Markers of angiogenesis (CD31, CD34, rCBV) and their prognostic value in low-grade gliomas.

BACKGROUND AND PURPOSE: Antigens CD31 and CD34 and relative cerebral blood volume (rCBV) in gliomas reflect in different ways neoangiogenesis of the tumour. Thus, we decided: (1) to estimate the correlation between the values of CD31 and CD34 and the value of rCBV in low-grade gliomas (LGG), and (2) to establish the prognostic value of these markers. MATERIAL AND METHODS: The investigated group consisted of 53 patients with LGG who were operated on in the Neurosurgical Department at Sosnowiec between 2005 and 2011. On the basis of perfusion-weighted imaging (PWI-MRI) in the tumour texture, rCBV was calculated. The values of CD31 and CD34 were estimated on the basis of immunohistochemical investigation. Three outcome measures were assessed: (1) overall survival, (2) progression-free survival, and (3) malignant-free survival. Statistical analyses were done using the STATISTICA 9.0 program. RESULTS: Higher value of rCBV in the texture of LGG significantly correlated with higher CD31 (p = 0.0006) and CD34 values (p = 0.0043). Progression-free survival was significantly longer in patients with rCBV < 1.75 than for persons with rCBV > 1.75 (p = 0.015). Lower expression of CD31 correlated with probability of longer survival of the patients after the operation of LGG (p = 0.068). CONCLUSIONS: Density of microvessels as assessed immunohistochemically with CD31+ and CD34+ in LGG correlated with the value of rCBV in the tumour. The value of 1.75 for rCBV may be the threshold for better or poorer outcome of these patients. Expression of CD31 antigen is an important prognostic factor for the time of survival for patients with LGG.

Meningiomas of the upper and middle part of the clivus and surrounding structures: early and long-term outcome.

BACKGROUND AND PURPOSE: Meningiomas of the upper and middle parts of the clivus and surrounding structures are removed using petrosal approaches: anterior, posterior, combined and complete. The purpose of this study is to show the results of treatment of these meningiomas and to present our interpretation of the treatment strategy. MATERIAL AND METHODS: Twenty-six patients (17 women, 9 men) were included in the study. The neurological status of the patients was assessed before and after surgery as well as at the conclusion of the treatment. The following measurements and data were collected and recorded: approximate volume of the treated lesion, its relation to large blood vessels, cranial nerves and the brainstem, as well as tumour consistency and vascularisation. RESULTS: Symptoms duration ranged from 1 to 60 months (median: 16 months). In 57.7% of patients, imbalance was the predominant sign. Less frequent symptoms were: head-aches, dysacusis and hemiparesis. Approximate volumes of the tumours ranged from 4 to 65 mL (mean: 32 mL). Total or subtotal resection was achieved in 73.1% of patients. The patients' performance improved postoperatively in 34.5%, remained unchanged in 46.2% and deteriorated in 11.5% of patients. Two (7.8%) patients died after the surgery. CONCLUSIONS: The use of petrosal approaches in the surgical treatment of meningiomas of the upper and middle parts of the clivus and the surrounding structures facilitates good or at least satisfactory neurological outcome with a high proportion of complete resections and relatively low mortality.

"True" aneurysm of the posterior communicating artery as a possible effect of collateral circulation in a patient with occlusion of the internal carotid artery. A case study and literature review.

"True" posterior communicating artery (PCoA) aneurysms are extremely rare. A case of a 63-year-old patient with a ruptured "true" aneurysm of the right PCoA associated with the occlusion of the right internal carotid artery is presented. For nine years before he suffered from subarachnoid hemorrhage, the patient had developed symptoms of transient ischemic attack (TIA) due to the occlusion of the right internal carotid artery. The left vertebral angiogram demonstrated a "true" right PCoA aneurysm and collateral flow from the right posterior communicating artery to the right internal carotid artery. The right internal carotid system was also fed by collateral circulation from the left carotid artery through the anterior communicating artery. Transcranial colour-coded real-time sonography (TCCS) demonstrated increased velocity and turbulent blood flow in both communicating arteries. The patient was operated on and the aneurysm was clipped successfully. This case report suggests that the blood flow disturbances resulting from the collateral circulation through the PCoA could be a conductive factor in the formation and development of the aneurysm. This is the first described case of a "true" aneurysm of the PCoA coexistent with the occlusion of the internal carotid artery.

