Coincidence of Tethered Cord, Filum Terminale Lipoma, and Sacral Dural Arteriovenous Fistula: Report of Two Cases and a Literature Review.

Spinal dural arteriovenous fistula (SDAVF) is the most common vascular malformation of the spine in adults. However, the coincidence of tethered cord syndrome, lipoma, and SDAVF on the sacral level is exceptionally rare. We describe two patients, probably the fifth and sixth ever reported. The first was a 33 year-old female who underwent surgical cord de-tethering. Surprisingly, a sacral SDAVF was discovered intraoperatively, despite negative digital subtraction angiography (DSA). The second patient was a 30 year-old male with similar pathologies. After three failed embolizations, the fistula was surgically disconnected. Both patients recovered well. A review of patients with sacral SDAVF coexisting with spinal dysraphism, with an emphasis on the basis of symptoms was done. As a rule, in these coincident disorders, the SDAVF was the direct cause of increasing symptoms. Previous reports and our findings reveal that surgery might be superior to endovascular embolization for treating sacral SDAVFs with coexisting entities, because surgery offers a one-step treatment.

Importance of Radiological Evaluation of Global Spinal Balance Together with Lower Limb Alignment in Planning Lumbar Spine Deformity Surgery - Illustrative Case Presentation.

BACKGROUND: The presented case illustrates the critical role of a detailed preoperative radiological evaluation in complex spine surgery. CASE REPORT: A 49-year-old patient was admitted for a revision surgery after L3-L5 fusion. Preoperative assessment showed preserved sagittal balance, coronal imbalance and valgus knee deformity. The patient reported pain of 8-10 in VAS (Visual Analogue Scale) and had an ODI (Oswestry Disability Index) of 60%. The first step of the surgery was L2-S1 fusion with decompression and spine deformity correction. The second step involved anti-valgus osteotomy of the right tibial bone. CONCLUSIONS: The assessment of global spinal balance together with lower extremity alignment should be strongly recommended.

Levels of selected pro- and anti-inflammatory cytokines in cerebrospinal fluid in patients with hydrocephalus.

Cytokines are widely known mediators of inflammation accompanying many neurodegenerative disorders including normal pressure hydrocephalus (NPH). NPH is caused by impaired cerebrospinal fluid (CSF) absorption and treated by surgical shunt insertion. The early diagnosis of NPH is difficult because of various manifestations of the disease. One of the most promising research directions is biochemical CSF analysis. The aim of this study was to determine the CSF levels of cytokines. The levels of various cytokines (IL-6, IL-8, IL-12, IL-10 and TNF-α) were measured in patients with idiopathic active normal pressure hydrocephalus, arrested hydrocephalus and hydrocephalus with brain atrophy compared to controls. Our study showed that the concentrations of IL-6 and IL-8 were significantly elevated in the group with idiopathic active hydrocephalus compared to control patients. Moreover, we observed that the levels of IL-6 and IL-8 in the group with idiopathic active hydrocephalus were significantly higher compared to patients with arrested hydrocephalus and hydrocephalus with brain atrophy..

Executive functioning pattern as a prognostic indicator for shunt implantation surgery in patients with normal pressure hydrocephalus - A preliminary report.

The problem of executive functions in patients with normal pressure hydrocephalus (NPH) was investigated in the study. Executive function parameters were assumed to be among factors that may differentiate the clinical pattern in NPH. Two major indicators of executive functioning, i.e. flexibility and productivity of thinking, were assessed in neuropsychological examination using the Trail Making Test (TMT), Verbal Fluency Test (COWAT), and the Wisconsin Card Sorting Test (WCST). Participants in the study were 18 patients with NPH divided using a set of diagnostic criteria into two subgroups: with idiopathic active hydrocephalus (ACT) or with arrested hydrocephalus (ARR). Executive functioning patterns were found to differentiate between the two NPH subgroups. Namely, patients diagnosed with active hydrocephalus (who qualify for shunt implantation surgery) tended to present lower levels of verbal fluency in all semantic categories, which suggests a decreased productivity of thinking. Besides, ACT patients' performance on the WCST was significantly inferior on two measures: (1) they committed more non-perseverative errors (which indicates their chaotic way of working on the test and the occurrence of random responses) and (2) displayed lower ability of "learning to learn" (which suggests their impaired flexibility of thinking). These aspects of executive function, with productivity and flexibility of thinking first and foremost, seem promising as additional prognostic indicators to consider in patient selection for shunt implantation.

