[Morphologic analysis of the coexisting anomalies of the arteries of the cerebral base and aneurysms: clinical study].

During operations of the aneurysms showing anatomical details is the means that leads to the aim, and it is not only a purpose in itself. Data on details that the surgeons come across during their work and which sometimes represent difficulties during interpretations of angiographic findings and planning operations, as well as the intraoperative orientations and identifications of the elements . Frequency of occurrence of such anatomical details and anomalies may be completely different from the one that autopsy series show. Knowledge of this makes the work of surgeons easier and gives a necessary feeling of confidence during operations. Thus, we decided to conduct a clinical, morphological study based on angiographic and surgical analyses of the explored segments of the Wilson circle. The study included 344 patients from the Institute for Neurosurgery, during the period of 2 years; the patients had complete angiographic diagnosing and operative exploration. Our findings confirm differences in localization of aneurysms according to sex. Aneurysms on the front communicant complex are to a great extent associated with anomalies of the front part of the Wilson circle.

[Screening of risk groups for discovering intracranial aneurysms before rupture].

In development of intracranial aneurysms contribute genetic factors together with smoking, hypertension, diabetes mellitus. Epidemiology studies suggest that as many as 5% of people harbour a cerebral aneurysm by age 75. Rupture of cerebral aneurysm is the most frequent cause of spontaneous subarachnoid haemorrhage (up to 80%.) Annual incidence of SAH is 10-14/100 000, but only 15-20% of aneurysms will rupture, and that will happen probably between 40-60 years. The morbidity and mortality of aneurismal subarachnoid (SAH) continues to be high. It is not possible to predict who has aneurysm and is it going to bleed or not, but it is possible to reveal high risk groups (polycystic kidney disease, Ehlers-Danlos sy, Marphan sy, family history of cerebral aneurysms, suspect de novo aneurysm formation in patients with prior history of cerebral aneurysm). Reviewing data from literature and reporting cases from each group with high risk, that have been screened and aneurysms discovered, authors wish to focus interest on this matter and propose screening program for these groups of patients. The mortality and morbidity in cases treated before rupture is significantly lower than after SAH, so screening programs could save many lives. According to our preliminara data, mostly based on control angiographies after 8-10 zears in patients previouslz operated for intracranial aneurysmas, from 15 angipgraphies 4 revealed new aneurysms (26% in 10 years period) with total number of 6 de novo formed aneurysms, which is not valid due to small number of patients but strongly suggests the importancy of screening program for risk groups.

[Space reconstruction of the aneurysms of the vertebrobasilary confluence based on conventional angiography--our experience].

Besides current development of the new diagnostic procedures conventional angiography still represents the golden standard in the diagnosing of intracranial aneurysms. Since it gives a two-dimensional image if the presentation of the third dimension is wanted it is necessary to apply appropriate algorithm structures and computers. In this study we show our experience in the application of space reconstruction of blood vessels and aneurysms of the vertebrobasilary confluence in 6 patients operated at the Institute for Neurosurgery, Clinical Center of Serbia. Intraoperative finding in all patients matched the finding that we got by space reconstruction of the blood vessels, which was possible to observe from different angles. Postoperative course in all patients was satisfying. Upon discharge the patients were without rough lateralization of the pyramidal system. Our initial results and their practical agreement with the interoperative finding give us right to recommend this method as the standard for the preoperative diagnostic protocol.

[Neurovascular compression (conflict)]].

Since Dandy first reported vascular compression of the trigeminal nerve, the concept of neurovascular compression syndrome for trigeminal neuralgia and hemifacial spasm (HFS) has been accepted, and neurovascular decompression has been performed for this condition. The further investigations indicated that some other clinical syndromes such as glossopharyngeal neuralgia, disabling positional vertigo, tinnitus, geniculate neuarlgia, spasmodic torticolis, essential hypertension, cyclic oculomotor spasm with paresis and superior oblique myokymia also may be initiated by vascular compression of the glossopharyngeal, cochleovestibular, intermediate, accessory, oculomotor and trochlear nerves or the ventrolateral medulla oblongata. In this study several hypotheses regarding the development of cranial nerves vascular compression syndromes are presented. It is alsoemphasized the value of high-resolution magnetic resonance tomographic angiography for visualization of vascular compression. The most frequent clinical syndromes caused by vascular compressionof the cranial nerves are discussed regarding the pathogenesis, symptomes and therapy. We present our series of 124 patients with preoperative evidently positive finding of vascular compression to the trigeminal nerve (MRI). Microvascular decompression (MVD) was performed in all of them. Initial postoperative result was excellent in 110/124 (89%) patients,while in 11/124 (9%) patients the pain relief was satisfactory. In the remaining three patients MVD failed. Recurrence of pain after two years reached 19%. Complications were related to diplopia associated with transient fourth nerve dysfunction in 5 (4%) patients, facial motor dysfunction in 4 (3%) patients, transient facial hypesthesia in 27 (22%) patients and partially hearing loss in 4 (3%) patients. Cerebellar hemorrhagic infarction occurred in 1 (0.8%) patient and cerebrospinal fluid leaks appeared in two (1.6%) cases. There was no lethal outcome.

