Analysis of the factors affecting outcome after combat-related cranial defect reconstruction.

INTRODUCTION: Reports on the outcomes of cranioplasty after combat-related injuries are relatively rare in the current literature. We present our results on the reconstruction of cranial defects resulting from injuries sustained in combat, comparing outcomes using autologous (iliac bone) grafts or (acrylate) allografts, and analysis of other factors that may influence the final outcome. MATERIAL AND METHODS: The study comprised 207 patients with cranial defects resulting from combat-related injuries, repaired with autografts or allografts. The final outcome was defined at least 5 years postoperatively on the basis of cosmetic restoration and the existence of complications as successful (acceptable cosmetic restoration + absence of complications) or unsuccessful (poor cosmetic restoration or acceptable cosmetic restoration + complications). RESULTS: Successful outcomes were achieved in 83.6% of patients; there was no operative mortality. There were 25 instances of complications: postoperative infection (n = 15, allograft (7/53), autograft (8/154)), autograft resorption (n = 8), and in two cases, graft luxation. Poor cosmetic restoration was noted in 9 (4.3%) patients who had received an autograft. CONCLUSIONS: Thin and poorly vascularized skin, a surface area of the defect larger than 88 cm2, previous local infection and communication with paranasal cavities significantly influenced outcomes after combat-related cranioplasty, the final three being independent predictors of an unsuccessful outcome.

Subdural tuberculous abscess of the lumbar spine in a patient with chronic low back pain.

INTRODUCTION: Despite modern imaging methods, tuberculous abscess in the subdural space of the spine can lead to misdiagnosis and to neurogical complications development, even more up to paraplegia. We presented an extremely rare case of subdural tuberculous abscess of the lumbar (L) spine and paraparesis in imunocompetent a 49-year-old patient. CASE REPORT: A patient with chronic L syndrome and a history of intervertebral (IV) disc L3 and L5 operations got severe back pain late in July 2007. At the same time the patient had a purulent collection in the left knee, and was treated with high doses of corticosteroids and antibiotics. Then, the patient got a high fever, the amplification of pain in the L spine and the development of paraparesis. Erythrocyte sedimentation rate was 108 mm/1 h, C-reactive protein 106.0 mg/L, white blood cell (WBC) 38.4 x 09/L with a left turn. Magnetic resonance imaging (MRI) of the spine was registered expansive formation in the spinal canal, from the level of the IV disc L2 to the mid-L4 vertebral body. This finding is a "spoke" in favor of the extrusion and sequestration of IV disc L3 with the cranial and caudal migration. The patient underwent an emergency neurosurgical operation. The diagnosis of subdural staphylococcal abscess of L spine was made. According to the antibiogram antibiotic therapy was applied but without effect on the course of the disease. Control MRI of the L spine showed spondylodiscitis L3/L4, abscess collection in the spinal canal and paravertebral muscle abscess. Late in September 2007 the patient underwent needle biopsy of the L3 vertebral body guided by computed tomography and the acid-fast bacilli (AFB) were found. Tuberculostatics were introduced in the therapy. Two years later the patient was without significant personal difficulties, and with normal clinical, laboratory and morphological findings. CONCLUSION: Subdural tuberculous abscess of the spine is extremely rare manifestation of spine tuberculosis. The exact and early diagnosis and adequate treatment of atypical form of spine tuberculosis are key factors of good prognosis.

Epidemiology of nosocomial colonization/infection caused by Acinetobacter spp. in patients of six surgical clinics in war and peacetime.