[Dynamics of cerebral circulation on the basis of transcranial Doppler ultrasonography evaluation in patients with moderate and minor head injury]. / Dynamika zaburzen krazenia mózgowego na podstawie oceny przezczaszkowej ultrasonografii dopplerowskiej u chorych po srednio-ciezkich i lekkich urazach czaszkowo-mózgowych.

Patients with moderate and minor head injury were evaluated with transcranial Doppler ultrasonography (TCD) and the relationship was studied between traumatic vasospasm (TVSP) and hyperaemia and the patients' age, clinical state, head CT examination and long-term results of treatment. The group examined consisted of 45 patients. The results obtained in this group were compared with the results in the control group. TVSP was observed in about 20% while hyperaemia occurred in 25% of the cases. Traumatic vasospasm in transcranial Doppler ultrasonography was found to occur most often in the group of patients with subdural or intracerebral haematomas.

[Diagnostic pitfalls in stereotactic biopsy]. / Trudnosci diagnostyczne w ocenie materialu z biopsji stereotaktycznej.

Between October 1998-August 2000, 65 patients were diagnosed, and underwent stereotactic biopsy of brain lesions. Procedures were performed with the Riechert-Mundinger stereotactic device. The diagnosis was made intra-operatively, by examination of cytological smears. The initial diagnosis was confirmed after H&E, and selective stains, as well as immunohistochemical examinations of paraffin specimens. The method applied makes possible to obtain a reliable, and precise morphological diagnosis in the majority of cases, so that a proper treatment method could be introduced.

[A case of complex development anomalies and aneurysm of the anterior part of arterial circles of the brain]. / Przypadek zlozonych nieprawidlowosci rozwojowych i tetniaka przedniej czesci kola tetniczego mózgu.

A case of complex developmental anomalies and an aneurysm of the anterior part of arterial circle of the brain is reported. Every developmental anomaly was analysed separately. Views on their embryologic conditions are quoted. Haemodynamic disturbances are pointed out as a reason of the occurrence of the aneurysm.

[Tethered cord syndrome in adults]. / Zespól zakotwiczonego rdzenia kregowego u doroslych.

The authors present a description of three patients in whom symptoms of spinal cord injury developed late after opening of the dural sac of the spinal canal. The material comes from two female and one male patients of age 37-47 years. In the first case the symptoms included increased paraesthesia, pain, paraparesis and sphincter disorders, which appeared 16 years after stab wound of meninges and the spinal cord at Th10. In the second patient, operated on for myelomeningocele at L3-4 at the age of five, sphincter disorders, trophic changes of feet and paraparesis appeared. The third patient was operated on for intra- and extramedullary lipoma at Th9-12. Seven months after the operation symptoms of sphincter disorders, pain, paraesthesia and paraparesis developed. The MR examination showed in all patients an adhesion of the posterior or posterolateral surface of the spinal cord with the dura mater at the sites of injury, which was confirmed intraoperatively. An operative treatment improved the clinical state. The tethering of the cord by the scar was the cause of a non-physiological stretching of the spinal cord on flexion of the body and head. It led to spinal circulation disorders and symptoms of myelopathy. It has been observed that the onset of the symptoms is often caused by sudden stretching of the spinal cord during fall or intense physical exercises. In such cases operative release of the spinal cord from the adhesion is a method of choice.

[Surgical treatment of pineal and tectal tumors from the subtentorial and supracerebellar approach]. / Leczenie operacyjne guzów szyszynki i pokrywy sródmózgowia z dostepu podnamiotowego, nadmózdzkowego.

The results of operative treatment of pineal and tectal tumours by infratentorial, supracerebellar approach were presented. There were 15 patients with pineal and 2 with tectal tumours. Clinical symptoms of the disease were as follows: signs of intracranial hypertension, tectal lesion, impairment of gait and hypoacusis. Diagnostic procedure included CT, MRI, and panangiography investigation. Application of infratentorial, supracerebellar approach enabled total resection of tumours in 14 patients (82.3%) and subtotal in 2 patients (11.8%) In 1 patient we managed to do only diagnostic biopsy (5.9%). This approach makes possible removal of pineal and tectal tumours growing in the midline toward the anterior part of III ventricle and also posterior fossa. The advantage of this approach is fact that the operation takes place below the vein of Galen. Drooping by gravity cerebellum creates enough places for microsurgical operation. During control investigation 13 patients (76%) had no announce any complaints and were without neurological disorders.

