[Screening of risk groups for discovering intracranial aneurysms before rupture].

In development of intracranial aneurysms contribute genetic factors together with smoking, hypertension, diabetes mellitus. Epidemiology studies suggest that as many as 5% of people harbour a cerebral aneurysm by age 75. Rupture of cerebral aneurysm is the most frequent cause of spontaneous subarachnoid haemorrhage (up to 80%.) Annual incidence of SAH is 10-14/100 000, but only 15-20% of aneurysms will rupture, and that will happen probably between 40-60 years. The morbidity and mortality of aneurismal subarachnoid (SAH) continues to be high. It is not possible to predict who has aneurysm and is it going to bleed or not, but it is possible to reveal high risk groups (polycystic kidney disease, Ehlers-Danlos sy, Marphan sy, family history of cerebral aneurysms, suspect de novo aneurysm formation in patients with prior history of cerebral aneurysm). Reviewing data from literature and reporting cases from each group with high risk, that have been screened and aneurysms discovered, authors wish to focus interest on this matter and propose screening program for these groups of patients. The mortality and morbidity in cases treated before rupture is significantly lower than after SAH, so screening programs could save many lives. According to our preliminara data, mostly based on control angiographies after 8-10 zears in patients previouslz operated for intracranial aneurysmas, from 15 angipgraphies 4 revealed new aneurysms (26% in 10 years period) with total number of 6 de novo formed aneurysms, which is not valid due to small number of patients but strongly suggests the importancy of screening program for risk groups.

[Development of new intracranial saccular aneurysms].

Newly formed aneurysms developing from a cerebral vessel which had appeared to be normal in a previous angiographic study are very rare. Four cases of angiographically documented newly developed saccular aneurysms are described in this report. In all four patients, the new aneurysms were symptomatic, causing subarachnoid hemorrhage (SAH). Repeat angiography, performed after the second SAH, revealed new aneurysms that were not demonstrated on initial angiograms after the first SAH. They were clipped with good postoperative course. Our observations and literature data suggest that some patients with SAH need further neuroradiological followup. The presence of the risk factors and age of the patient should be taken into consideration.

[Subarachnoid hemorrhage caused by a rupture of a spinal arteriovenous malformation].

The authors report on a patient presenting with subarachnoid hemorrhage that was caused by a rupture of an spinal combined arteriovenous malformation at cervicothoracic junction. The patient was a 30-year-old female, who had exhibited an abrupt onset of severe low neck and occipital pain with radiation into shoulders and vomiting. Neurological examination revealed severe meningism without motor or sensory deficit. Digital subtraction angiography did not demonstrate any intracranial source of bleeding, whereas spinal angiography revealed a spinal arteriovenous malformation at cervicothoracic junction. Endovascular treatment of the malformation was considered for this patient. Occipital and neck pain with radiation into schoulders and severe meningism are clues pointing to a spinal origin of the haemorrhage.

[Space reconstruction of the aneurysms of the vertebrobasilary confluence based on conventional angiography--our experience].

Besides current development of the new diagnostic procedures conventional angiography still represents the golden standard in the diagnosing of intracranial aneurysms. Since it gives a two-dimensional image if the presentation of the third dimension is wanted it is necessary to apply appropriate algorithm structures and computers. In this study we show our experience in the application of space reconstruction of blood vessels and aneurysms of the vertebrobasilary confluence in 6 patients operated at the Institute for Neurosurgery, Clinical Center of Serbia. Intraoperative finding in all patients matched the finding that we got by space reconstruction of the blood vessels, which was possible to observe from different angles. Postoperative course in all patients was satisfying. Upon discharge the patients were without rough lateralization of the pyramidal system. Our initial results and their practical agreement with the interoperative finding give us right to recommend this method as the standard for the preoperative diagnostic protocol.

[Endovascular occlusion of the intracranial aneurysms--an alternative for surgical treatment].

