Evaluation of factors for poor outcome in preterm newborns with posthemorrhagic hydrocephalus associated with late-onset neonatal sepsis.

PURPOSE: Preterm newborns, due to many factors, are at increased risk for poor neural development, intraventricular hemorrhages, infections, and higher rate of mortality. The aim of this study was to evaluate the risk factors associated with poor outcome in preterm neonates with late-onset neonatal sepsis (LONS) who had posthemorrhagic hydrocephalus and underwent neurosurgical procedures for treatment of the hydrocephalus. PATIENTS AND METHODS: Preterm neonates who had undergone insertion of ventriculoperitoneal shunt or Ommaya reservoir, during the 10-year period at University Children's Hospital, were retrospectively analyzed. According to the presence or absence of LONS, patients were divided into LONS group and non-LONS group. In both groups, we analyzed demographic and clinical data as well as nondependent factors. Additionally, we evaluated the patients who had lethal outcome in respect to all the analyzed factors. RESULTS: A total of 74 patients were included in the study, 35 in LONS group and 39 in control group. Patients in LONS group were born significantly earlier with lower birth weight, needed significantly higher O2 inspiratory concentration, and had longer duration of mechanical ventilation when compared to the nonseptic group. Five patients in LONS group had lethal outcome, and for these patients we identified a grade American Society of Anaesthesiologists score of 4 (P=0.000), ductus arteriosus persistens (P=0.000), bronchopulmonary dysplasia (P=0.003), and pneumothorax (P=0.003) as independent preoperative risk factors for lethal outcome. CONCLUSION: Neurosurgical procedures are relatively safe in neonates with posthemorrhagic hydrocephalus without LONS after birth. However, if LONS is present, various conditions such as preoperative high grade American Society of Anaesthesiologists score, ductus arteriosus persistens, bronchopulmonary dysplasia, and pneumothorax markedly increase the risk for a lethal outcome after the operation.

The Value of Multidetector Computed Tomography of Orbits in Globe Protrusion in Comparison to Hertel Exophthalmometry

The use of multidetector computed tomography (MDCT) is an integral part of contemporary diagnostics of Graves' orbitopathy. The aim of this study was to assess proptosis measurement by MDCT and to compare it to the current standard, Hertel exophthalmometry. A cross-sectional study was conducted at the Clinical Centre of Serbia and included 91 patients (19 male and 72 female) with verified Graves' orbitopathy. Globe protrusion measured by MDCT (globe protrusion, GPR) was correlated to Hertel measured protrusion (HR). There was no constant or any systematic bias between the two methods. GPR significantly correlated with the best-corrected visual acuity, while HR did not. Age, body mass index and duration of the disease did not influence proptosis measurement by either method. Proptosis was significantly larger in males. According to our results, GPR compared to HR provides better assessment of the protrusion in Graves' disease. GPR measurement is simple and should always be part of the radiological assessment of orbits in Graves' disease.

Determination of Predictive Anatomic Parameters for Bleeding of Brain Arteriovenous Malformations by Multidetector CT Angiography.

Patients with brain arteriovenous malformation (AVM) have a certain risk to bleed, and the goal of this study was to examine the effect of radiological and clinical predictive characteristics of AVM hemorrhage using multidetector computed tomographic (MDCT) angiography. The study included a series of 57 patients, mean age 35.46 years, who were diagnosed during their hospitalization at Clinical Department of Neurosurgery, Clinical Center of Serbia, in the period from January 2008 to March 2016. In all patients, the diagnosis was made using MDCT angiography. Two groups of patients were observed. The first group included patients who did not initially present with hemorrhage, while the second group initially presented with hemorrhage. Both groups were treated with medical therapy or a combination of medical therapy with embolization/surgery/radiotherapy. Deep venous drainage (p<0.05), combined arterial supply from different basins (p<0.05) with a length <60 mm, venous dilatation present in the drainage vein (p<0.01), and the angle of casting sup-ply arteries in the nidus (p<0.01) carry a risk of repeated bleeding. In the group of patients who had initial hemorrhage, the mean value of the casting angle size was 130°, while in the group that did not have initial bleeding the mean value of the measured angle size was 103.81° with standard deviation of 17.21° (p<0.01). In conclusion, AVMs with deep venous drainage from the carotid and vertebrobasilar basin, the length of the feeding arteries <60 mm, the angle of the casting feeding arteries in the nidus ≥130° and dilatation and/or venous aneurysm of drainage vessel are predictive for clinical presenting by hemorrhage.

