Arteries of the anterior wall of the maxilla in sinus lift surgery.

Knowledge of the anatomical course of the anterior maxillary wall and alveolar process arteries is essential for sinus lift procedures. The aim of this study was to analyse the localization of anastomoses between the infraorbital and posterior superior alveolar artery on 101 computed tomography (CT) scans of maxillary sinuses (patients aged 18-70 years). The distance from the anastomosis to the bone point was measured on CT scans for each tooth location; for edentulous patients measurements were made to the lower edge of the alveolar process, and for dentate patients to the neck of the tooth. Measurements were done independently by two observers. The anastomosis analysed was identified on 50% of CT scans. The distance to the anastomosis was longest above the premolar (20.4 mm from tooth cervical line) and shortest above the first molar (15.9 mm to the edge of the alveolar process). The anastomosis can be localized on a CT scan for exact positioning of the antrotomy in 50% of patients. For the remaining patients, the anatomical information provided in this study can be used to reduce the risk of damage to the anastomosis. This study provides information on the distance from the anastomosis to the neck of preserved teeth in partially edentulous patients, which can be used as a reference point during sinus lift procedures.

[A case of partial hearing recovery after ablation of cerebello-pontine angle neurinoma]. / Un cas de récupération partielle de l'audition après l'ablation d'un neurinome de l'angle pontocérébelleux.

A case of a 44 year-old woman farmer with a total deafness and lack of vestibular function on the left side operated upon the cerebello-pontine cystic neuroma 2.5 x 2.0 x 1.5 cm large via the retromastoidal craniectomy is presented. Despite of the negative audiological tests' results the cochlear nerve flatten on the tumor was cautiously separated. Some time after surgery, she observed "a partial recovery of hearing" in the operated ear confirmed by the tonal (mean 0.5-2 kHz 36 dBHL) vocal SRT 70 dB), BERA and EOAEs tests. The paralysis of the left vestibular function did not recover. In consecutive audiogram a notch at 6 kHz 15 dB deep appeared in the operated ear and one can presume an increased vulnerability of this ear to the noise of the agricultural machines used by then by the patient.

Infratentorial approach to internal acoustic meatus.

Surgical exposure of internal acoustic meatus via typical suboccipital retrosigmoid craniotomy is limited by inner ear structures that should remain intact if hearing preservation is attempted. Feasibility of supracerebellar-infratentorial approach to the meatus with more medial angle of exposure and with preservation of inner ear structures was studied on fresh cadavers and on computed tomography pictures of temporal bones. Anatomical relationships of internal acoustic meatus and adjacent structures show marked individual variability. When typical retrosigmoid craniotomy is used to expose meatal fundus, significant medial retraction of cerebellar hemisphere is required in 47% of the patients to avoid opening endolymphatic spaces. Internal acoustic foramen and meatus can be exposed via craniotomy situated under transverse sinus, with 10-15 mm downward retraction of cerebellum. Medial extent of craniotomy can be planned on preoperative imaging studies. Infratentorial supracerebellar exposure of internal acoustic meatus allows for more medial angle of surgical approach than standard retrosigmold craniotomy. It can be used when preoperative imaging studies show that anatomical relationships between internal acoustic meatus and inner ear structures would require excessive cerebellar retraction to visualize a whole tumor inside meatus.

[Reconstruction methods in skull base surgery]. / Metody rekonstrukcji w chirurgii podstawy czaszki.

