Endoscopic third ventriculostomy in an infant with vein of Galen aneurysmal malformation treated by endovascular occlusion: Case report and a review of literature.

INTRODUCTION: Vein of Galen aneurysmal malformations (VGAMs) can, through multiple mechanisms, complicate with hydrocephalus (HCP). It is generally agreed that management strategies in this scenario should focus on endovascular embolizations. Treatment options for non-responders, however, have been only scarcely reported upon. CASE PRESENTATION: We present a nine-month-old boy with a mural type VGAM complicated by HCP. Despite endovascular occlusion of the sole feeder, the child exhibited hydrocephalus progression prompting an Endoscopic Third Ventriculostomy (ETV). This procedure restored a cerebrospinal fluid (CSF) circulation otherwise impaired by aqueduct obstruction. Later, a new feeder arose and a second embolization was ultimately needed in order to achieve VGAM regression. Throughout four years of follow up, the child attained all developmental marks. DISCUSSION/CONCLUSION: VGAMs are prone to hydrocephalus development as there is both an underlying venous congestion and a mechanical, obstructive component. Although there is a rationale for addressing both components, the underlying AV shunts and subsequent venous pressure elevations usually determine failure of traditional CSF shunting strategies. It is therefore challenging to manage HCP in patients who failed to improve following endovascular embolizations. For such cases, ETV stands as an elegant minimal invasive alternative with potential to provide a more physiologic drainage route and thus better allow for neurological development.

Minimally invasive endoscopically assisted remodelation (MEAR) of sagittal craniosynostosis: an alternative technique to open and endoscopic procedures with cranial orthosis time span reduction.

INTRODUCTION: Sagittal craniosynostosis represents the most frequent simplex skull suture pathology. There are currently several operative approaches to this defect. Minimally invasive techniques are preferred for young infants. Since July 2017, we have employed endoscopically assisted craniectomies followed by cranial orthosis. Gradually, we have developed our modified technique, the minimally invasive endoscopically assisted remodelation (MEAR). SURGICAL TECHNIQUE: MEAR is a combination of principles gained from classical cranial vault remodeling techniques and minimal invasive approaches. The long and wider lateral osteoectomies performed in the parietal and occipital bones along with loosening of the periosteum and dura adhesions at the lambdoid sutures lead to early correction of parieto-occipital dimensions. RESULTS: Thirty-one consecutive patients with scaphocephaly underwent MEAR. The median preoperative cephalic index of 67 units (P25:63.3, P75:70) was improved to a median postoperative cephalic index of 77 units (P25:75, P75: 81). Sufficient correction was achieved in all patients. Cranial orthosis was needed for a median of 1.5 months (P25:1, P75:2). We had no major surgical complications in this pilot series. CONCLUSIONS: With MEAR, we have achieved good cosmetic results. Duration of cranial orthosis was significantly shortened compared to conventional endoscopic-assisted procedures.

Electromagnetic navigation-guided neuroendoscopic transfrontal transaqueductal fenestration of expansive posterior fossa arachnoid cyst with simultaneous endoscopic third ventriculostomy in an infant.

INTRODUCTION: We present an infant with an expansive posterior fossa arachnoid cyst and severe clinical deterioration due to decompensated obstructive hydrocephalus. Given the dilated Sylvius aqueduct, we favoured the endoscopic transfrontal transaqueductal route to approach the cyst. CASE REPORT: A 12-month-old boy was acutely admitted for severe symptoms of intracranial hypertension. Imaging revealed spacious cystic formation in the posterior fossa with expansive behaviour towards the brain stem, fourth ventricle and cerebellum associated with obstructive triventricular hydrocephalus. The patient underwent electromagnetically navigated transfrontal transaqueductal cyst fenestration with simultaneous ETV from two precoronal trajectories with a rigid endoscope. CONCLUSION: A transaqueductal approach with a rigid endoscope is rarely published, and we were amazed by the impact on the child's clinical improvement after this minimally invasive endoscopic procedure. The case is well documented with imaging and perioperative neuroendoscopic views.

[Is the lower extremities amputation rate on decrease?]. / Klesá pocet amputací dolních koncetin?

In the past few years, rates of the lower extremity amputations for ischemia have been decreasing in some countries and many world regions. Surely, growing numbers of revascularization procedures contribute to the situation. In the Czech Republic, the amputation and large amputation rates are similar to those in the developed countries (45, resp. 24/100 000) (according to hospital data), as well as the numbers of surgical revascularizations. However, in our country, foot amputations are on increase, while numbers of major amputations do not decrease, probably as a result of the human age prolongation and fast increase of diabetes mellitus rates. The following prerequisites are required to improve the situation: primary prevention of atherosclerosis, building a network of vascular centres which are able to provide all modern revascularization methods. In cooperation with general practitioners, angiologists, diabetologists and other medical specialists, it is necessary to prevent most patients from developing critical extremity ischemia. If it develops, it should be diagnosed immediately and the revascularization procedure should be considered.

