Clinical features and therapeutic outcomes of patients with acromegaly: single-center experience.

The aim of this study was to review the outcome of acromegaly treatment, as well as co-morbidity and mortality in a series of patients with acromegaly attending a single center in the last 10 yr. In that period, 53 patients were treated for acromegaly. Transsphenoidal operation was applied as the first-line therapy in 94.3% of patients and it led to disease remission in 59.2% of them. The remission criteria included a nadir GH<1 µg/l after glucose load, and normal age-related IGF-I levels. The remission rate after transsphenoidal surgery was significantly higher in the group of patients with microadenoma (76.9%), than in the group of patients with macroadenoma (52.8%). Patients with invasive tumors had remission rate of 16.7% after transsphenoidal surgery. There were no perioperative deaths. As the second-line treatment somatostatin analogues, radiotherapy, and dopaminergic agonists were used. Hypertension and diabetes were the most frequent co-morbidities in the group of patients. After successful treatment, 30% of patients with diabetes or impaired glucose tolerance had significant improvement of glycemic control. Transsphenoidal surgery is the appropriate firstline therapy in patients with somatotropinoma. Medical and radio-therapy should be reserved as the second-line therapy after surgery failure.

The difference between ultrasound-guided and stereotactic-guided neurosurgical procedures.

We evaluate two different methods, ultrasound (US) guidance and stereotactic guidance, routinely used in our Department for navigation in various neurosurgical procedures. We have performed 53 US-guided and 101 stereotactic-guided procedures. These procedures were intracranial lesion biopsies, intracranial cysts and abscesses puncture and evacuations, ventricular punctures for hydrocephalus shunt operations, stereotactic-guided microneurosurgical resections, and stereotactic-guided endoscopic operations. Advantages of the US-guided operations are the shortness of the procedure, simplicity (no need for moving patient for additional CT scanning), no irradiation and the possibility of real-time imaging. The disadvantages of the US-guided procedures are worse resolution of the images in deep-seated and small lesions as well as the need for a bigger trepanation because of the transducer's dimensions. Stereotactic procedures are time-consuming but more precise and usually done in local anaesthesia because only a small trepanation is required. Main disadvantage of the stereotactic-guided procedures when compared with the US-guided procedures is a lack of real-time intraoperative control. According to our experience, both methods are complementary and safe and they do not cause any additional complications when used as a navigation tool in microneurosurgical operations. Both methods are highly reliable when used in properly selected patients.

Management of war penetrating craniocerebral injuries during the war in Croatia.

From September 1991 to December 1992, during the war in Croatia, the General Hospital in Slavonski Brod served as an evacuation centre. During that period 197 patients with war-related penetrating craniocerebral injuries were admitted. They were analyzed according to wound characteristics, operability, mortality, operative and post-operative complications, and their condition after hospital discharge and follow-up. A less aggressive surgical approach was accepted in our surgical strategy, recommended in recent studies, followed by an aggressive intensive management. All patients received antibiotics ("war scheme") and anticonvulsants. Early results of treatment do not differ significantly from other recent studies (Vietnam, Israel) in respect to both mortality and complications. Follow-up was difficult. Most of the patients were Bosnia and Herzegovina citizens who were refugees and banished to foreign countries; thus their addresses were unknown. They are consequently lost to follow-up. A less aggressive surgical approach proved to be justified. Routine use of antibiotics and anticonvulsants lowered the infection rate and early seizure incidence to an acceptable level. Late seizure incidence is similar to those previously reported.

[Use of intraoperative ultrasound in neurosurgery]. / Uporaba intraoperacijskog ultrazvuka u neurokirurgiji.

Intraoperative ultrasound (US) is a device which is a great help to neurosurgeon in intracerebral lesions localization, in the definition of inner tumors structure, in its relation to the surrounding structures, as well as during stereotaxic operations. We report our experiences with US in more than 500 operations. Its maximum usage is during gliomas and metastases operations because of their subcortical localization. Choosing this optimal approach to the tumor, the surrounding brain is minimally damaged. Using modern devices we are able to distinguish edema from infiltrative gliomas, which was not possible using former devices (both edema and gliomas are hyperechoic). In vascular neurosurgery we use US mostly in the localization of small arteriovenous malformations (AVMs). In pediatric neurosurgery the usage is very often in drainage operations for ventricular catheter placement control. The main US shortage is lower image resolution, and the basic advantage is real time imaging. It enables our prompt intervention in every unfavorable situation.

Reducing the incidence of infection in pediatric cerebrospinal fluid shunt operations.

We reviewed our experience with shunt implantation during two time periods. From June 1985 to December 1990, 201 children with hydrocephalus underwent 382 operations. Among these children 36 (18%) developed a proven shunt infection, with an incidence rate per procedure of 9.4%. As a result of this study, a new effective protocol for shunt procedures involving modifications to the perioperative (antibiotic prophylaxis) and intraoperative management (meticulous surgical technique, complete shunt revision) of children undergoing initial shunt implantation or revision was initiated. With this new protocol 75 children underwent a total of 112 procedures between January 1991 and December 1995. The incidence of shunt infection decreased, with a per patient rate of 8% and a per procedure rate of 5.3%. The majority of infections in our study were caused by Staphylococcus epidermidis, which was found in 22 (52.3%) patients.

Analysis of projectile destructive effect in missile injury to the brain.

During the war in Croatia so far, more than 250 casualties having missile wounds of the brain, spinal chord and peripheral nervous system were admitted to the Neurosurgical Clinic, University Hospital-Rebro. These injuries were mainly caused by low-velocity missiles. However, the high-velocity ones, used nowadays, in direct injury to the head, cause destruction of the brain that is incompatible with survival in most of the cases. This paper deals with a patient injured by a 7.62 mm projectile. The mechanism of the brain destruction is not completely clear since the missile was found at the very entrance of the missile wound, while the brain was destroyed up to the opposite side of the endocranium. Four mechanisms of the missile's effect aimed at explaining the cause of death of the patient, as well as the bizarre position of the missile, were taken into consideration. The review shows how perilous a wound from a direct missile injury to the head could be, regardless of its speed.