Surgery for extensive skull base lesions inevitably creates multiple tissue defects that require reconstruction. In this paper reconstruction methods applied in 41 skull base surgery procedures are presented. Anterior cranial fossa was involved in 13 operations (4 malignant and 9 non-malignant tumours), middle and posterior cranial fossa in 28 (9 malignant and 19 non-malignant). As a rule all the defects were reconstructed in one stage, immediately after tumour removal. Titanium mesh was the only alloplastic material used to cover bone defects in 7 patients. Otherwise only autografts were used. Postoperatively in all the patients in whom excision and repair of dura was necessary, continuous lumbar drainage of cerebrospinal fluid was maintained for 4-6 days. In anterior cranial fossa area large pediculated, vascularized periosteal flap allowed for reliable separation of upper airways from intracranial cavity. Titanium mesh was used to cover orbital wall defects. In the area of middle cranial fossa and temporal bone the most important aspects of reconstruction were watertight closure of the dura, separation of the surgical cavity from nasopharynx with rotated temporalis muscle, and facial nerve reconstruction (the nerve was reconstructed in 7 cases). Additionally in 1 patient hypoglossal nerve was sutured end-to-end. In 2 patients the invaded segment of internal carotid artery was excised and replaced with prosthesis. In 13 patients the surgical procedure was performed in an area that was previously operated upon and/or irradiated. Delayed healing was seen in 6 cases, but none required additional procedures and the wounds were completely healed with local treatment. Reconstruction methods presented in this paper are relatively simple and do not necessitate modern materials. Even in extensive procedures proper wound healing and satisfactory cosmetic result were obtained.

Reanimation of the face after facial nerve palsy resulting from resection of a cerebellopontine angle tumour.

Twenty-three patients with facial nerve paralysis following surgery for a cerebellopontine angle tumour had a facial-hypoglossal anastomosis and simultaneous anastomosis of the cervical ansa with the distal stump of the hypoglossal nerve. In 18 patients, simultaneously with the neural anastomoses, additional transpositions of the temporalis and masseter muscles were performed. At follow-up examination 3-87 months after reconstructive surgery, eight patients had House grade II, ten grade III and five grade IV outcome. The EMG evidence of reinnervation was observed 5-11 months after anastomosis. Combination of the facial-hypoglossal anastomosis with simultaneous myoplasty and with anastomosis of the distal hypoglossal nerve stump to the ansa cervicalis provides the advantage of immediate protection against ophthalmic complications, prevents hemiatrophy of the tongue and gives good functional results when reinnervation of the facial muscles takes place.

Brain abscess in infants.

Brain abscesses are rare in infants and their clinical presentation is specific for this age group. Seven cases of brain abscess in infants aged 2-11 months are reported. The underlying cause was meningitis in four, sepsis in two, and unknown in one. Gram-negative organisms were cultured in 6 patients. The abscess size was 5 cm or more in five cases; in four there were multiple lesions. Two abscesses were aspirated and irrigated; four particularly large lesions were drained and repeatedly aspirated and irrigated. One craniotomy was done. There were two deaths, one in the postoperative period and the other 6 months after discharge. Follow-up information is available for four children, showing a good result in only one of them. Formation of an abscess should be diagnosed early, and close ultrasound monitoring or CT scanning in infants with bacterial meningitis and sepsis is essential. The prognosis in cases in which large/multiple abscesses develop is poor.

Oculomotor nerve repair using interposed nerve graft.

A case of interposed nerve graft repair of an oculomotor nerve damaged during surgery for a laterally growing retrosellar pituitary adenoma is reported. The patient showed partial but functionally useful recovery of nerve function and was able to resume professional work. Only a few reports of end-to-end repair have been published, and they indicate that partial return of nerve function can be expected in such cases.

Cerebral hydatid cysts in children.

Twelve children with intracranial cysts of Echinococcus granulosus underwent surgery during a period of 5 years and constituted 19% of all children operated on for intracranial space-occupying lesions. The more common symptoms were raised intracranial pressure (8 cases) and hemiparesis (7 cases). The total number of procedures was 14, with a standard craniotomy approach in 13. In 6 the cysts were removed without puncture or rupture, in 5 puncture and drainage were carried out before removal of capsule, and in 3 the cyst ruptured accidentally. Recurrence of multiple cysts occurred in 1 case and another patient was reoperated on twice for recurrent cysts after an operation in another center. There was no mortality. Non-bacterial meningitis occurred in 2 cases. Although drainage of the cyst contents greatly facilitates removal, it also carries a risk of contamination; thus a traditional approach via a large craniotomy seems to be the safest choice.