[History of the beginning and the development of the contemporary Second Surgical Clinic of the General Teaching Hospital and of the First Faculty of Medicine, Charles University in Prague]. / Historie vzniku a výstavby budovy soucasné II. chirurgické kliniky 1. lékarské fakulty Univerzity Karlovy a Vseobecné fakultní nemocnice v Praze.

Construction of the building of contemporary Second Surgical Clinic of the cardiovascular Surgery was finished in 1921. Since the first intention to erect a new building for the Clinics of Gynaecology to its accomplishment full 46 years had elapsed. Since 1941 the building was used first by the German and later the Czech Clinics of Dermatovenerology and since 1955 it belonged to the Second Surgical Clinic of the General Teaching Hospital. In 1966 specialization of the clinic turned to the cardiovascular surgery. In relation to that, the building was to a great extent reconstructed.

[Abdominal aortic aneurysm. Results of surgical therapy during 1992-2003]. / Výdute b risní aorty--výsledky chirurgické lécby v letech 1992-2003.

BACKGROUND: Total of 142 procedures for abdominal aortic aneurysm were performed over the 1992-2003 period. METHODS AND RESULTS: Among this group, 106 patients (74%) underwent elective surgical procedure and 36 patients (26%) required urgent surgical treatment for acute ruptured aneurysm. The surgical mortality of the first group decreased from 19.5% to 4.7% over the past 40 years. On the other hand, in the same period, there is no significant change in surgical mortality rate for bleeding aneurysm (50% over the 1960-1980 and 41.6 over the 1992-2003). CONCLUSIONS: The average time between the first sign of rupture and the onset surgery is approaching 22 hours. The delay results form the time for necessary examination and for the complicated determinations of the diagnosis. Patients with the ruptured aortic abdominal aneurysm should be immediately transferred to the specialised vascular surgical clinics.

[Postcatheterization pseudoaneurysm of the radial artery]. / Postkatetrizacní pseudoaneuryzma arteria radialis.

A postcatheterization pseudoaneurysm of the radial artery remains a rare complication, considering frequencies of its punction. The radial artery is easily accessible for the punction site management after the catheter removal. We present pathogenesis of their origin, their prevention and options for surgical management of the radial artery pseudoaneurysms.

[Popliteal artery aneurysms--acute ischemic complications]. / Výdut' podkolenní tepny--akutní ischemické komplikace.

The authors present a group of 10 patients with the diagnosis of acute ischaemia of an extremity caused by an aneurysm of the popliteal artery, during the period from 1997 till October 2002, who within a short time interval were treated by a combination of endovascular and surgical therapy. The group comprised 8 men and 2 women. The mean age was 58 years, the range 48-78 years. A bilateral aneurysm was present in 3 patients, coincidence with an aneurysm of the abdominal aorta was found in one patient. In all ten patients combined treatment was used involving local thrombolysis rtPA (Actilyse Boehringer Ingelheim) for 24-48 hours followed within 24 hours by exclusion of the aneurysm with vascular reconstruction. No death, amputation nor closure of the reconstruction was recorded during hospitalization. The medium term results suggest a 100% patency when an autologous vein was used, much poorer results are obtained when prostheses were used in particular in patients with femoropopliteal bypasses. In our opinion in acute ischaemia of the extremities as a result thrombosis of an aneurysm of the popliteal artery the application of a combination of local thrombolysis rtPA followed within a short time interval by vascular reconstruction increases the probability of saving the affected extremity and markedly reduces the necessity of amputation as compared with primary surgical treatment.

[Thrombectomy and embolectomy using the adherent clot catheter]. / Trombektomie a embolektomie Adherent Cloth katetrem.

The efficacy of the Adherent Cloth Catheter is demonstrated on the three above described cases. The different mechanism of function on contrary to the classic Fogarty Catheter enables us to remove the older, strongly adherent thrombus from prothesis, artery or vein. The catheter is a functional instrument not only for vascular surgery, but also for invasive angiology.

[A nontraditional method of surgical treatment of an aortocaval fistula. Case report]. / Netradicní zpusob chirurgické lécby aortokavální pístele. Kazuistika.