Aneurysms on cerebral blood vessels due to their localization, size, relationship with neurovascular structures, even today, represent besides the constant progress of the diagnostic techniques and instruments in the operating theaters, a great therapeutic challenge. Gigantic aneurysms, aneurysms localized within the cavernous sinus and aneurysms of the vertebrobasilary confluence carry a great perioperative risk of mortality and morbidity. In fact, development of the endovascular procedures for the occlusion of their lumen made possible great progress in the treatment of aneurysms of this localization. In a not so small number of cases endovascular procedure means remodeling of the lumen of the main blood vessel. Endovascular obliteration of aneurysms has a certain advantage as regards the surgical treatment of aneurysms in which, on the basis of the expected natural course and presumed operative risk, may be judged that there exists unacceptably great operative risk. We present a personal series and results in 6 patients with aneurysms of various localizations.

[Treatment of patients with spontaneous intracranial hematomas].

Spontaneus intracerebral haemorrhage is a common cause of stroke especially in the young. The term "spontaneuos intracerebral haemorrhage" refers to bleeding without coincident trauma. About 80% of this haemorrhage occur supratentorial in the basal nuclei and they are associated with hypertension. Etiological factors range from congenital vascular malformations (aneurysmas, AVM, cavernomas) to acquired and degenerative vascular and brain conditions. In primary intracerebral hemorrhage arterial hypertension and consequent vascular changes are the major etiological factors. In secondary- nonhypertensive hemorrhage cause may be associated with aneurysms, AVM, tumors, coagulation disorders. Contemporary diagnosis imaging (CT, MRI) and neurological evaluation, allow early diagnosis and effective medical and/or surgical therapy in a majority patients. Without treatment, the risk of mortality and morbidity is high. Medical management involves normalization of blood pressure, reduction of intracranial pressure, control of brain edema and prevention of seizures. In design for operative treatment must be include age of the patient, hematoma size and location, clinical condition, the level of consciousness and patient outcome. The role of surgery remains contraversial.

[Neurosurgical treatment of spontaneous and traumatic intracerebral hematomas].

In the period from 01.01.2000 until 31.12.2002 34 patients with spontaneous intracerebral hematoma (ICH) and with deeply disturbed state of consciousness were operated in the Department of neurosurgery of the Urgent Center, Clinical Center of Serbia. In all operated patients the indication for surgery was given on the basis of CT scan of the brain, state of consciousness, defined Glasgow coma score (GCS) and neurological status, but due to existing or threatening incarceration not even one patient was submitted to angiography of the blood vessels at the cerebral base, thus preoperatively we did not know the cause of the hemorrhage. Of 34 operated patients 22 or 64.7% died, and 12 or 35.3% survived. 14 patients were in the deepest phase of coma, where the preoperative GCS is from 3 to 5 points, and in the postoperative course only one survived, aged 25. The other survivors had somewhat less disturbed state of consciousness, they also were younger, CT scan of the brain was without blood in the chamber system. In the same period, in the Department of Neurosurgery of the Urgent Center, Clinical Center of Serbia 43 patients with traumatic intracerebral hematoma (TIH) were operated; 9 patients survived, 34 died. Only 4 patients had acute TIH. All of them were in the terminal stage of incarceration, and despite being immediately submitted to surgery all of them died. The remaining 39 patients had, the so called delayed TIH where the secondary CT scan of the brain showed development of the traumatic intracerebral haematoma that was not verified on the incipient scanner. Indication for a repeated CT scan was given in 19 patients due to focal or general neurological deterioration. However in 20 patients subsequent neurological disturbances were not registered. Those that survived were younger patients, and they were not in the deepest stage of coma, most often they had a temporal localization of hematoma.

[Results of surgical treatment of patient with supratentorial cavernoma and epilepsy].

In past, cavernoma was frequently cause of symptomatic epilepsy without pathological supstrat. We present the group of the patient (32) who illness were presented by epilepsy, and who were treated in Institut for Neurosurgery from 1998 to 2003. There is the good correlation between presentation of epilepsy and largness of the cavernoma (Phi 0.683). In 22 patinets the epilepsy was controlated by medicaments, and in other the seayurs were uncontrolled. Cavernoma initially presented with seayures had no inclination for massive intralesional or parenhimal bleeding. After surgical extirpation of leasion, there was good outcome during the following period of 3 years

[Surgical treatment of brain stem cavernoma--current approaches].

