Clinical and neurophysiological changes in patients with pineal region expansions.

In the last 20 years neurological and neurosurgical follow up of our patients with pineal region expansions (118 patients) pointed to certain clinical and neurophysiological regularities. We performed retrospective study which included 84 patients with pineal region expansions in the period from 1992 to 2009. The study included 55 women and 29 men, mean age 30.08 +/- 13.93 years, with positive brain magnetic resonance imaging (MRI)--70 patients (83.4%) had simple pineal gland cysts, and 14 patients (16.67%) had expansive process in pineal region with compressive effect. All patients had headache, while 32 patients (38%) had epileptic phenomena--primary generalized seizures. Patients had common electroencephalography (EEG) pattern with paroxysmal discharges of 3Hz (or more than 3 Hz) spike-and-wave complexes. Operation with supracerebellar infratentorial approach was performed in 70 patients. In most of our patients indication for the operation was established based on the size of the cyst (15 mm or more), with the signs of compression on the quadrigeminal plate and compression of the surrounding veins, which could result in seizures and EEG changes verified in our group of patients. Pathohistological analysis revealed pineocytomas in 11 cases (15.71%), pinealoblastomas in 2 cases (2.86%), one case of teratoma (1.43%), while 56 patients had pineal gland cysts (80%). Following surgery clinical condition improved in all patients--patients became seizure-free and headaches significantly decreased. Other symptoms including diplopiae, nausea, vomiting, vertigo as well as blurred vision also disappeared. There were no complications after surgical procedures. This study points to often appearance of seizures that clinically and neurophysiologically present as primary generalized epilepsy in patients with pineal region expansions. Our hypotheses are that mass effect on the surrounding veins that affects normal perfusion, compressive effect on the quadrigeminal plate and the aqueduct of the midbrain, hemosiderin deposists, as well as secretion disturbances of anticonvulsive agent melatonin can be involved in the pathogenesis of seizures. We suggest to perform high resolution brain MRI with special demonstration of pineal region in all young patients that have seizures and specific EEG changes.

Treatment of pineal region lesions: our experience in 39 patients.

The pineal region is the origin of lesions with a highly diverse histopathology. The aim of this study was to present our experience in treating patients with the pineal region lesions. In period between 1990 and 2007, 39 patients with pineal region lesions were operated on at the Department of Neurosurgery, University Hospital "Sestre milosrdnice", Zagreb, Croatia. The study group consisted of 21 female and 18 male patients with the median age of 24.4 years (4-66 years). Surgery was performed using the infratentorial supracerebellar approach in all patients. The pineal region lesions were removed totally in 23 (58.97%), subtotal in 14 (35.9%) and partially in 2 (5.13%) patients. Pathohistological examination revealed 13 pineocytomas (33.33%), 10 germinomas (25.64%), 7 glial cysts (17.94%), 3 pineoblastomas (7.69%), two pilocytic astrocytomas (7.69%) and one case (2.56%) of papilloma plexus chorioideus, epidermal cyst, yolk sack tumor and ganglioglioma. There was no surgical mortality. Thirteen patients (33.3%) experienced complications in the postoperative period. During the follow-up period that ranged from 3 to 48 months six patients died (15.4%). The infratentorial supracerebellar approach is a safe and effective surgical approach. Benign pineal lesions could be cured with surgery alone. In the case of malignant pineal lesions radical surgical resection allowed determining the exact pathohistological diagnosis and facilitated adjuvant therapy (irradiation and chemotherapy).

Recommendations for neuropathic pain treatment.

Damage to the somatosensory nervous system poses a risk for the development of neuropathic pain. Such an injury to the nervous system results in a series of neurobiological events resulting in sensitization of both the peripheral and central nervous system. The symptoms include continuous background pain (often burning or crushing in nature) and spasmodic pain (shooting, stabbing or "electrical"). The diagnosis of neuropathic pain is based primarily on the history and physical examination finding. Although monotherapy is the ideal approach, rational polypharmacy is often pragmatically used. Several classes of drugs are moderately effective, but complete or near-complete relief is unlikely. Antidepressants and anticonvulsants are most commonly used. Opioid analgesics can provide some relief but are less effective than for nociceptive pain; adverse effects may prevent adequate analgesia. Topical drugs and a lidocaine-containing patch may be effective for peripheral syndromes. Sympathetic blockade is usually ineffective except for some patients with complex regional pain syndrome.

[Recommendations for care of patients with cerebral accident. Part One: Organization of care for patients with cerebral accidents, treatment of cerebral accident and neurorehabilitation]. / Preporuke za zbrinjavanje bolesnika s mozdanim udarom. Prvi Dio: Organizacija skrbi za bolesnike s mozdanim udarom, lijecenje mozdanog udara i neurorehabilitacija.

Stroke is the leading cause of disability in modern society. In developed countries stroke is the second or the third cause of death, and in Croatia it is the leading cause of death. Therefore, stroke is not only a great medical, but also economic burden. Figures show that the incidence of stroke in transitional countries is increasing, so the epidemic of stroke could be expected in the forthcoming years. The Croatian Society for Neurovascular Disorders of the Croatian Medical Association and the Croatian Stroke Society wrote the recommendations for stroke management. The first part presents the recommendations for organization of stroke care, stroke treatment and neurorehabilitation, and the second part will present the recommendations for prevention of stroke.

[Recommendations for management of patients with cerebral stroke. Part Two: Primary and secondary prevention of cerebral stroke]. / Preporuke za zbrinjavanje bolesnika s mozdanim udarom. Drugi Dio: Primarna i sekundarna prevencija mozdanog udara.

Despite the enormous progress done in the course of last years in diagnosis, treatment and rehabilitation of stroke patients, prevention is still main strategy in approaching the stroke. After the comprehensive review of the organization of stroke care, treatment and neurorehabilitation of stroke patients, this part shows the recommendations of the Croatian Society for Neurovascular Disorders of the Croatian Medical Association and the Croatian Stroke Society for primary and secondary prevention of stroke.

Cerebral cysticercosis and echinococcosis: a preoperative diagnostic dilemma.

BACKGROUND: Seven cases of neurocysticercosis and three cases of neuroechinococcosis with symptoms of elevated intracranial pressure requiring urgent neurosurgical treatment are described. No neuroradiologic procedure established exact diagnosis preoperatively; this was achieved by pathohistologic analysis of bioptic material. METHODS: Ten patients with duration of clinical symptoms ranging from 1 week to 1 month were operated on at the Department of Neurosurgery of Sestre Milosrdnice University Hospital in Zagreb, Croatia during the period 1988-2000. On receipt, bioptical material was examined pathohistologically at the Ljudevit Jurak Clinical Department of Pathology of the same hospital. We compared our data with facts collected by reviewing the pertinent literature over the past 10 years. RESULTS: The most common localization of parasitic cysts in our study was posterior cranial fossa, i.e., subtentorial, which, according to the literature, is a rare localization. Due to this unusual localization, dominant clinical symptoms included elevated intracranial pressure, requiring urgent surgical removal of parasitic cysts. CONCLUSIONS: With the exception of the epidemiologic aspect, cerebral cysticercosis and echinococcosis are important as a true diagnostic and therapeutic problem. These human parasitic zoonoses are rarely diagnosed preoperatively despite newly developed neuroradiologic and serologic methods, especially in cases of primary appearance in brain when exact diagnosis reveals adequate surgical removal with subsequent complete recovery.