[Risk of hemorrhage and size of hematoma in patients with cerebral arteriovenous malformations]. / Ryzyko krwawienia i rozmiary krwiaka sródmózgowego u chorych z naczyniakami tetniczo-zylnymi mózgu.

The occurrence of intracranial haemorrhage, epileptic seizures and focal neurological signs was estimated in the group of 40 patients with AVMs. Size of AVM, its localization was established by angiography. Maximum diameter of a haematoma was measured on preoperative CT. We found that small AVMs (diameter < 3 cm) are more often the source of intracranial haemorrhage than larger ones. Intracerebral haematoma was the larger the lesser was AVM. Intracerebral haematoma has no influence on immediate and long-term results of operative treatment of AVMs.

Approaches to posterior circulation aneurysms and results of the operations.

Surgical approaches and operative results in 32 operations of aneurysms of the vertebrobasilar system are presented. The orbitozygomatic and temporopolar approach was used for aneurysms of the bifurcation of the basilar artery lying high in the interpeduncular fossa. In aneurysm which neck was located less than 10 mm above or less than 5 mm below the anterior and posterior clinoid processes the pterional transylvian subtemporal and pterional anterior temporal approaches were performed. A large aneurysm with the neck lying 5 mm below the line connecting the anterior and posterior clinoid processes was operated on via pterional transcavernous approach. The used approaches made it possible to clip the aneurysms. Good and very good results were obtained in 82 per cent of cases. The perioperative mortality was 9 per cent.

[Surgical treatment of intramedullary tumors: preliminary results]. / Leczenie operacyjne guzów sródrdzeniowych--doniesienie wstepne.

Since 1995 in the Department of Neurosurgery, Mining Hospital in Sosnowiec a surgical technique has been used of total or gross total removal of tumour. It includes the use of CO2 laser for myelotomy and tumour vaporisation as well as ultrasonic aspirator, microsurgical techniques and intraoperative monitoring of SSEP. Ten patients 11-61 years of age were operated on. Four tumours were located in the cervical part of the spinal cord, three in the cervico-thoracic area while the remaining three in the thoracic part. The condition of four patients before the operation was assessed as I-II degree on the McCormick scale, of one patient as--III degree--and of the other five patients as IV-V degree. Only in two cases the removed tumour was ependymoma; in six cases these were benign astrocytomas and in two other--anaplastic tumours. After the treatment, the clinical condition of almost all patients improved. Pain and trouble some paraesthesias subsided. Five patients are completely self-dependent and three other walk with the aid of handrails. The treatment proved unsuccessful in one patient with an anaplastic tumour in whom paralysis of lower limbs occurred before the operation. Six months after the operation the patient died of tumour metastasis. The observation period ranged from 6 months to 3 years. On the basis of our own observations it is suggested that total safe removal of even infiltrating intramedullary tumours is possible when proper surgical techniques are used. Best results are obtained in patients in good clinical condition irrespective of tumour extent.

Occlusion of radicular arteries - reasons, consequences and anastomotic substitution pathways.

AIM OF STUDY: To investigate the cause of radicular artery occlusion. METHOD: Fifty specimens of spinal cords were taken at postmortem from individuals in whom no symptoms of spinal cord and spine injuries were present in life. The spinal cord arterial system was filled with colour contrast material and then each radicular antery was studied individually at 5 - 25 operative microscope magnification. RESULTS: Two hundred and fifty two anterior radicular arteries joining the anterior spinal artery and 525 posterior radicular arteries joining the posterior spinal arteries were examined. There were five obstructed vessels: four were anterior radicular arteries including the artery of Adamkiewicz and one of the initial branches of the spinal artery originating from the vertebral artery. CONCLUSIONS: As the presented examples show, the formation of a fully efficient collateral circulation is possible.