BACKGROUND/AIM: Acinetobacter spp. has emerged as nosocomial pathogen during the past few decades in hospitals all over the world, but it has increasingly been implicated as a serious nosocomial pathogen in military hospitals. The aim of this study was to analyse and compare the surveillance data on Acinetobacter nosocomial colonization/infection (NCI) collected during the wartime with the data collected in peacetime. METHODS: We conducted a prospective study of incidence of Acinetobacter spp. colonization/infection. Also, the two nested case-control studies were conducted. The patients with nosocomial infection (cases) were compared with those with nosocomial colonization (controls) during the two different periods, wartime and peacetime. The patients with NCI by Acinetobacter spp. were identified by the case-based surveillance. The surveillance covered all the patients in 6 surgical clinics. RESULTS: During the study periods a total of 166 patients had cultures that grew Acinetobacter spp. and the pooled rates of Acinetobacter spp. colonization and infection were significantly higher in wartime. When patients with NCI in wartime were compared with those with NCI in peacetime significant differences were observed. In the war year, the patients were more significantly males (p < 0.000). In a period of peace, most of the colonization/infections were reported from patients with certain chronic diseases (p = 0.020) and the survival of patients was more significant (p = 0.049). During the peacetime, proportions of Acinetobacter isolates resistent to ciprofloksacin, imipenem and meropenem were significantly higher (p < 0.001). CONCLUSION: This study provides additional important information about the risk factors of nosocomial Acinetobacter spp. infections in a large cohort of surgical patients. This is also the first study that directly examines epidemiological differences between NCI caused by Acinetobacter spp. during the war and peace period.

Peripheral nerve lesions associated with missile-induced pseudoaneurysms.

OBJECT: Reports of traumatic pseudoaneurysms associated with nerve compression are rare, and typically do not focus on the damaged nerves. This prospective study examines the clinical presentation, management, and treatment outcome of such nerve injuries. METHODS: Between 1991 and 1995, 22 patients with a missile-induced nerve injury associated with a pseudoaneurysm were treated surgically at the Belgrade Military Medical Academy. The artery and nerves involved with the injury were treated using appropriate surgical procedures, and both the sensorimotor deficit and pain intensity were assessed. RESULTS: The occurrence of a pulsatile mass depended on the location of the pseudoaneurysm (p = 0.003) and correlated significantly with the preoperative diagnosis (p < 0.001). In cases in which neurological worsening was due exclusively to the compressive effect of the pseudoaneurysm, the nerves involved were found to be in anatomical continuity intraoperatively, and recovery depended on the actual nerve damage and surgical procedure required (neurolysis or nerve grafting). A symptomatic nerve compression duration of more than 3.5 days was the critical factor that determined if neurapraxia developed into severe nerve damage (p = 0.014). Pain syndromes responded well and rapidly to the surgical treatment (p < 0.001). CONCLUSIONS: Whether or not a missile-induced pseudoaneurysm associated with a nerve lesion will be recognized before surgery depends on its location and clinical presentation. The nerves involved almost invariably exhibit a lesion in continuity, but the resulting nerve damage can be severe, particularly if surgery is delayed for more than 3 to 4 days after neurological worsening has begun. A successful outcome may be expected if an appropriate surgical technique (neurolysis or grafting) is chosen on the basis of the intraoperative discovery of nerve action potentials.

Difference in recovery potential of peripheral nerves after graft repairs.

OBJECTIVE: To our knowledge, few studies have been published regarding differences in nerve recovery potentials. In this study, sensory and motor recovery potentials were compared between different nerves. METHODS: A prospective study of a homogenous group of 393 graft repairs of the median, ulnar, radial, tibial, peroneal, femoral, and musculocutaneous nerves, with the scoring of motor and sensory recoveries. Sensory and motor recovery potentials, defined on the basis of average scores and rates of useful recovery, were compared between the different nerves, and separately for high-, intermediate-, and low-level repairs. RESULTS: Sensory recovery potential was similar for all nerves tested (P > 0.05), but motor recovery potential differed significantly. After high-level repairs, motor recovery potential was significantly better for the radial and tibial nerves (useful recovery in 66.7 and 54.5% of patients, respectively), than for the ulnar and peroneal nerves (useful recovery in 15.4 and 13.8% of patients, respectively; P < 0.05). After intermediate-level repairs, motor recovery potential was better for the musculocutaneous, radial, and femoral nerves (useful recovery in 100, 98.3, and 87.5% of repairs, respectively), than for the tibial, median and ulnar nerves (useful recovery in 63.9, 52, and 43.6% of repairs, respectively; P < 0.05). In addition, motor recovery potential was significantly the worst with peroneal nerve repairs (useful recovery in 15.2% of patients; P < 0.05). After low-level repairs, motor recovery potential was similar for all nerves (useful recovery in the range of 88.9-100% of patients and in 56.3% of peroneal nerve repairs). CONCLUSION: Sensory recovery potential is similar for the median, ulnar, and tibial nerves. The expression of motor recovery potential depends on the repair level. With low- and high-level repairs, it does not stand out in an obvious way, but it is fully expressed with intermediate-level repairs, classifying nerves into three categories with excellent, moderate, and poor recovery potential.