Unusual method of aortocaval fistula and venous aneurysm repair is discussed and possible advantages of this type of surgery are cleared up. The aortoiliac prosthetic substitution and exclusion of the region, where aorta and inferior vena cava communicate without direct suture of the fistula makes the operation safer and lowers the risk of postoperative bleeding. In authors' opinion, this method is effective even in acutely rising aortocaval fistulas.

[Comparison of the effectiveness of crystalloid and warm blood cardioplegia in patients with significant left ventricular dysfunction]. / Srovnání úcinnosti krystaloidní a krevní teplé kardioplegie u pacientu s významnou dysfunkcí levé komory srdecní.

UNLABELLED: In a group of 84 patients undergoing elective coronary artery bypass surgery and with the ejection fraction lower than 40% two types of myocardial protection were studied. Group I (41 cases) was given intermittent cold crystalloid cardioplegia and group II (43 patients) was given intermittent warm blood cardioplegia followed by normothermic reperfusion. Preoperative, intraoperative and postoperative data were retrospectively collected. There were no differences between the two groups except more rhythm disturbances in group I and higher incidence of neurological complications in group II. CONCLUSIONS: Warm blood cardioplegia is an effective, cheap and practical myocardial protection technique.

[Aneurysm of the descending aorta causing destruction of vertebral bodies. Case report]. / Výdut sestupné aorty jako prícina destrukce obratlových tel. Kazuistika.

A case report of 59-year-old woman with combined lesion of the aneurysm of the descending thoracic aorta and the destruction of vertebral bodies is presented. Considering the infectious aetiology of the whole lesion and the possibility of the future orthopaedic intervention we use the less usual operative approach and technique in this case. Only indirect method to prevent the spinal cord injury was used and the aneurysm was repaired with bypass and exclusion. The only postoperative complication requiring future surgery was the dissection and thrombosis of the right superficial femoral artery used for blood pressure monitoring. We perform, in local heparinization, the proximal femoropopliteal prosthetic bypass. The latter postoperative course was uneventful. Follow-up digital angiography of the aorta 12 month later showed good filling of the prostheses and normal anastomosis, X-ray film and CT scans one, three and five years after operation showed almost complete reconstruction of the vertebral bodies. This article also discusses the technical and tactical aspects of the thoracic aortic aneurysm repair and also analyses the diagnostic and therapeutic chance to influence the spinal cord ischaemia.

[Long-term results of femorocrural arterial reconstruction]. / Dlouhodobé výsledky femorokrurálních tepenných rekonstrukcí.

The objective of the paper is the fate of femorocrural arterial reconstructions during the long-term follow-up of 197 patients operated in 1970-1993. The patients were followed up after operation at 3-12-month intervals and cumulative curves of the patency of the reconstruction and preservation of the extremity were assessed by Kaplan-Meier s method. It was revealed that 5-year cumulative patency of femorocrural reconstructions is 55% and five-year preservation of the extremity even 78%, regardless of the patency of the reconstruction. The authors did not find a difference in the cumulative curves of patency between different crural arteries. The arteria fibularis is from the aspect of preservation of the extremity equivalent to both other arteries. From the comparative result of curves of cumulative patency for the reverse autologous asphena and for cast vascular prostheses ensued that even after five years there is no substantial difference between the two types of prostheses. In case of cast prostheses we must however foresee early thrombotic obstructions and thus repeated surgery such as thrombectomies sand plastic operations of distal anastomoses.

[Surgery of infectious complications in prostheses in the abdominal aorta]. / Chirurgické resení infekcních komplikací náhrady brisní aorty.

The authors describe the successful solution of a serious and feared complication, i.e. infection of a vascular prosthesis. A hitherto not used procedure was adopted-concurrent removal of the infected prosthesis and restoration of the blood flow into both extremities by an extra-anatomical axillobiiliac bypass. The authors draw attention to the advantages of this method in context with possible future solutions; and with regard to the hitherto not complicated postoperative course they assume that this type of treatment could be final. At the same time they draw attention to the complexity of the problem from the diagnostic and therapeutic aspect.

Do preoperative branched-chain amino acids have a beneficial effect on the heart after cardiac surgery?