[Aneurysms of the pericallosal artery and its branches]. / Tetniaki tetnicy okolospoidlowej i jej rozgalezien.

A group of 33 patients with 34 aneurysms of the pericallosal artery and its branches are reported. They were treated in the Department of Neurosurgery, Medical Academy in Warsaw in the years 1965-1981. In 4 patients coexistence of other cerebral vascular anomalies (aneurysms of other location and/or angiomas) was demonstrated. The group comprised 21 men and 12 women aged from 7 to 60 years. Nine patients were not operated on, 8 of them died due to haemorrhagic brain damage and one gave no consent to operation. Out of surgically treated 24 patients in 3 cases the common carotid artery was ligated in 4 cases the wall of the aneurysm was reinforced with plastic mass, and in 17 cases the neck of the aneurysm was closed with a clip. In the clinical group I (Botterell's scale) 7 patients were treated surgically, in group II - 5, in group III - 9 and in group IV - 3. The immediate operative mortality was 8.5% (2 patients). One patient died 2 months after the operation from other disease. Deterioration of the neurological status occurred in 33% of cases (8 patients). Late result of the treatment was known in 16 cases with a mean follow-up of 4 years. Six patients returned to work, five resumed work with restrictions, and five other could not work and required care. The results of surgical treatment depended, in the first place, on the clinical state of the patient and the surgical risk was not greater than in cases of aneurysms of other location.

[Late recurrent subarachnoid hemorrhage after strengthening the aneurysm wall with aneuroplastic]. / Odlegle nawrotowe krwawienia podpajeczynówkowe po wzmocnieniu sciany tetniaka aneuroplastykiem.

Two patients are presented in whom repeated subarachnoideal haemorrhages developed 4 and 13 years after operations for intracranial aneurysms including strengthening of aneurysm wall with aneuroplastic. The patients were reoperated on by microsurgery. In both cases it was possible to clip the aneurysm after removing aneuroplastic.

[Atypical pain syndrome after amputation of the lower limb]. / Nietypowy zespól bólowy po amputacji konczyny dolnej.

A very unusual case if described of ischialgia coexistent with phantom pains in the amputated extremity. The cause of pain was prolapse of a lumbar intervertebral disc diagnosed only during operation. The case points out the necessity of differentiating between postamputation pains and pains not directly related to amputation. This differentiation may help in successful treatment.

[Surgical treatment of epilepsy caused by extensive brain damage]. / Leczenie operacyjne padaczki spowodowanej rozleglymi uszkodzeniami mózgu.

An analysis of the clinical data on the intervention and results of treatment of 73 patients operated upon for epilepsy is reported, in whom resection was done of more than one cerebral lobe. They accounted for 17% of all patients treated surgically at this neurosurgical centre for seizures. A characteristic finding in this group was the presence of signs of severe brain damage, such as frequent and variegated seizures, neurological deficits, impairement of mental development, extensive EEG changes. In 50 patients resection of more than two lobes was done, in 22 cases three lobes were removed, and in 1 case even four lobes were removed. The operative mortality was 2.7%. The duration of follow up was 6 years, on the average. Forty-two per cent of the patients are without seizures, isolated seizures occurred in 16.5%, in 18% of cases the frequency of seizures was decreased, in 23.5% there was no improvement. Statistical analysis of the effects of certain elements of the clinical state on the final result of the treatment was carried out and it was found that a significant influence was exerted by: age below 20 years, occurrence of two or more types of seizures, and presence of generalized slow waves in EEG. In these patients the results were worse. On the other hand, the age of disease onset, disease duration, aetiology, intellectual level, changes in neuroradiological investigations, extent of resection were without effect on the final result of the treatment.