Pain syndromes after missile-caused peripheral nerve lesions: part 1--clinical characteristics.

OBJECTIVE: To report on the clinical characteristics of pain and factors influencing pain intensity in patients with missile-caused nerve injuries. METHODS: The prospective study included 326 patients with clinically significant pain syndromes including complex regional pain syndrome Type II, deafferentation pain, reinnervation pain, and neuralgic pain. Diagnostic procedures were analyzed, factors influencing the pain intensity were identified, and the patients' characteristics, pain characteristics, and other clinical symptoms and signs were compared between different types of pain syndromes. RESULTS: The rate of painful injuries ranged from 17.3 to 22.9% for mixed nerves and from 2.6 to 4.6% for motor nerves. Peripheral nerve block and sympathetic block were useful and safe adjuvant diagnostic procedures, obtaining pain relief in 66.7% of patients with neuralgic pain and in 90.1% of patients with complex regional pain syndrome Type II. Pain started 2.6 days after injury in patients with complex regional pain syndrome Type II and 11.9 days after injury in patients with painful nerve adhesions (analysis of variance, P < 0.001). Permanent pain was more frequent (79.1%) than paroxysmal pain, superficial pain was more frequent (55.2%) than deep pain, and burning pain was the most frequent pain descriptor (43.6%). Ten factors were found to significantly influence the pain intensity (binary logistic analysis), including three independent predictors (multivariate analysis): type of pain syndrome (P < 0.001), multiple nerve damage in the injury site (P = 0.022), and onset of pain in the first two days after injury (P = 0.031). CONCLUSION: Pain syndromes after missile-caused nerve injury differ significantly regarding time of pain onset, pain characteristics, and other symptoms and signs. The type of pain syndrome, multiple nerve damage, and early onset of pain are independent predictors of initial pain intensity. Although medical history and physical examination are the main diagnostic keys, nerve exploration preceded by a nerve block and sympathetic block are safe and useful adjuvant diagnostic procedures.

Pain syndromes after missile-caused peripheral nerve lesions: part 2--treatment.

OBJECTIVE: To analyze treatment procedures and treatment outcomes of painful missile-caused nerve injuries and factors influencing the outcome. METHODS: The study included 326 patients with clinically significant pain syndromes, including complex regional pain syndrome Type II, deafferentation pain, reinnervation pain, and neuralgic pain. Treatment modalities included drug therapy, nerve surgery, sympatholysis, and dorsal root entry zone operation. Pain intensity was assessed before and after the treatment using a visual analog scale, and treatment outcome was defined as successful (pain relief >70%), fair (pain relief between 50 and 69%), or poor (pain relief <50%). The outcome was compared between different pain syndromes and different treatment modalities. RESULTS: A successful outcome was achieved in 28.6% of patients with deafferentation pain, in 76.9% of patients with complex regional pain syndrome Type II, and in 87.9 to 100% of patients with other pain syndromes (P = 0.002). Each type of pain syndrome required a specific treatment algorithm, but average pain relief was similar for all definitive treatment modalities (range, 81-88%; P > 0.05). Ten factors were found to significantly influence the treatment outcome, but only three factors were independent predictors of a successful outcome: type of pain syndrome (P < 0.001), severity of nerve injury (P < 0.001), and absence of pain paroxysms (P = 0.03). CONCLUSION: The treatment outcome of painful nerve injury depends on several factors, including the type of pain syndrome, severance of nerve injury, and absence of pain paroxysms. Drug therapy (carbamazepine, amitriptyline, or gabapentin) should be recommended, at least as a part of treatment, for patients with reinnervation pain, deafferentation pain, and complex regional pain syndrome Type II. Nerve surgery should be recommended for patients with posttraumatic neuralgia, either as the first treatment choice (acute nerve compression or intraneural foreign particles) or after unsuccessful pharmacological treatment (other causes of neuralgic pain).