Decompressive craniectomy in trauma: when to perform, what can be achieved.

SUBJECT: The goal of the study was to evaluate the effectiveness of the decompressive craniectomy (DC) concerning its various parameters. MATERIAL AND METHODS: Forty-five patients were studied (6 female, 39 male, mean age 53 years). All patients were treated because of severe traumatic brain injury. CT was performed before surgery and on the 1st to 3rd days postoperatively, and was evaluated using specific software. Parameters such as diameter of DC, volume of the additional intradural space obtained, and the shift of the midline were measured. RESULTS: In the group of patients treated with unilateral DC, the 11-cm craniectomy resulted in an average of 69 mL of additional space. The best score on the Extended Glasgow Outcome Scale (GOS-E) after DC was in patients younger than 35 years old. CONCLUSION: In our opinion DC is a suitable method of treatment for patients after severe traumatic brain injury. The best results were achieved in a group of patients aged <50 years, in particular <35 years old. DC gives extra additional space for damaged and edematous brain. DC should be performed early enough and should be large enough. Parameters of the DC obtained positive results with regard to patient status, but there are also other factors such as age and initial Glasgow Coma Scale (GCS) score, which can affect outcome.

The impact of Pleurotus ostreatus on organic matter transformation processes.

This study showed the effect of Pleurotus ostreatus on the external organic matter (OM) transformation processes. The kinetics of these changes were determined. The experiment was conducted as 42-day pot experiment done in four combinations (with four replications). The four combinations of different substrates were: (1) organic, (2) composted hay, (3) organic soil + composted hay, (4) organic soil + composted hay + lead. The study results showed that P. ostreatus had the ability to transform external OM as well as metal-organic complexes. These transformations were reflected in the constant rate of characterized changes and correlation coefficients. The study also indicated the direction of the external OM transformation. The direction leads to the selective oxidation of aliphatic structures, and an increase in humic substances which are resistant to oxidation. The study also identified the negative impact of lead on the ability of P. ostreatus to transform humic substances. The impact of lead was expressed as the lower value of the rapid rate constant k1 in objects enriched with lead acetate.

Cerebrovascular reactivity evaluated by transcranial doppler sonography in patients after aneurysmal subarachnoid haemorrhage treated with microsurgical clipping or endovascular coiling technique.

OBJECTIVE: To examine cerebrovascular reactivity in patients after subarachnoid haemorrhage (SAH) during long-term follow-up, using Acetazolamide test and transcranial Doppler (TCD) monitoring of blood flow velocities (BFVs), to compare of CO(2) reactivity between patients after SAH treated with three different methods: surgical (clipping), endovasculary (coiling) and conservative. METHODS: The study was performed in a group of 24 patients treated for SAH. Cerebrovascular reactivity (CVR) has been evaluated after intravenous administration of 1000 mg of Acetazolamide. Studied patients were divided into three groups: group I (n = 10) treated with clipping, group II (n = 8) treated with coiling and group III (n = 6)--patients with negative angiography treated conservatively. RESULTS: Results of this study have shown that: (1) BFVs were normal in cerebral arteries and did not differ between right and left head sides, (2) CVR was normal in all studied patients, (3) method of aneurysm treatment as well as its localization had no influence on BFV and CVR, and (4) occurrence of vasospasm in early days after SAH did not result in permanent disturbances of CO(2) arterial reactivity. CONCLUSION: BFV values in cerebral arteries were in normal range and did not differ on the left and right head sides. CVR was normal in all examinated patients. A method of the ruptured aneurysm treatment and its localization had no influence on CBFV and CRV. Vasospasm in early period after SAH did not provoke a persistent impairment of CO(2) reactivity.

A non-invasive assessment of intracranial volume reserve by measuring cerebrospinal fluid volume with the aid of CT imaging.