Results of our series of 10 operated patients who had cavernous malformation of the brain stem, in accordance with the findings of other authors, have confirmed that surgical removal of cavernomas is an absolutely appropriate approach as regards the prevention of repeated and disabling hemorrhages, also from the point of view of the recovery of the neurological deficit. In patients with disturbed vital functions (breathing, swallowing) evacuation of hematomas and removal of the malformation eliminate life endangering compressive effect on the vital structures of the brain stem. It is not disputable that patients with superficially localized cavernomas and progressing neurological deficit should be subjected to surgical treatment. In cases of deep lying lesions that are covered by a considerable layer of nervous parenchyma, it is indispensable to have a very careful preoperative planning of a safe entry into the brain stem, without damage to the vital functional structures. In case of a complete neurological recovery after a single hemorrhagic episode, the decision to perform surgery is delicate and demands individual appraisal of each patient. As regards the procedure with incidentally found and clinically asymptomatic lesions, regardless of the MR-signs of hemorrhage in the form of the hemosiderin ring around the lesion, we support the view of those authors who think that such lesions should not be operated but should be subjected to clinical treatment and MR with periodical MR check-ups.

[Neurovascular compression (conflict)]].

Since Dandy first reported vascular compression of the trigeminal nerve, the concept of neurovascular compression syndrome for trigeminal neuralgia and hemifacial spasm (HFS) has been accepted, and neurovascular decompression has been performed for this condition. The further investigations indicated that some other clinical syndromes such as glossopharyngeal neuralgia, disabling positional vertigo, tinnitus, geniculate neuarlgia, spasmodic torticolis, essential hypertension, cyclic oculomotor spasm with paresis and superior oblique myokymia also may be initiated by vascular compression of the glossopharyngeal, cochleovestibular, intermediate, accessory, oculomotor and trochlear nerves or the ventrolateral medulla oblongata. In this study several hypotheses regarding the development of cranial nerves vascular compression syndromes are presented. It is alsoemphasized the value of high-resolution magnetic resonance tomographic angiography for visualization of vascular compression. The most frequent clinical syndromes caused by vascular compressionof the cranial nerves are discussed regarding the pathogenesis, symptomes and therapy. We present our series of 124 patients with preoperative evidently positive finding of vascular compression to the trigeminal nerve (MRI). Microvascular decompression (MVD) was performed in all of them. Initial postoperative result was excellent in 110/124 (89%) patients,while in 11/124 (9%) patients the pain relief was satisfactory. In the remaining three patients MVD failed. Recurrence of pain after two years reached 19%. Complications were related to diplopia associated with transient fourth nerve dysfunction in 5 (4%) patients, facial motor dysfunction in 4 (3%) patients, transient facial hypesthesia in 27 (22%) patients and partially hearing loss in 4 (3%) patients. Cerebellar hemorrhagic infarction occurred in 1 (0.8%) patient and cerebrospinal fluid leaks appeared in two (1.6%) cases. There was no lethal outcome.

Osteoid osteoma of a cervical vertebral body.

We report a very rare case of 5-year-old boy with osteoid osteoma of the cervical vertebral body. The patient presented with a 6-month history of neck pain with radiation into the shoulder and arm on the left side, which was relieved by ibuprofen. Neurological examination and plain radiographs of the cervical spine were normal. CT scan and bone scintigraphy, rather than MRI suggested the pathological diagnosis, which was confirmed on histological examination. The patient underwent excision of the lesion via an anterior approach with complete resolution of the pain postoperatively.

[Relation of surgical results and proposed skull base meningioma grading system: analysis of clinical series with 42 patients].