Missile-caused complete lesions of the peroneal nerve and peroneal division of the sciatic nerve: results of 157 repairs.

OBJECTIVE: There are few large-volume studies of the repair of complete missile-caused peroneal nerve and peroneal division lesions. In this prospective study, the outcomes of such repairs are studied and the factors influencing the outcomes are analyzed. METHODS: During a 3-year period, 157 patients with complete missile-caused lesions of the peroneal nerve or peroneal division were treated surgically in the Belgrade Military Medical Academy: 37 patients with high-level (above the middle of the thigh), 90 patients with intermediate-level (above the popliteal crease), and 30 patients with low-level repairs. After at least 4 years of follow-up, outcome was defined on the basis of motor recovery, neurophysiological recovery, and patient judgment of the quality of outcome (poor, insufficient, good, or excellent). Good and excellent outcomes were considered successful. The factors of repair level, defect length, manner of repair, preoperative interval, severity of tissue damage in the repair region, and patient age were studied for their effect on outcome. RESULTS: A successful outcome was obtained in 10.8% of high-level repairs, 31.1% of intermediate-level repairs, and 56.7% of low-level repairs (P < 0.001). Nerve defect and preoperative interval were significantly shorter for patients with a successful outcome compared with those with an unsuccessful outcome (P< 0.001). Worsening of the outcome began with the nerve defect larger than 4 cm and preoperative interval greater than 3 months (P< 0.001). Severity of local tissue damage significantly influenced the outcome (P= 0.008). Repair level (P< 0.001), preoperative interval (P= 0.001), severity of local tissue damage (P= 0.011), and length of nerve defect (P= 0.011) were independent predictors for a successful outcome. CONCLUSION: After peroneal nerve or peroneal division repairs, a successful outcome is most probable with low-level lesions repaired in the first 3 months after injury using grafts smaller than 4 cm. Conversely, high-level repairs delayed for more than 7 months after injury and using grafts larger than 8 cm are probably not worthwhile.

Missile-induced complete lesions of the tibial nerve and tibial division of the sciatic nerve: results of 119 repairs.

OBJECT: Very few extensive studies regarding the repair of missile-induced tibial nerve or tibial division complete lesions have been published to date. In this prospective study, the outcomes of such repairs as well as factors influencing them are presented. METHODS: Between 1991 and 1994, 119 patients with missile-induced complete lesions of the tibial nerve or tibial division were treated in the neurosurgical department of the Military Medical Academy, Belgrade. After at least 4 years of follow up, the final outcome was defined as poor, insufficient, good, or excellent, based on sensorimotor recovery, electromyoneurography-demonstrated recovery, and patient judgment. Good and excellent outcomes were considered to be successful. The influence of the repair level, length of the defect, and preoperative interval on final outcome was also tested. A successful outcome was obtained in 30.3% of high-level, 50% of intermediate-level, and 85.7% of low-level repairs (p < 0.001). On average, the nerve defect and preoperative interval were significantly shorter in patients with a successful outcome. Significant worsening of the outcome was related to a nerve defect longer than 5 cm and a preoperative interval longer than 4 months. Repair level, preoperative interval, and length of the defect were independent predictors of a successful outcome. CONCLUSIONS: A successful outcome is most probable following the low-level repairs, within the first 4 months after injury, and using grafts shorter than 5 cm. Other repairs can also be beneficial in preventing dangerous anesthesia of the sole of the foot and enabling almost normal walking.

Missile-caused median nerve injuries: results of 81 repairs.

