[Early and urgent (micro)surgery of single and multiple intracranial aneurysms of anterior and posterior circulation and total mortality rate after operative and conservative treatment]. / Rana i hitna (mikro)hirurgija pojedinacnih i multiplih intrakranijalnih aneurizmi prednje i straznje cirkulacije i ukupni mortalitet poslije operativnog i konzervativnog tretmana.

INTRODUCTION: The early and urgent ruptured cerebral aneurysm microsurgery principle is being presented. In Bosnia, this principle was pioneered by author (KD) as a part of aneurysmal subarachnoid hemorrhage treatment. The main goal of this strategy was to prevent the rehemorrhage which mortality rate is up to 80%. PATIENTS AND RESULTS: A one-year (April 2003-April 2004) prospective study of 24 no selected patients with 33 anterior and posterior circulation aneurysms was conducted. Patients were operated on early (42%) and urgently (58%) regardless of their Hunt-Hess grade, age and vasospasm, but also localization, size and number of aneurysms. Twenty four ruptured aneurysms underwent the clip occlusion (100%). A total of 30 (91%) aneurysms were clipped with only one intraoperative rupture (3.3%). The overall mortality rate for anterior circulation aneurysms regardless of HH grade was 12.5%. All patients with HH gr I and II had excellent outcome (100%). Mortality rate of patients with HH gr III harboring anterior circulation aneurysms was 7.6%. The patients with HH gr IV and V died in 50% of cases despite surgical treatment. Multiple aneurysms increased mortality rate of operated patients. DISCUSSION: Ruptured aneurysm should be occluded immediately although the operative outcome of early and urgent surgery is worse than late surgery. Especially urgent surgery has bad outcome because it is mainly performed during cerebral vasospasm. But the overall outcome is the worst after utilizing the principle of late surgery. In one month period of time, no operated patients have 50% of chance to experience rehemorrhage (80% mortality rate), 36% of chance to develop symptomatic vasospasm with 7-15% mortality, and 20-50% possibility of occurring the hydrocephalus. According to recent studies, the overall mortality rate of untreated patients with aneurysmal SAH is over 50%. Mortality of surgically and conservatively treated patients is 20-30%. The survival rate of patients with HH gr IV and V who are exclusively treated by conservative therapy is only 10%. CONCLUSION: Early and urgent aneurysm microsurgery resulted in outcome improvement of operated patients up to 30% compared with expected outcome of patients without surgery. The justification for early and urgent aneurysm surgery was found in almost all patient groups, HH gr I&II patients had benefit in 23-30% of cases, HH gr IV&V had benefit in 20-40% and HH gr III with anterior circulation aneurysms had benefit in 15-20% of cases.

[Detection and treatment of intracranial hemorrhage at the intensive care unit of the Pediatric Clinic in Sarajevo]. / Otkrivanje i lijecenje intrakranijalne hemoragije na odjelu intenzivne njege djecje klinike u Sarajevu.

Intracranial haemorrhage (ICH) is the common name for periventricular and intraventricular haemorrhage. We analyzed patients diagnosed as ICH in period January 2001 till May 2002. In 29/323 (8.9%) pts was verified ICH, 16/29 (55.1%) were male sex. Birth weight under 1000 grams had 6/29 (20.6%), birth weight 1000-1499 grams was 10/29 (34.4%), than 1500 to 2499 grams 8/29 (27.5%) and over 2500 grams 5/29 (17.2%). APGAR score were under 7 in 20/29 (68.9%), and four of tham 4/20 (20%) had severe and 16/20 (80%) pts had modest and mild forms of perinatal asphyxia. According to Papile classification of ICH, we found: I degree ICH had 12.29 (41.3%) pts, II degree 8/29 (27.5%) pts, while severe forms III and IV degree of of ICH had 9/29 (31.2%) pts. In 3/29 (10.4%) pts, posthemoragic hydrocephalus were registrated. Risk-factors for development of ICH were low birth weight, small gestational age and perinatal asphyxia.

[Neural tube dysraphism: meningomyelocele and related disorders]. / Disrafizam neuralne cijevi: meningomijelokele i srodni poremecaji.

Neural tube disorders develop as a result of failure of neural tube closure between 3rd and 5th gestational weeks. This failure can cause soft structure anomalies (spina bifida, lumbal meningocela) or possible can contain neural tissue (meningomyeloccla, encephaloccla). Etiology of this disorder is not clear enough, and probably has multifactorial roots. Besides genetic factors, there are impact of some nutritional causes like folic acid. 28 cases with neural tube dysraphism hospitalized during period August 1999 till August 2002. at the Pediatric Clinic KCU Sarajevo were analyzed through retrospective study. 19/28 (67.8%) of newborn were from controlled pregnancy but without folic acid supplementation, 4 of them (14.2%) had prenatal diagnosis. Dysraphic disorder was the most often accompanied by paraplegia 16/28 (57.1%), hydrocephalus 17/28 (60.7%), from which 6/17 (35.2%) with Arnold Chiary malformation. 13/28 (46.4%) had skeletal deformities. Active preoperative treatment was conducted in 20/28 (71.4%) cases, and the rest of them were treated with home palliative care because of parent's rejection of surgery or major accompanied anomalies presence. In order to decrease the incidence of dysraphic disorders it is necessary to conduct periconceptional folic acid prevention, and provide early prenatal diagnosis. Long term treatment of children with meningomyclocele requires multidisciplinary approach that includes surgeons, orthopedists, pediatricians, physical therapists, in order to improve life quality of survived children.