[Diagnosis and operative treatment cavernous angiomas of the central nervous system]. / Diagnostyka i leczenie operacyjne naczyniaków jamistych osrodkowego ukladu nerwowego.

UNLABELLED: Among all detected cerebral angiomas the frequency of cavernous angiomas (CAs) is 5-13%. The aim of this study is to present the diagnostic methods of CA of the central nervous system (CNS), indications for surgery and assessment of its outcome. Between 1993-2000, eleven cases of CAs were operated on at the Department of Neurosurgery, Medical College, Jagiellonian University in Krakow. In 6--seizures were observed, in 4--headache (supratentorial CAs), increasing neurological deficits in 4 (location in vertebral channel and cerebellum), hemorrhage--1 case (CA in pons combined with supratentorial lesion). Surgery was carried out by means of craniotomy, and via laminectomy in the cases of spinal channel tumours. Early and late outcome were assessed in following cathegories: very good, good, fair, bad (significant deterioration). The shortest late observation was 5 years. Direct very good surgical outcome was attained in 4 cases (36%), good in 4. (36%), fair in 2. (18%), bad in 1 case. In late observation, 7 patients were very good (64%), and 3 good (27%). In one case the neurological improvement was poor, later observed--late outcome was fair. In 6 cases they suffered from frequent epileptic seizures before surgery; they were seizure free in the late assessment. CONCLUSIONS: (1) direct surgical outcome in CA of the CNS is good and very good in the majority of cases; (2) in late observation, further neurological improvement allows to attain over 90% good and very good outcomes; (3) the high antiepileptic effectiveness after surgery of CA is observed.

[Vascular abnormalities in patients with primary intracerebral hemorrhage]. / Malformacje naczyn mózgowych u chorych z pierwotnym krwotokiem sródmózgowym.

BACKGROUND: To prevent the recurrence of primary intracerebral hemorrhage (PIH) it is important to identify patients with underlying structural vascular abnormalities (VA). According to previous study data-- the site of hemorrhage, the patient's age and pre-existing hypertension affect the likelihood of finding VA. However, the indications for angiography, the gold standard for the diagnosis of VA, still remain controversial. PURPOSE: To assess the frequency of VA and to determine features that might increase the probability of finding VA in patients with PIH. MATERIAL AND METHODS: 100 patients with PIH, without a history of trauma, coagulopathy, or known pre-existing brain abnormality, who were admitted to the Stroke Unit of the Department of Neurology, Jagiellonian University, between January 1999 and November 2000 entered this prospectively designed study. In the group of 96 patients, 53 persons underwent conventional angiography within 14 days of stroke onset (in 4 cases we found bleeding into the tumor and these patients were not included in further analysis). RESULTS: Vascular abnormalities were found in 14 of 53 patients (26.4%); ruptured aneurysms in 9 patients (17.0%), arteriovenous malformations (AVM) in 3 patients (5.7%), venous angioma in 1 patient (1.8%) and cavernous angioma in 1 patient (1.9%). Vascular malformations were found in 12 of 25 patients with lobar hemorrhage, in 1 of 8 patients with hemorrhage originating in the thalamus and in 1 of 2 patients with hemorrhage originating in the pons. Angiographic findings were negative in 8 patients with hemorrhage in the periventricular white matter, in 8 with hemorrhage originating in the basal ganglia and in 2 patients with hemorrhage in the cerebellum. Patients with VA were significantly younger than patients without VA (49.9 +/- 11.7 years and 58.7 +/- 13.3 years respectively, p = 0.03) and they had a history of hypertension significantly less often (50.0% and 89.7%, p = 0.001). Intraventricular hemorrhage and subarachnoid bleeding occurred in a similar percentage of patients with ICH, independent of whether or not they had VA (28.6% and 38.5%; 21.4% and 10.3% respectively, p = n.s.). CONCLUSIONS: (1) A vascular abnormality is the cause of about 26% of ICH, with a higher likelihood in younger patients and with lobar hemorrhage. (2) A history of hypertension does not exclude the presence of VA. (3) Intraventricular hemorrhage or subarachnoid bleeding does not predict the presence of VA.

[Pneumocephalus after shunt in a patient with hydrocephalus. A case report and review of the literature]. / Odma sródczaszkowa po zalozeniu zastawki u chorej z wodoglowiem. Opis przypadku i przeglad pismiennictwa.

Pneumocephalus in hydrocephalic shunted patients is very rare. So far only 46 cases have been described in the literature. A case of pneumocephalus in a patient with shunted hydrocephalus, and the diagnostic and therapeutic problems were described. A 38-year-old woman suffered from a subacute headache, dizziness and bradyphrenia. Eight years ago, the ventriculo-atrial shunt was implanted due to idiopathic hydrocephalus, and the shunt was changed 2 months before the present admission (ventriculo-peritoneal valve). CT and MRI revealed pneumocephalus, but neither clinical nor radiological symptoms of the CSF fistula were found. After temporary ligation of a distal catheter, the anterior fossa and a sellar area were directly repaired via right fronto-temporal craniotomy, with a good outcome. In the case of pneumocephalus in hydrocephalic shunted patients, the direct closure of the skull base fistula via craniotomy combined with restoration of the proper shunt function is usually the most effective treatment. If the site of the fistula can not be established, dural cranioplasty in the most likely site of the fistula is recommended.

[Mechanically detachable coils in the treatment of posterior circulation aneurysms: a comparison with surgical repair]. / Mechanicznie odszczepialne spirale w leczeniu tetniaków ukladu kregowo-podstawnego-- porównanie z metoda chirurgiczna.