UNLABELLED: Anatomical localisation of skull base meningioma link, their growth and relations with neurovascular structures reduce possibility for radical operation, and offten request additional preoperative or postoperative radiotherapy. We compared personal results of extent surgical resection and skull base meningioma treating outcome with predispose factors scale for surgical radicality and postoperative outcome. We present 42 patients, who were operated in Institute of neurosurgery CCS during the period from 2004 to 2006. RESULTS: Radical resection was possible in 29 cases, and in 13 cases reduction of tumor mass has been performed. Statistical significant predispose factor for radical resection were: absance of preoperative radiotherapy, intact functions of n.III, n.VI, tumor borders inside one skull base fossa and outside of magistral blood vessels. Karnofsky index at the end of following period statistical significant higher in patients with radical resection of skull base meningeioma. Preoperative radiological finding is singificant guide in planning of therapeutic protocol for skull base meningioma. Growth of tumor and relation with neurovascular structures restrict extent of resection and often request additional postoperative radiotherapy or reoperation.

Olfactory groove meningiomas.

Meningiomas, usually histologically benign tumors, are originating from the arachnoidal cap cells normally present intracranially in varying sites. Olfactory groove meningeomas arise from the medline of the anterior fossa between the crista galli and the tuberculum sellae. The most common presenting symptoms are the visual field defects, epilepsy, and psychological change. They are often large before they are detected because of slowly asymptomatic growing in the interhemispheric space of the frontal lobes. This series is consisted of 29 patients suffering from olfactory groove meningiomas treated surgicaly between May 1992 and November 2003. The surgical results and complications are presented and analized, comparing them by the other reported series.

Peritumoral edema and karyometric variables in astrocytoma of the brain.

PURPOSE: The aim of this study was to evaluate karyometry as a quantitative and objective histological method by showing correlation of some karyometric variables with the severity of peritumoral edema in patients with brain astrocytoma. PATIENTS AND METHODS: 63 patients of different ages and both genders were enrolled. The patients were diagnosed with astrocytoma of the brain, histologically confirmed on the surgically removed material. Maximal tumor excision was performed in all patients, who were postoperatively treated according to current oncologic therapeutic protocols. The intensity of perifocal edema (preoperative CT scan) was correlated to the duration of survival and the values of 9 karyometric tumor variables: area, density, maximal axis, mean axis, circumference, roundness, integrated optical density and number of nuclei. RESULTS: There were 17 cases with small perifocal edema, 19 with medium-sized and 27 with large perifocal edema, and their respective survival was around 149, 62 and 48 weeks. Those with small edema had statistically significant prolonged survival compared to those with medium and large perifocal edema (log-rank test, p=0.045). Six out of 9 karyometric variables examined were significantly related (p<0.05) to the intensity of peritumoral edema: long and mean axis, circumference, roundness, integrated optical density and number of nuclei. CONCLUSION: Patients with larger peritumoral edema have shorter survival. Correlation of karyometric variables with CT findings revealed that higher degrees of tumor cellularity and nuclear wrinkling with increased integrated optical density is associated with larger peritumoral edema.

Traumatic delayed epidural hematoma.

OBJECT: Traumatic delayed epidural hematoma (DEH) can be defined as a hematoma that is insignificant or not present on the initial computerized tomography (CT) scan made after trauma but subsequent CT scan shows sizeable epidural bleeding. During a 3-year period we have treated a total of 96 epidural hematomas, eight (8.3 %) of which had a delayed onset. CASE REPORT: We present here an analysis of the eight patients with traumatic DEH which had a significant mass effect in all patients and required surgical evacuation. In three patients with mild head injury (GCS > 12) neurological deterioration indicated the necessity of repeating the CT scan and preceded the detection of DEH. In only one case of the five patients with moderate (8 < GCS < 13) and severe head injury (GCS < 9) was neurological deterioration the precursor of the DEH. All patients were immediately operated on after diagnosis. Postoperative outcome was favorable in all cases. CONCLUSIONS: DEHs are highly unpredictable and continue to cause diagnostic difficulty. Close observation for signs of clinical deterioration and repeat CT scan are the most important factors for early detection of DEH. Early diagnosis and prompt operation offers excellent results for DEHs.

Extranodal marginal zone B-cell lymphoma most probably of MALT type appearing in CNS as parasagittal extracerebral tumor.