BACKGROUND: Missile-caused median nerve injuries have rarely been reported in current literature. We present repair outcome for all median nerve injuries in which the median nerve was severed either by missile injury or secondarily in the subsequent resection of a neuroma in continuity. METHODS: Prospective study included 81 casualties with proximal, intermediate, or distal complete median nerve lesions, repaired by nerve graft or direct suture. Final outcome was defined at least 4 years postoperatively, on the basis of motor recovery, sensory recovery, neurophysiological recovery, and patient's judgment on the outcome, each estimated by 0 to 5 points and according to the total sum, as poor, insufficient, good, or excellent. The last 2 modalities were considered to be successful. RESULTS: Successful outcome was obtained in 68.7% of distal, in 33.3% of intermediate, and in 10% of proximal repairs. Average outcomes were good, insufficient, and poor, respectively (P < .001). Nerve defect and preoperative interval were both significantly shorter on average for patients with successful outcome than for those with unsuccessful outcome (P < .001 and P = .007, respectively), but only preoperative interval and height of repair were independent predictors for successful outcome. Age of patient, associated ulnar nerve complete lesion, and manner of repair did not influence the outcome significantly (P > .05). CONCLUSIONS: The level of repair, duration of preoperative interval, and length of nerve defect significantly influence outcome after median nerve repair, but only level of repair and duration of preoperative interval were independent predictors for successful outcome.

Missile-caused ulnar nerve injuries: outcomes of 128 repairs.

OBJECTIVE: This prospective study presents repair results after missile-caused ulnar nerve ruptures as well as factors influencing the outcomes. METHODS: Between 1991 and 1994, 128 casualties with missile-caused complete ulnar nerve injury were managed surgically in the Neurosurgical Department of the Belgrade Military Medical Academy. At least 4 years after surgery, we scored sensorimotor recovery, neurophysiological recovery, and patient judgment of the outcome. On the basis of the total score, we defined the final outcome as poor, insufficient, good, or excellent. The last two outcomes were considered to be successful. RESULTS: A successful outcome was obtained in 0% of high-level, 33.8% of intermediate-level, and 77.3% of low-level repairs (P < 0.001). On average, the nerve defect, preoperative interval, and patient age were lower for patients with a successful outcome than for those with an unsuccessful outcome (P = 0.004, P = 0.032, and P = 0.003, respectively). Worsening of the outcome was related to nerve defect longer than 4.5 cm, preoperative interval longer than 5.5 months, and age older than 23 years (P = 0.002, P = 0.034, and P = 0.023, respectively). A successful outcome occurred in 48.8% of patients repaired with direct suture and in 41.2% of patients repaired with a nerve graft (P > 0.05). A successful outcome also occurred 22.2% of combined ulnar-median nerve repairs and in 49.5% of isolated ulnar nerve repairs (P = 0.011). Repair level (P < 0.001), preoperative interval (P = 0.001), length of the nerve defect (P < 0.001), and associated median nerve rupture (P = 0.028) were independent predictors of a successful outcome. CONCLUSION: The outcome of ulnar nerve repair depends significantly on the repair level, preoperative interval, associated median nerve injury, length of the nerve defect, and age of the patient. High-level ulnar nerve repair is probably useless if performed in the classic manner.

[Outcome of surgical treatment of malignant astrocytoma of the brain]. / Ishod hirurskog lecenja malignih astrocitoma mozga.