INTRODUCTION: Monitoring changes in the intracranial volume (ICV) reserve and intracranial pressure (ICP) is one of the key issues in the treatment of intracranial pathologies. The aim of this study is to develop a method of monitoring the ICV reserve by analyzing CSF volume measured using CT in specific regions. MATERIALS AND METHODS: A total of 20 patients with cerebral injury were evaluated. Analysis was performed using imaging software. On selected scans (three at the basal cistern level and three at the pineal level), the following regions were analyzed: total cerebral surface (TC1, TC2) and bilateral ambient cistern (AC) only at the basal cistern level for cerebrospinal fluid (CSF) volume. Results were correlated with patients' Glasgow Coma Scale (GCS) scores. RESULTS: An increase of CSF volume was observed with an improvement in the GCS. From the examined regions, only AC volume showed a statistically significant linear correlation (p < 0.0005) with GCS. Mean AC: 0.021, 0.454, and 0.678 mL CSF/scan in severe (3-8 pts GCS), moderate (9-12 pts GCS), and mild (13-15 pts GCS) TBI groups, respectively. DISCUSSION: Assessment of CSF volume changes in mL CSF/scan can be conducted using CT. Counting voxels corresponding to the CSF eliminates mistakes due to inaccurate region demarcation. The obtained results (AC volume) show a high correlation with patient state.

A new CT-based classification of spontaneous supratentorial intracerebral haematomas.

BACKGROUND AND PURPOSE: In patients with intracerebral haematoma (ICH) secondary to ruptured aneurysm or arteriovenous malformation (AVM), conservative therapy and follow-up without angiographic evaluation is associated with a risk of recurrent bleeding. It is necessary for a clinician to identify a subgroup of patients with spontaneous supratentorial ICH who are likely to harbour high-flow vascular malformations that require specific treatment - neurosurgical or neuroradiological. A new CT-based classification for supratentorial ICH aimed at a close correlation between ICH localization and occurrence of high-flow vascular malformations diagnosed on angiography is presented. MATERIAL AND METHODS: According to the proposed classification, supratentorial ICHs are divided into deep and cortico-subcortical. The deep group is further subdivided into striatocapsular, lobar ICH and isolated intraventricular haemorrhage and the cortico-subcortical group into paracisternal and convexity ICH. A new classification was used in a consecutive series of 108 patients with spontaneous supratentorial ICH subjected to angiographic evaluation. RESULTS: Deep ICH in non-hypertensive patients was secondary to AVM rupture in 57.1% (8/14). High-flow vascular malformation was a source of bleeding in 93.6% of patients with paracisternal ICH - aneurysm in most cases (41/47). Convexity ICH was found to be AVM-related in 35.7% of patients (5/14). CONCLUSIONS: Our clinical experience shows that the proposed classification appears to be closely associated with angiographic findings. Its clinical application with consideration of other factors such as age and arterial hypertension may help clinicians to identify high-risk ICH patients for angiographic evaluation and further specific treatment to prevent rebleeding.

Early cerebral hemodynamic alternations in patients operated on the first, second and third day after aneurysmal subarachnoid hemorrhage.

Surgery timing after aneurysmal subarachnoid hemorrhage (SAH) may influence the risk of vasospasm after early surgical procedure and is correlated with SAH extensiveness. A group consisting of 127 patients with aneurysmal SAH was studied. The changes of mean flow velocity (MFV) were measured in middle cerebral artery (MCA) and in anterior cerebral artery (ACA) by transcranial Doppler sonography (TCD) in three groups of patients divided according to the surgery timing (on the first, second and third day after SAH). Changes of MFV values in MCA and in ACA were similar in all groups. MFV values in the group of patients operated on the third day were the lowest and the pathologic values lasted for the shortest time. In patients with massive SAH (Fisher IV group) and mild SAH (Fisher II group), the lowest MFV values were observed, if patients were operated within 24 hours after SAH. In patients without SAH (Fisher I group), the MFV values were the lowest, if they were operated on the third day after SAH. In patients with severe SAH (Fisher III group), the lowest risk of vasospasm was observed, if they were operated on the second day after SAH; however, the highest risk was found in patients operated on the first day after SAH. Our study suggests: (1) in patients with severe SAH operated on the second day, the lowest risk of vasospasm was observed, and the highest risk of vasospasm was observed if those were operated on the first day; (2) the highest risk of vasospasm was observed in patients operated within 24 hours with mild and massive SAH and in patients without SAH operated on the third day after SAH.