[Prognostic factors in patients with intracerebral hematoma caused by ruptured middle cerebral artery aneurysm]. / Wybrane czynniki prognostyczne u chorych z krwiakami sródmózgowymi z peknietego tetniaka tetnicy srodkowej mózgu.

In a retrospective study, the authors analysed surgical outcomes in patients after intracerebral haemorrhage (ICH) as a result of ruptured middle cerebral artery (MCA) aneurysm. Between January 1989 to June 1997, 836 patients with ruptured aneurysm were admitted. Of these 207 (24.8%) patients had MCA aneurysm. Sixty-seven patients (32.4%) with MCA aneurysm had ICH. The types of ICH were classified into three groups according to CT findings on admission: A) temporal ICH (with or without a minor SAH); B) intrasylvian haematoma (with or without a minor SAH); C) ICH with diffuse SAH (SAH with cisternal clots on the side contralateral to the haematoma). The outcome was assessed according to the Glasgow Outcome Scale. Each patient was classified as having made either a good recovery including moderate disability (a favourable outcome) or a poor recovery including severe disability, vegetative state, or death (an unfavourable outcome). Overall, 31 patients (46.3%) had a favorable outcome (good recovery in 12 (17.9%) cases and moderate disability in 19 (28.4%) cases), and 36 patients (53.7%) had an unfavourable outcome (18 (26.9%) suffered severe disability, 4 (5.9%) remained in vegetative state, and 14 (20.9%) died. A temporal ICH occurred significantly more often in patients with favourable outcomes (67.7%) (p < 0.01). In patients with favourable outcomes the incidence of Grade I and II was higher (51.6%) than that in patients with unfavorable outcomes (19.4%) (p < 0.025). Surgical complications were significantly higher in patients with unfavourable outcomes (52.8%; p < 0.01). Patients who developed more than 25 ml of ICH had significantly worse outcomes (p < 0.05). Factors that could be used to predict a favourable outcome include temporal ICH, WFNS Grade I or II, absence of a surgical and postoperative complication, and a haematoma volume less than 25 ml.

[Clinical course and results of surgical treatment of epidermoid and dermoid tumors]. / Obraz kliniczny oraz wyniki leczenia operacyjnego torbieli naskórkowych i skórzastych.

Seventeen cases (7 males and 10 females) of intracranial epidermoid tumours and one case (a male) of intracranial dermoid tumours were described. The patients with epidermoids represented 1.7% and the patients with dermoids represented 0.1% of all patients operated from January 1989 to July 1998 because of intracranial tumours. The average age of the patients with epidermoid tumours was 44.5 and ranged from 17 to 69 years whereas in patient with dermoid it was 19 years. Twelve epidermoid tumours (70.6%) and one dermoid tumour (100%) were located at the basal cisterns of the brain, i.e. 4 epidermoid tumours were located at the cerebello-pontine angle, 4--in the suprasellar region, 3 (2 epidermoid and 1 dermoid tumours)--in the parasellar region, and 2 in the retrosellar region. Four epidermoid tumours (23.5%) were found intraventricularly while only one (5.9%) located in the cerebral hemisphere. Mainly symptoms of cranial nerves (II, V, VII, VIII) dysfunction were observed among the patients. The average duration of the symptomatic period was 3 years. All operations were performed in a single stage using microneurosurgical techniques. Radical removal was possible in nine cases (50%) while in other nine cases the removal was subtotal. Two patients (11.1%) died in the postoperative period. Mean follow-up for the patients was 3.3 years. Among the patient three (16.7%) had a recurrence of the tumor and were operated on again. In 14 patients (72.2%) the results were very good and good. There was no difference of statistical significance of the results between patients with total and subtotal removal of tumours.

[ A case of parasellar tumor with double histological texture: chromophobe pituitary adenoma and epidermoid cyst]. / Przypadek guza okolicy siodla tureckiego o podwójnym utkaniu histologicznym: barwnikoopornego gruczolaka przysadki i torbieli naskórkowej.

A rare case of a 42-year-old woman with an intra- and suprasellar tumour with double histological texture (chromophobe pituitary adenoma and epidermoid cyst) is presented. Elevated serum prolactin levels were found on admission. After the surgery symptoms of diabetes insipidus appeared. On the ground of the presented case and review of references it seems that the coexistence of an epidermoid cyst and a pituitary adenoma suggest their common histogenetic origin.