BACKGROUND: The aim of this study was to analyze the outcome after the surgical treatment of patients with malignant brain astrocytomas, as well as the factors influencing the outcome. Retrospective study was performed on 145 operated patients (102 with glioblastoma multiforme, and 43 with anaplastic astrocytomas). METHODS: Clinical state was graded according to the Yasargil scale (grades I-IV) and the Karnofski score, and the outcome was defined either as good (better or unchanged clinical state) or as poor (deteriorated state or death). The outcome was correlated with patients age and preoperative clinical condition, as well as with the localization, extensiveness and the extent of resection of the tumor. RESULTS: Preoperative clinical state of patients most frequently corresponded to grades II-III (75.9%). Radical resection was done in 48.3%, subtotal in 15.2%, partial in 30.3%, and biopsy was performed in 6.2% of patients, with the total operative mortality of 16.5%, morbidity of 9.7%, and good postoperative outcome in 73.8% of the patients. The incidence of good postoperative outcome did not significantly depend on the tumor location (42.6-78.3%), cortical presentation, the extent of resection (68.2-75.7%), and preoperative clinical state (67.8-81.5%). Good outcome was seen in 82.7% of patients with one, and in 53.8% of patients with three or more infiltrated lobes (p < 0.01). Patients with poor outcome were significantly older in average than the patients with good outcome (58.9 +/- 12.1 and 50.9 +/- 13.4 years of age, respectively; p < 0.05). Operative mortality was 7.4%, and 27.3% for clinical grades II and IV (p < 0.05), namely 11% and 23.8% for the patients with the Karnofski score above and under 50 (p < 0.05), respectively. CONCLUSION: The outcome after the operative treatment of malignant cerebral astrocytomas significantly depended on patients age and the extensity of the tumor. For such patients operative mortality was also significantly influenced by clinical preoperative state.

Factors influencing the outcome after the operative treatment of cerebral aneurysms of anterior circulation.

BACKGROUND: The influence of various factors on the outcome after the operative occlusion of the cerebral aneurysm was to be defined through the retrospective study on 111 surgically treated patients with aneurysm of anterior cerebral circulation. METHODS: Preoperative clinical condition was graded from 0 to V, according to Hunt & Hess. Postoperative outcome, defined as good or bad according to modified Glasgow Outcome Scale, was correlated in homogenous experimental groups with the following factors: gender, age, aneurysmal size, preoperative interval, nimodipine therapy, experience of surgical team and existence of chronic vascular diseases. RESULTS: Surgical outcome was good in 74.4% of males and 71.4% of females (p > 0.05); in 83.3% of patients with and 41.2% of patients without chronic diseases (p < 0.01); in 71.4% of patients underwent early, 83.3% of ones underwent postponed and 85% of those underwent late surgery (p > 0.05); in 81.5% of patients treated by nimodipine and in 41.7% of those untreated by the same drug (p < 0.01); in 78.9% of patients operated by the experienced surgical team and in 40% of those operated by less experienced surgical team (p < 0.01). In patients with both good and bad outcome, the mean age was 50.6 and 47.6 years (p > 0.05), and the mean aneurysmal size was 12.3 mm and 13.3 mm, respectively (p > 0.05). Before rupture, the mean size for aneurysms on the bifurcation of the middle cerebral artery was 14.3 mm, and for posterior communicating artery aneurysms only 9.7 mm (p < 0.05). CONCLUSION: Surgical outcome was significantly influenced by the existence of chronic diseases, nimodipine therapy and experience of surgical team, whereas gender, age, timing for surgery and aneurysmal size were not of significant influence.

[Complications and mortality in surgery of cerebral aneurysms]. / Komplikacije i smrtnost u hirurgiji mozdanih aneurizmi.

AIM: To establish the risk factors for complications and fatal outcome after the operative occlusion of cerebral aneurysms. METHODS: Retrospective study on 91 (lethality rate) and on 72 operated patients (complications). For survived and dead patients, as well as for patients with and without complications, following parameters were compared: gender, age, clinical condition, preoperative interval, use of temporary clips, vasospasm, outcome, as well as localization, size and intraoperative rupture of the aneurysm. RESULTS: Complications existed: in 54.5% of aneurysms of middle cerebral and 13.6% of aneurysms of internal carotid artery (p < 0.01); in 18.2% of patients in the first and 45.8% of patients in the third clinical Hunt and Hess group (p < 0.05); in 57.9% of patients with and 20.5% of patients without intraoperative rupture (p < 0.01); in 50% of patients with and 18.7% of patients without vasospasm (p < 0.05). Average aneurysmal size was 18 mm in group with complications and 10.8 mm in patients with no complications (p < 0.05), while average preoperative intervals in these two groups were 20 and 8.7 days (p < 0.05). Lethality rate was 25% for the third and 83.3% for the fourth and fifth clinical group (p < 0.01), and the existence of complications significantly increased mortality (from 15.7% to 50%, p < 0.01). Good outcome existed in 19.2% of operated patients with complications and in 78.3% of those without complications (p < 0.01). CONCLUSIONS: Incidence of complications depended significantly on preoperative clinical condition, duration of preoperative interval, size, localization and intraoperative rupture of aneurysm. Complications significantly minimized the surgical treatment outcome and increased the lethality rate mortality.