Adult Brainstem Gliomas: Retrospective Analysis of 51 Patients.

AIM: Brainstem gliomas (BSG) constitute less than 2% of brain tumors in adults. Therapeutic options are limited and BSG are associated with a high morbidity and mortality. MATERIAL AND METHODS: We reviewed the records of 51 patients with BSG treated at the Institute of Neurosurgery, Clinical Center of Serbia in Belgrade between 1998 and 2012. We recorded demographic and clinical variables as well as radiological findings and survival. RESULTS: Of the 51 patients, 62.7% were male and 37.3% were female. The mean age was 30.6±19.3 years. High grade glioma (Astrocytoma grade III and IV) was most common at the age of 38.2±17.9 years (t=.481, p=0.017) while low grade glioma (Astrocytoma grade I and II) was common in younger age as 25.4±17.4 years (X2=4.013; p=0.045), with localization in the pons (X2=5.299; p=0.021) and exophytic presentation (X2=3.862; p=0.049). Ataxia, as initial symptom, was a predictor of poor outcome (HR:5.546, p=0.012). CONCLUSION: Due to its specific localization, BSG present a major challenge for neurosurgery, because of the necessity of safe approach for radical resection. Histological verification of BSG determines the need for additional therapeutic procedures such as radiotherapy and chemotherapy. Benefit from correct diagnosis is reflected in the avoidance of potentially adverse effects of treatment.

GLIOBLASTOMA MULTIFORME BRAIN TUMORS LOCATED IN THE MOTOR CORTEX--SPECIFIC FINDINGS IN COMPARISON WITH LOW GRADE GLIOMAS OF THE SAME LOCALIZATION: ANALYSIS OF A SIXTY PATIENT SERIES.

The verified presence of a glioblastoma multiforme (GBM) tumor in the motor area of the brain, in a patient lacking preoperative neurological deficit, offers no certainty that the tumor can be radically removed without the possibility of causing postoperative motor deficit. We present a series of 60 patients hospitalized at the Clinical Department of Neurosurgery, Clinical Center of Serbia in Belgrade between October 2011 and February 2015, harboring tumors located within and in the vicinity of the motor zone of the brain. By using Karnofsky's index (KI), the pre- and postoperative conditions of the patients were evaluated. Regarding electrical stimulation of the motor cortex, significantly lower values of the electrical current intensity, frequency, and pulse wave duration (p < 0.01) were needed for triggering motor response in case of GBM tumor compared to a slowly growing tumor (low-grade). Patients with low-grade gliomas (LGG) had statistically significantly higher KI values pre- and postoperatively than patients with GBM (p < 0.01). Using electrical stimulation of the cortex, a higher grade of resection of LGG could be achieved as compared with the group presenting with GBM (χ² = 5.281; df = 1; p < 0.05). Our findings and review of the results reported by other authors underline the necessity of routine application of electrical stimulation of the cerebral cortex in order to identify the primary motor field (M1).

Surgical treatment problems of hydrocephalus caused by spontaneus intraventricular hemorrhage in prematurely born children.