[The use of pedicle periosteal flap in plastic surgery of anterior skull base]. / Zastosowanie uszypulowanego plata okostnowego w plastyce podstawy dolu przedniego czaszki.

In 12 cases of large traumatic defects of the anterior skull base plastic surgery was performed using large periostial flap to separate the nasopharynx from the extradural area. After a large biauricular scalp flap was formed, precise preparation of periostial flap was done. The bifronto-transfrontal sinus or transfrontal sinus approach was performed. Next cranialization of the frontal sinus was done and then it was filled with muscle. Afterwards the floor of the frontal sinus and skull base with defect were covered with periostial flap pedicled along supraorbital ridge. Finally irradiated homograft of dura or fascia lata was glued intradurally onto the place of the dural defect. In all of the patients CSF-rhinorrhea stopped immediately after surgery. Among patients observed from 2 to 4 years after surgery neither recurrent rhinorrhea nor infection appeared.

The accessory anterior cerebral artery: case report and anatomic analysis of vascular anomaly.

BACKGROUND: The term "accessory artery" was formulated to describe one of the developmental anomalies of the middle cerebral artery. This anomaly consisted of the incidence of a vessel that branched off close to the anterior communicating artery and supplied a part of the cortex in the region of the middle cerebral artery vascularization. METHODS: A panangiography of the cerebral vessels was carried out, using the subtraction method, on a woman who suffered from subarachnoid hemorrhage. An aneurysm of the anterior communicating artery and developmental anomaly of the right anterior cerebral artery were found. During the aneurysm operation, the existence of the developmental anomaly was confirmed. It was revealed also during a control angiography. RESULTS: An atypical branch of the right internal carotid artery was found branching off from section C2, and passing below the right optic nerve and the anterior communicating artery. This branch ended with a division into the orbitofrontal and frontopolar artery. CONCLUSIONS: The atypical branch of the internal carotid artery that partly performs the function of the existing proper right anterior cerebral artery, has been defined as the accessory anterior cerebral artery.

[Assessment of cerebral blood flow velocity changes by transcranial Doppler examination in patients with closed craniocerebral trauma]. / Ocena zmian predkosci przeplywu krwi w naczyniach mózgowych metoda TCD u chorych po zamknietych urazach czaszkowo-mózgowych.

24 patients after minor or moderate, closed isolated head injuries and 10 patients of control group were included to this study. Right after admission blood flow velocities of both middle cerebral arteries (MCAs) by using transcranial Doppler method (TCD) and blood flow velocities of both extracranial parts of internal carotid arteries (ICAs) by "duplex-scan method" were examined. Changes in mean flow velocities (MFVs) in MCAs and ICAs, VMCA/VICA ratio were analysed. 40% of patients who had minor or moderate head injury demonstrated increase of MCA velocity homolateral to the trauma or bilateral. We observed cerebral hyperemia in 16.7% of patients and posttraumatic vasospasm (TVSP) in 25% of patients. There is a high risk of occurring TVSP in patients with CT shows evidence of subdural or intracerebral hematoma.

[Views on the etiology and pathogenesis of intracranial saccular aneurysms]. / Poglady na etiopatogeneze workowatych tetniaków wewnatrzczaszkowych.

The anatomical structure of intracranial arteries may favour the development of aneurysms because of poorly developed external elastic lamina and adventitia, gaps in the muscular layer and great number of collagenous fibres. However, the haemodynamic factor has the principal significance in initiation, growth and rupture of the aneurysms. The importance of this factor is especially great in cases of coexistence with developmental abnormalities of the arteries, arterial occlusion, hypertension, atherosclerosis or hereditary connective tissue disorders.

[Extramedullary erythropoiesis in cerebellar hemangioblastomas]. / Pozaszpikowa erytropoeza w naczyniakach plodowych mózdzku.

Three patients operated on for cerebellar haemangioblastoma are reported. Rarely observed extramedullary erythropoiesis was found in tumour tissue. One patient had erythrocytosis (solid form of the tumour), the remaining patients with cystic tumour had normal erythrocyte count.