[One-stage operation in 4 intracranial aneurysms]. / Jednoetapowa operacja czterech tetniaków wewnatrzczaszkowych.

The authors report a patient aged 58 years with a history of two episodes of subarachnoid haemorrhage and with arteriographic finding of four intracranial aneurysms: two on the internal carotid artery, one on the trifurcation of the middle cerebral artery, and one on the anterior communicating artery. Despite rather poor general and local condition (III clinical group) during the operation all four aneurysms were closed with clips. After a stormy postoperative course the condition of he patient improved and 6 months later he was feeling well, had no paresis, and only some memory disturbances remained. This case shows that multiple intracranial aneurysms should be treated in one-step operation, if this can be done from one surgical approach. This is important particularly in these cases in which it is difficult to say which aneurysm is bleeding.

[Embryonal hemangioma and adenoma of the pituitary gland in a patient. Case report]. / Naczyniak plodowy i gruczolak przysadki u jednej chorej.

The authors describe a 54-year-old woman treated surgically 28 years earlier for embryonal haemangioma of the cerebellum and admitted with signs of hypophyseal tumour. Radiological examinations confirmed this suspicion and the patient was treated surgically from the approach through the nose and sphenoidal bone. The previous disease and intraoperative observation suggested the possibility of embryonal angioma in the sella but histological examination demonstrated that the tumour was a chromophobe adenoma.

[Value of axial computerized tomography for the evaluation of the effectiveness of the ventriculo-atrial shunt]. / Znaczenie osiowej tomografii komputerowej w ocenie skutecznosci dzialania polaczenia zastawkowego komorowo-przedsionkowego.

The authors describe 32 cases of hydrocephalus of different aetiology in which the effectiveness of the ventriculoatrial shunt was evaluated by means of repeated computerized axial tomographic (CT) investigations. This investigation made it possible to demonstrate in a way not exposing the patients to any complications that the shunt was effective in 87.4% of cases with reduction of the size of the ventricular system of significant and moderate degree. Simultaneously with reduction of the size of the ventricular system an improvement of the clinical state was observed in these patients with disappearance of the signs of increased intracranial pressure. It was observed that in cases of normotensive hydrocephalus presence of cortical atrophy in CT investigation made the prognosis unfavourable despite treatment with the shunt. The analysis of the presented material demonstrated a high usefulness of CT in the observation of hydrocephalus dynamics in cases of different aetiology treated by means of the shunt.

[Operations on the peripheral nervous system in the treatment of spasmodic torticollis]. / Operacje na obwodowym ukladzie nerwowym w leczeniu kurczowego kreczu karku.

The aetiopathogenesis of spasmodic torticollis has not yet been explained. The problem of surgical treatment selection is also at issue. The authors present own observations in 5 cases treated by operations on the peripheral nervous system. In 3 cases a very good therapeutic results was obtained, in 2 cases the results was not satisfactory. A characteristic fact was appearance of ultimate improvement only several months after the operation, similarly as it is observed after stereotactic operations. In the light of own observations and a survey of the literature the authors reach the conclusion that operations on the peripheral nervous system as the first stage of surgical treatment give good results in most cases.

[Microsurgical treatment of cerebral arteriovenous aneurysm]. / Mikrochirurgiczne leczenie naczyniaków tetniczo-zylnych mózgu.

The authors describe a group of 9 patients with arteriovenous malformations of the brain operated upon using the microsurgical technique and controlled arterial hypotension. In all cases the malformations were radically removed. In one patient the neck of a coexistent aneurysm of the pericallosal artery was clamped with a clip. Disability in one patient was the effect of haemorrhage, another patient with hemiparesis is being rehabilitated. The remaining patients are feeling well and in only one of them epileptic seizures remained after the operation, they had, been however, present before the operation. The use of the microsurgical technique makes possible reduction of the surgical trauma to the brain tissue and opens greater possibilities of intraoperative evaluation of radical performance of the operation.