AIM: The aim of this study was to identify the most appropriate method of surgical treatment of hydrocephalus in preterm infants that is caused by spontaneous intraventricular hemorrhage (IVH) and to identify predictive factors of poor perioperative outcomes. MATERIAL AND METHODS: We present a series of 60 patients with IVH and hydrocephalus, to whom a VP shunt or subcutaneous (Omaya) reservoir was placed, during the period from March 2006 to March 2011. RESULTS: Predictors of poor outcome with VP shunt placement were: gestational age (t=2.323, p=0.024), head circumference at birth (t=2.072, p=0.043), birth weight (t=2.832, p=0.006), Apgar score at birth (t=5.026, p < 0.01), number of days on assisted ventilation (Z=6.203, p < 0.001), peripartal asphyxia (χ < sup > 2 < /sup > =17.376, p < 0.01), respiratory distress (χ < sup > 2 < /sup > =9.176 p=0.002). Predictors of poor outcome in getting Omaya reservoir are: low birth weight (t=2.560, p=0.016), low Apgar scores (t=3.059, p=0.005), an extended number of days on assisted ventilation (Z=4.404, p < 0.001), presence of peripartal asphyxia (χ2=9.977, p=0.002) and cardio-respiratory arrest (χ2=12.804, p < 0.001). CONCLUSION: The outcome of hydrocephalus caused by IVH in premature born children is the worst in perinatology. Our results suggest that the main predictive factor is preoperative condition of the child and that the VP shunt and Omaya reservoir are complementary methods of surgical treatment.

Application of the Ommaya reservoir in the treatment of hydrocephalus in prematurely born children: correlation with animal results.

INTRODUCTION: Intraventricular hemorrhage occurs in almost one fifth of prematurely born children. Due to present complications, such as hydrocephalus and neurological deficit, it endangers the child's life, therefore there is the need for understanding and prevent risk factors as well as the need for finding most optimal methods of treatment. OBJECTIVE: The aim of the study was to point out the current therapeutic modalities of the treatment of posthemorrhagic hydrocephalus in prematurely born children. METHODS: The study included 60 patients divided into two groups of 30 patients treated at the University Children's Hospital of Belgrade in the period 2003-2008. RESULTS: Treatment outcome of the control group of patients treated by standard methods was influenced by gestational age (p=0.024), head circumference on birth (p = 0.043), body mass on birth (p = 0.006), Apgar score on birth (p < 0.001), peripartum asphyxia (p < 0.001), cardiorespiratory arrest (p < 0.001), respiratory distress (p = 0.002) and intraventricular hemorrhagic grade (p < 0.001). As statistically significant predictors of the poor treatment outcome of the experimental group of patients treated by using Ommaya reservoir were identified: low body mass on birth (p < 0.05), low Apgar score (p < 0.05), prolonged number of days on assisted ventilation (p < 0.05), presence of peripartum asphyxia (p < 0.05) and cardiorespiratory arrest (p < 0.05). CONCLUSION: No statistically significant difference was detected in the outcome between the patients treated by the standard method and those with installed Ommaya reservoir. However, the difference of 10% in mortality between the two groups may be clinically significant so that further studies of larger samples are necessary.

Assessing the quality of angiographic display of brain blood vessels aneurysms compared to intraoperative state.

BACKGROUND/AIM: Aneurysms in brain blood vessels are expanding bags composed of a neck, body and fundus. Clear visibility of the neck, the position of the aneurysm and surrounding structures are necessary for a proper choice of methods for excluding the aneurysm from the circulation. The aim of this study was to evaluate the reliability of spatial reconstruction of blood vessels of the brain based on the original software for 3D reconstruction of the equipment manufacturer and a personal computer model developed earlier in the Clinic for Neurosurgery, Clinical Center of Serbia, Belgrade, compared to intraoperative identification of these aneurysms. METHODS: This study included 137 patients of both sexes. The presence of an aneurysm was verified by angiographic methods [computed tomographic angiography (CTA), multislice computed tomography angiography (MSCTA), magnetic resonance imaging angiography (MRA), or digital subtraction angiography (DSA)]. RESULTS: The quality score (0 to 5) for CTA was 3.180 +/- 0.961, MSCTA 4.062 +/- 0.928, and for DSA 4.588 +/- 0.758 (p < 0.01). The results of this study favorite conventional angiography as the gold standard for diagnostic of intracranial aneurysms. CONCLUSION: The results of this study are consistent with current publications review and clearly recognize the advantages and disadvantages of diagnostic neuroradiological procedures, with DSA of brain blood vessels as a binding preoperative diagnostic procedure in cases in who it is not possible to clearly visualize the supporting blood vessel and neck of the aneurysm by using the findings of CTA, MRA and MSCTA.