The use of thoracodorsal nerve transfer in restoration of irreparable C5 and C6 spinal nerve lesions.

There are only a few reports on the use of thoracodorsal nerve (TDN) transfer to the musculocutaneous or axillary nerves in cases of directly irreparable brachial plexus injuries. In this study, we analysed outcome and time-course of recovery in correlation with recipient nerves and type of nerve transfer (isolated or in combination with other collateral branches) for 27 patients with transfer to the musculocutaneous or axillary nerves. Using this nerve as donor, we obtained useful functional recovery in all 12 cases for the musculocutaneous nerve, and in 14 (93.3%) of 15 nerve transfers for the axillary nerve. Although, we found no significant statistical difference between analysed patients according to the percentage of recoveries and mean values, we established a better quality and shorter time of recovery for the musculocutaneous nerve. According to obtained results, we consider that transfer may be a valuable method in reconstruction after directly irreparable C5 and C6 spinal nerve lesions.

Missile injuries of the sciatic nerve.

Missile injuries of the sciatic nerve are not common in civil practice. We analysed a war series of 55 cases operated on in a period from 1991 to 1995. Nerve continuity was preserved at least partially in 76.4% of cases, but only 13.3% of cases had preserved some nerve function. Surgical results were analysed in 45 cases followed for more than two years. The rates of useful functional recovery were 86.7% for tibial division, 53.3% for peroneal division and 86.7% for the sciatic nerve complex. On the basis of the obtained results we were able to make the following conclusions: (1) missile injuries to the sciatic nerve are characterised by partially preserved nerve continuity and complete functional loss in the majority of cases, (2) surgery should be performed 3 to 6 months after injury, (3) reconstruction of tibial division is the major goal of surgical repair, (4) the extent and severity of nerve damage and the type of surgical procedure are the main prognostic factors and (5) failures of surgical repair are usually related to nerve grafting at gluteal level.

Results of cable graft technique in repair of large nerve trunk lesions.

Cable grafting was reintroduced in the beginning of the 1980's as a modified method for repair of large polyfascicular nerves without group arrangement such as trunks and cords of the brachial plexus, sciatic nerve and its divisions, or the other main nerve trunks. We used this method in 25 patients with brachial plexus injury and 29 patients with injuries to the sciatic nerve. Results were analyzed according to the individual nerve elements and were available for 32 elements of the brachial plexus and for 19 tibial and 19 peroneal divisions of the sciatic nerve. We defined useful functional recovery according to the priorities in repair of the brachial plexus and sciatic nerve with lower limits M3 for relevant muscles and functions and S2 for sensory function. Results were especially favourable for the brachial plexus with a total rate of recovery 84% and for tibial division with the same total rate of recovery. On the basis of the results obtained we were able to conclude that the results of the modified cable grafting were at least similar to those of interfascicular nerve grafting and that this method could be useful for repair of large polyfascicular nerve trunks. However, the main advantage of this technique is a considerable gain in operative time.

Gunshot injuries to the brachial plexus.

OBJECTIVE: Gunshot wounds to the brachial plexus present a specific problem in peripheral nerve surgery. The purpose of this study is to analyze the characteristics of these injuries and the possibilities for functional recovery after their surgical treatment. DESIGN: Retrospective analysis of nerve lesions and results of surgery. MATERIALS AND METHODS: The series consists of 54 patients operated on, with 148 injured nerve elements, i.e., with 163 injured nerve elements when individual components of complex brachial plexus structures are included. Surgical procedures involved exploration, neurolysis, and nerve grafting, or their combination, depending on intraoperative findings. The surgical results were analyzed in 46 patients (85.1%) with 119 (80.1%) of the 148 nerve elements, with follow-up periods of more than 24 months. Standard grading scores for motor and sensory function were used and ranged according to functional priorities in the surgery of brachial plexus and individual nerves. MEASUREMENTS AND MAIN RESULTS: Neurolysis and nerve grafting generally gave similar rates of functional recovery, 90.2 and 87.8%, respectively. They were successful in all cases with injuries to the upper spinal nerves, the upper trunk, the lateral and posterior cord, and the musculocutaneous and axillary nerves. The failures were related to neurolysis or grafting of the ulnar and radial nerve lesions. CONCLUSION: Compared with previous studies, the number of lesions with complete functional loss and complete anatomic loss of continuity is larger. In cases that were prognostically favorable according to the location of injury, the results are similar regardless of the type of nerve repair.