AIM: To compare craniotomy and clip application with endovascular coiling in patients with posterior circulation aneurysms. MATERIAL AND METHODS: Among 676 consecutive patients with aneurysmal SAH who had been treated with either clipping or coiling, a group of 46 patients with aneurysms in the posterior circulation (32 treated surgically and 14 endovascularly) were selected for further investigation. Patient and aneurysm characteristics, procedural complications, and clinical and radiological results were compared retrospectively. The odds ratio for poor outcome (Glasgow outcome scale 1, 2, 3) adjusted for preoperative clinical condition parameters was assessed by logistic regression analysis. The group was not randomized. RESULTS: In the endovascular group 6 patients (42.9%) had a poor outcome vs. 8 (25%) in the surgical group; the adjusted odds ratio for poor outcome after coiling vs. clipping was 3.21 (p = NS). The observed difference in outcome was consequent on higher incidence of severe neurological deficit (GOS 3) after embolisation, compared with clip application (26% and 9.4% of patients respectively); mortality was comparable in both groups (14.3% vs. 15.6%). Optimal or suboptimal aneurysm occlusion immediately after coiling was achieved in 12 patients (85.7%). Clipping was successful in 31 patients (96.9%). CONCLUSION: There was no statistically significant difference in outcome between the two treatment groups. However, patients were less likely to be dependent when treated by craniotomy and clip application, compared with endovascular MDS embolisation.

[Bilateral cerebellar hematoma after supratentorial glioma surgery]. / Obustronny krwiak mózdzku po operacji glejaka nadnamiotowego.

We present a case of bilateral hematoma in cerebellar hemispheres in a 30-year-old man after surgical treatment of extensive left frontal glioma. 16 hours after surgery the patient lost consciousness. An immediate CT revealed hematoma in both cerebellar hemispheres. The hematoma was subsequently removed via bilateral suboccipital craniectomy. After the operation the clinical status of the patient gradually improved - he was discharged in a good general condition. In the presented case the hematoma developed presumably as a consequence of extensive cerebrospinal fluid (CSF) loss (670 ml) via postoperative wound drainage. The resulting cerebellar displacement caused strain of the draining veins, affecting blood outflow, and causing parenchymal hemorrhage. In order to prevent the complication, massive CSF loss during and after operation should be avoided. Careful monitoring of the patient's condition in the postoperative period, even if the general status is good, is important because only an immediate intervention may prevent the development of irreversible consequences of cerebellar hematoma formation.

[Multiple cerebral glioma or tumor dissemination via CSF pathways? Case report]. / Przypadek mnogiego glejaka mózgu, czy rozsiew guza drogami plynowymi? Opis przypadku.

A case is presented of a 38-year-old female patient who developed bifocal metachronous cerebral glioma with the same histological appearance (glioblastoma multiforme). Two separate tumors were operated on within six months: the first one was localized in the left parieto-occipital area, and the other in the right temporal lobe. The tumor cells dissemination occurred probably via the CSF pathways: during the first operation the posterior horn of the left lateral ventricle was opened, and the second neoplastic lesion was situated also in the direct vicinity of CSF spaces (the Sylvian cistern). For all practical purposes, the case presented testifies to the necessity of intraoperative protection of the CSF spaces by separating any open CSF cisterns from the removed tumor mass with cotton pads. In case of diagnosing cerebral glioma, a possibility of the presence of multiple foci should be taken into account. It is especially important for the differentiation of multiple lesions occurring synchronically, where similarity of radiological features is seen in metastases, cerebral abscesses and demyelinating lesions.

[Endovascular coiling and microsurgery of the cerebral arteriovenous malformations. Assessment of criteria of treatment and outcome]. / Embolizacja wewnatrznaczyniowa i mikrochirurgia naczyniaków tetniczo-zylnych mózgu. Ocena kryteriów stosowanych w wyborze postepowania oraz wyniki leczenia.

BACKGROUND: Three available methods of therapy of arteriovenous malformations (AVM) i.e. microsurgical resection, intravascular embolization and stereotactic radiosurgery, make possible definitive treatment in the majority of patients. During qualification to these procedures the risk of complications and efficacy of each method should be considered. OBJECTIVE: To analyze criteria of qualification, risk factors and results of embolization and surgical treatment of AVMs. PATIENTS AND METHODS: Within four years (1999-2002) 53 patients were treated for arteriovenous malformations (AVMs) in the Department of Neurosurgery of the University Hospital in Krakow (24 women and 29 men). The group of 25 patients was treated with intravascular embolization, 20 patients were operated and 8 patients were treated conservatively or were qualified to radiotherapy. We retrospectively analyzed clinical findings, criteria of qualification and results of embolization as well as microsurgical treatment of AVMs with regard to Spetzler-Martin scale. RESULTS: 25 patients qualified for embolization underwent 39 embolization procedures. Complete embolization of AVM was obtained in 4 (16%) cases. 18 patients (72%) presented very good or good condition on discharge. In 5 (20%) serious complications were noted: in 2 hemorrhagic and in 3 ischemic. Three patients (12%) died. In the group of 18 operated patients, 13 (72%) patients presented very good or good condition on discharge and 1 patient died because of hemorrhagic complications. CONCLUSIONS: 1. Spetzler-Martin scale is very useful in evaluation of operative risk of AVM operations but, in our opinion, before operation there should be considered also such factors like number and diameter of feeding arteries, exact localization of AVM and initial condition of the patient. 2. Although intravascular embolization is less invasive than neurosurgical operation, the risk of hemorrhagic and ischemic complications is present. 3. Complete AVM embolization is possible in the minority of patients. The remaining group require follow up and control radiological examinations to establish indications for further treatment.