[Multiple cerebral aneurysms]. / Multiple mozdane aneurizme.

BACKGROUND: To define risk factors for the multiplicity of cerebral aneurysms, as well as clinical and therapeutical characteristics of patients with single aneurysms (SA) and multiple aneurysms (MA). METHODS: Retrospective study on 95 patients with SA and 22 patients with MA. For patients with SA and MA the following parameters were compared: gender, age, clinical state, aneurysmal localization and size, incidence of rebleeding and vasospasm, manner and outcome of treatment, preoperative interval, intraoperative rupture and postoperative complications. RESULTS: Aneurysms on anterior communicating artery existed in 37.4% of SA and in 17.8% of all MA (p < 0.05). As much as 44.2% of all aneurysms on middle cerebral artery and only 19% of all aneurysms on anterior communicating artery were associated with some other aneurysm (p < 0.02). The average size of SA was 15.4 +/- 11.8 mm, and 9.8 +/- 9 mm for MA (p < 0.05). Surgery was performed in 77.3% of patients with MA and 78.9% of patients with SA (p > 0.05), but complete surgical clipping was performed in 89.3% of patients with SA and in 47.1% of patients with MA (p < 0.01). Among operated patients with MA and SA, intraoperative rupture occurred in 36% and 17.6% of cases, respectively (p < 0.05) and ischemic postoperative complications were found in 29.4% and 17.3% of the cases (p > 0.05). Among 72.7% of all patients with MA and in 69.5% of all patients with SA the outcome was good, while among surgically treated patients it was good in 76.5% and 70.7% of cases, respectively. CONCLUSION: The treatment outcome was similar for patients with MA and SA, but complete operative treatment is significantly more frequent for SA. Multiple aneurysms were considerably smaller and with different anatomical distribution in relation to solitary aneurysms.

[Treatment of aneurysms in the anterior cerebral circulation]. / Tretman arterijskih aneurizmi prednje mozdane cirkulacije.

OBJECTIVES: To analyze the outcome of either surgical or conservative treatment of patients with aneurysms on cerebral arteries. DESIGN: Retrospective study on 114 patients (89 operated and 25 not operated). METHODS: Clinical state was graded from 0 to V, according to Hunt & Hess (HHG), and the treatment outcome was defined as favorable or poor, according to the modified Glasgow Outcome Score. The outcome was correlated with the type of treatment (operative or conservative), clinical state and aneurysmal localization. RESULTS: Aneurysm was localized mostly on the anterior communicating (33.6%) and middle cerebral arteries (32.8%) and the patients were mostly in HHG II or III (34.4% and 25.2%). HHG after the aneurysmal rupture did not depend on the aneurysmal location (p > 0.05). Favorable treatment outcome was noted: in 74.1% of all operated and in 60% of all conservatively treated patients (p > 0.05); in 81.6% of operated and in 33.3% of not operated patients with HHG = II-III (p < 0.01); in 78.8% of aneurysms of the middle cerebral artery and in 66.7% of those of the anterior communicating artery (p > 0.05); in 73.1% of patients with HHG = III and in 25% of patients with HHG = IV (p < 0.01). CONCLUSIONS: Clinical state after the aneurysmal rupture did not depend on its localization. Results were better after the surgical, than after the conservative treatment. Outcome after the surgery depended on the clinical state of the patient, but not on the aneurysmal localization.