A 63 years old male patient with systemic extranodal marginal zone lymphoma, most probably originating from mucosa associated lymphoid tissue (MALT) involving central nervous system (CNS) is presented. The usual site of origin of this type of lymphoma was not identified. The diagnosis was stated after neurosurgery according to histopathology, immunohistochemistry and additional haematologic examination. Postoperative therapy included local irradiation (30Gy) of rest tumor, combined by Rituximab-CHOP (R-CHOP) protocol, which resulted in complete remission lasting three years up to now.

Enlargement to a saccular aneurysm and subsequent rupture of infundibular widening of posterior communicating artery.

A small dilatation known as infundibular widening (IFw) is frequently seen (7%-25%) on the posterior communicating artery (PComA) at its origin from the internal carotid artery. Development and subsequent rupture of an aneurysm on a previously radiographically demonstrated IFw has rarely been documented. We present two patients who suffered from subarachnoid hemorrhage (SAH). Initial cerebral angiography demonstrated IFw on PComA. They were readmitted to the hospital 9 and 11 years later, after a new SAH. Repeated cerebral angiography revealed an aneurysm arising from the site where the IFw had been seen previously in both cases. The aneurysms were clipped with favorable outcome. This report adds two new cases documenting enlargement of PComAIFw into an aneurysm. Patients with PComAIFw, especially those who have experienced SAH, should be considered for periodic follow-up to rule out the development of an aneurysm over time.

[The results of surgical treatment for cervical spondylotic myelopathy].

OBJECTIVE: Cervical spondylotic myelopathy is th emost serious consequence of cervical intervertebral disc degeneration. The purpose of this study is to evaluate functional results of surgical treatment of patients with cervical spondylotic myelopathy who underwent anterior or posterior decompressive operations. METHODS: we prospectively analyzed 57 patients with cervical spondylotic myelopathy who were operated in Institut for Neurosurgery in Belgrade (1995-2002). The severity of myelopathy is graded by Nurick myelopathy grading system. The average foloow-up period was 20 months. RESULTS: Postoperative improvement schowed 75% of patients and 21% remained unchanged. Myelopathy worsening was observed in two patients, 4%. We didn't have serious operative complications. Selection of surgical approach was not significantly correlated with surgical outcome. CONCLUSION: surgical decompression of cervical medulla is safe treatment that gives good chances for functional recovery in patients with cervical spondylotic myelopathy.

[Surgical management of cervical neurinomas with extraspinal extension]. / Hirursko lecenje cervikalnih neurinoma sa ekstraspinalnom propagacijom.

Neurinomas are the most common type of tumor that cause medullary compression at the cervical level. About 15% of all cervical neurinomas have extradural and extraspinal extension. Their resection raises the problems of nerve root preservation, vertebral artery control and spinal stability. Three patients with cervical neurinomas with significant exstraspinal components are presented in this report. They all had raducular pains and signs of medullary compression. Preoperative neuroimaging revealed cervical intraspinal and extramedullary mass with extraspinal extension. Complete tumor resection was achieved in all three patients by using staged posterior and anterolateral approach. Postoperative results were favorable. The complete removal of cervical neurinomas with extraspinal components is still a real surgical challenge. They can be completely resected by using staged posterior and anterolateral approach.

[UV-densitometry determination of pentazocine hydrochloride in tablets after low temperature extraction]. / UV-denzitometrijsko odredjevanje pentozocin hidrohlorida u tabletama nakon termomikro extrakcije.

TLC-UV densitometric method has been used for quantitative analysis of pentazocine hydrochloride in the pure form, as well as in tablets after thermomicro extraction and direct application on the thin layer plate. This procedure was based on the conversion of the investigated substance into the gaseous state, quantitative application on the silica gel GF254 plate and the elution was made with 100:0.15 (v/v) methanol-conc. ammonium hydroxide. Gas chromatography-mass spectometric identification was performed by NIST 90 mass spectra library. Densitometric determination of pentazocine hydrochloride was performed by HPTLC Scanner on 278 nm and the results were compared to the officinal BP 93 method. The method was precise (RSD % 0.69-3.88), accurate (recovery 96.04-101.65) and reproducible (SD 0.03-0.23). The linearity level (correlation coefficient r = 0.9911) was very satisfactory.