To verify the hypothesis, formulated on the basis of data emerging from animal experiments, that branched-chain amino acids (BCAA) exert a protective effect on the heart during ischaemia, eight patients immediately before aortocoronary reconstruction were provided 400 ml of a 3% BCAA solution. A control group comprised another eight patients. Per- and postoperative myocardial status and myocardial enzyme levels were assessed. Myocardial biopsy was performed during surgery to determine glycogen levels. Creatine kinase (CK) levels were invariably higher in the BCAA group, with statistically significant differences in samples obtained immediately after surgery (10.6 +/- 3.35 mu kat/l vs. 4.07 +/- 0.59, p < 0.0004), in the evening after surgery (14.2 +/- 5.92 vs. 5.91 +/- 2.21, p < 0.06) and in the morning of the first postoperative day (18.0 +/- 10.1 vs. 7.5 +/- 4.76, p < 0.025) when aspartate aminotransferase (AST) levels were likewise higher (1.35 +/- 0.28 vs. 1.00 +/- 0.26, p < 0.035). There were no differences between the groups in the number of defibrillations after ischaemia, myocardial glycogen content, peroperative ischaemia, incidence of arrhythmia and catecholamine support. We conclude that BCAA at the above indicated doses did not raise myocardial glycogen content or improve myocardial status after cardiac surgery. Their administration resulted in a rise in CK and AST in the postoperative period.

The changes in the myocardium under experimental conditions.

An effect of different interventions on the electron microscopic structure and morphometric parameters of the myocardium were studied. Application of cyclophosphamide and isoprenaline in the experimental animals allows the similar changes of mitochondrial partial volume like hypoxic periods of cardiac surgery by coronary bypass operation. Although the initial agents are different, the primary affected structures are sarcoplasm and mitochondria, whose proportions change promptly. The primary effect may be connected with alteration of membrane permeability caused by increased osmotic active ion transport on responsibility of the inhibited Na, K-ATP-ases (or F0 F1-ATP-ases irreversibly altered in mitochondria). The morphometric evaluation confirms not only statistically significant differences among the experimental groups treated by cyclophosphamide, isoprenaline and by cardioplegic ischaemic periods in the human myocardium but also by application of physiological saline in the control groups. Comparing the morphometric evaluation by manual processing with computer mediated image analysis we can conclude that the results correspond upon conditions of the specific defined raster for Weibel's intersection test only.

[A program for prevention of pseudomonas infections and immunoprophylaxis with PSAEVA vaccine]. / Program prevence pseudomonádových infekcí a imunoprofylaxe vakcínou PSAEVA.

The authors present three main trends of prevention of Gram-negative opportunistic infections investigated at the Cardiosurgical Clinic of the Institute of Clinical and Experimental Medicine. An important part is played by active and systematic surveillance with early signalling and analysis of new infections with subsequent aimed interventions against concrete sources of infection and mechanisms of transmission. It is necessary to think more of activation of endogenous infection the specific features of which make repression difficult and motivate investigations of preventive approaches. Rational antibiotic policy has so far not appreciated the danger of selection of endogenous and exogenous agents in standard situations where antibiotic therapy lacks an aimed and restrained approach. Immunoprophylaxis with the PSAEVA vaccine in the first preliminary controlled clinical investigation was characterized by the absence of nosocomial epidemics and septicaemia and a significant (fivefold) reduction of the incidence of non-pyocyanic Gram-negative bacteriaemia. The success of vaccination seems to be related to the anti-colonization and anti-invasive mechanism of specific and unspecific nature.

[The effect of mechanical support of the heart on the extent of experimental myocardial necrosis. I]. / Vliv mechanické podpory srdce na rozsah experimentální nekrózy myokardu. I. cást.

The authors investigated the influence of mechanical cardiac support with a non-pulsating blood flow on the size of an ischaemic after ligature of the descendent branch of the left coronary artery in the dog. As compared with a control group of experimental animals where mechanical cardiac support was not used, the size of the necrotic focus of the heart muscle diminished by 50% (p less than 0.01). In some of the experimental animals the size of the necrotic focus did not change despite the use of a mechanical cardiac support. Analysis of haemodynamic parameters (assessed and calculated) revealed that for the fate of the necrotic focus of the myocardium the degree of relief (decompression) of the left ventricle is decisive. In complete relief the necrosis diminishes in size.

[Metabolic aspects of hypothermic extracorporeal circulation]. / K nekterým metabolickým aspektum hypotermního mimotelního obehu.

The submitted paper is devoted to some aspects of metabolic and immunity reactions of the organism to extracorporeal circulation. The authors focused attention in particular on a correlation of the whole-body oxygen consumption and the blood sugar level. Surprising findings comprise the rise of the whole-body oxygen consumption which occurs before the tissue temperature rises. As far as toxic oxygen radicals are concerned, their release is individual. It is, however, important that during the perfusion proper the activation of the immune system is suppressed. The course of the extracorporeal circulation was satisfactory from the clinical aspect; despite that it cannot be considered physiological, as also apparent from some biochemical findings.