Institute of Neurosurgery of Clinical Centre of Serbia in the period from January 2002 to January 2004. RESULTS: The prevalence of hydrocephalus in patients with a shunt (shunt-dependent) was most significant in women (18%:9.5%), but not statistically significant (p > 0.05). Concerning the significance of age (years), we found that hydrocephalus in patients with a shunt was most significant in older patients (p < 0.025). The HiH and Fisher gradings were not statistically significant in our study (p > 0.05%). In patients with intraventricular haemorrhaging (29.3%:10.5%) and vasospasms (34.6%:6.5%), the prevalence of shunt-dependent hydrocephalus was statistically very significant (p < 0.005; p < 0.001). The frequency of ventriculomegalia in the initial CT scan was greater for patients with a confirmed diagnosis, but of no statistical significance (p > 0.05). The prevalence of shunt-dependent hydrocephalus with aneurysms in the a. basillaris basin was 47.4%, with multiple aneurysms 17.2%, and with aneurysms of the anterior segment 9.5%, which represents a statistically significant difference (p < 0.001). CONCLUSION: We discovered that hydrocephalus, as a complication of spontaneous subarachnoidal haemorrhaging, was most frequent in patients older than 50 years, manifesting in ventricular haemorrhaging, vasospasm, and aneurysms of the posterior segment.