[Diagnostic difficulties due to atypical symptoms in normal pressure hydrocephalus. A case report]. / Problemy diagnostyczne nietypowych objawów w wodoglowiu normotensyjnym. Opis przypadku.

This paper presents a case of a female patient with unusual symptoms of diagnosed hydrocephalus. Symptoms demonstrated by the patient were initially diagnosed as immature personality, after that she was diagnosed with reactive depressive disorders. For those reasons she was treated for over 20 years in different psychiatric outpatient clinics and psychiatric hospitals. She was treated pharmacologically with different medications: antidepressants, neuroleptics etc. She also participated periodically in individual and group psychotherapy. Computed tomography performed after the loss of consciousness with significant motor deficits revealed relevant dilation of the cerebral ventricular system. The neuropsychological examination revealed disturbances in emotional-motivation area and cognitive deficits. Those disorders caused significant problems in social and professional activities. After completing the diagnosing process the patient was diagnosed with arrested hydrocephalus. Results of clinical examinations suggested that at this stage of the disease there are no indications for shunt implantation. Probably earlier diagnosis could bring a chance of successful neurosurgical intervention and definitely more efficient therapy.

Cerebrospinal fluid free-radical peroxidation products and cognitive functioning patterns differentiate varieties of normal pressure hydrocephalus.

The aims of the study were as follows: first, to verify the hypothesis that free radical peroxidation may be one of the factors implicated in pathophysiology of normal pressure hydrocephalus (NPH) and, second, to find out whether these biochemical characteristics together with neuropsychological cognitive deficits can differentiate between various types of NPH. This provides prognostic criteria for selection of patients for shunt surgery. Lipid peroxidation was measured in terms of thiobarbituric acid-reactive material (TBAR) and protein sulphydryl (SH) groups were measured as CSF content. Cognitive deficits were assessed using a number of neuropsychological tests. In the sample of NPH patients (n = 24), three categories were distinguished using these criteria: idiopathic active hydrocephalus (A), arrested hydrocephalus (AH), and post-traumatic hydrocephalus (PT). TBAR levels for NPH patients were higher than that of controls without CNS pathology (n = 2). Moreover, NPH patients had increased levels of total and soluble protein groups, and decreased levels of protein SH groups, which suggests the occurrence of processes that activate peroxidation of free radicals in normal pressure hydrocephalus. Levels of these indicators varied across NPH types. Two categories of NPH patients, with active (A) or posttraumatic (PT) hydrocephalus differed significantly from the controls (C)--their TBAR levels were 0.58, 0.56 and 0.28 nmol/mg protein, respectively; soluble SH levels: 41.5; 58.15 and 11.3 nmol/mg protein, and protein SH levels: 34.3, 21.8 and 57.5 nmol/mg protein. In PT group, many individual differences were noticed. These findings seem promising because the studied biochemical indicators may serve as additional diagnostic criteria for selection of NPH patients for shunting.

[The first system of image transmission and neurosurgical telecommunication in Poland]. / Pierwszy w Polsce system transmisji badan obrazowych i telekonsultacji neurochirurgicznej.

OBJECTIVE: The goal was to develop a fast and efficient neurosurgical teleconsulting network to improve acute neurosurgical patient care, to reduce transport costs and unnecessary occupation of neurosurgical beds. METHODS: Modems with 56 kilobits/s data transmission speed are used. CT images are transmitted straight from CT scanner via modem/telephone lines to receiving personal computer in Department of Neurosurgery. Receiving PC runs with Microsoft Windows operating system and the network software MultiView (EMED, Inc.). Network connects Department of Neurosurgery Polish Academy of Sciences in Warsaw with transmitting hospitals in Ciechanów and Ostroleka. RESULTS: The system is fast, one study consisting 18 images is transmitted in about 5 minutes and it is simple to use, to date more than 1000 CT images have been transmitted. Operator acceptance has been very high. The system has improved acute neurosurgical patient care. Transfer of appropriate patients has been accelerated and unnecessary transfer is almost eliminated. CONCLUSION: Applied Neurosurgical Teleconsulting System has significantly improved acute neurosurgical patient care and has reduced transport expenses. Better availability of neurosurgical consultation has been achieved. The network is simple to use and has gained physician acceptance. It has to be emphasized that the creation and using of the system is relatively not expensive.