The influence of embolization of internal carotid artery aneurysms on arterial tortuosity: a prospective cohort study

PURPOSE

To compare quantitative tortuosity descriptors of Internal Carotid Artery (ICA) on aneurysmal and non-aneurysmal side before and after embolization of aneurysm and to determine possible factors associated with its change.

MATERIAL AND METHODS

An analysis of 52 patients with intracranial aneurysm, treated with endovascular procedure, was performed. Based on their Digital Subtraction Angiography images, obtained prior to the procedure and after first follow-up examination, tortuosity of ICA, both on the side of embolization and on the other side was analysed. For each patient tortuosity descriptors were calculated: Relative Length, Sum of Angle Metrics, Triangular Index, Product of Angle Distance, and Inflection Count Metric. To represent changes in tortuosity, for each descriptor delta value (Δ) was defined as value of the descriptor prior to embolization - value of the descriptor on follow-up examination.

RESULTS

In the follow-up We found no statistically significant changes in tortuosity on non-embolized side. On the embolized side SOAM (2.89±0.92 vs. 2.38±0.94;p<0.001), PAD (5.01±1.83 vs. 3.95±1.72 ;p<0.001) and ICM (12.18±4.55 vs. 9.76±4.04 vs.;p = 0.006) was significantly higher after embolization than before embolization. Mean ΔRelative Length (-0.02 [-0.045--0.002] vs. -0.01 [-0.02-0.003];p - 0.003),ΔProduct of Angle Distance (0.84 [0.30 - 1.82] vs. 0.10 [-0.001 - 1.10];p<0.001) and ΔInflection Count Metric (2.05 [0.42 - 3.50] vs. 0.27 [0.02 - 2.16];p = 0.004) were significantly higher on the embolized side.

CONCLUSION

Following study showed that embolization may increase the tortuosity of ICA.

Possible association between β-blocker use and a risk of intracranial aneurysm rupture

INTRODUCTION

Aneurysmal subarachnoid hemorrhage is a devastating type of stroke, associated with high mortality and morbidity. One of modifiable risk factors of aneurysm rupture is hypertension, however, it is still not clear whether any particular antihypertensive drugs play a significant role in the prevention of aneurysm rupture.

OBJECTIVES

We decided to investigate whether there is any association between acetylsalicylic acid, α-blockers, β‑blockers, angiotensin‑converting enzyme inhibitors, angiotensin II receptor blockers, calcium channel blockers, diuretics, statins, and anticoagulants and a risk of intracranial aneurysm rupture.

PATIENTS AND METHODS

We retrospectively analyzed 334 patients with ruptured and unruptured intracranial aneurysm. Based on logistic regression models, we obtained unadjusted and adjusted odds ratios (ORs) of subarachnoid hemorrhage associated with the use of vasoactive medications and with indices of tortuosity.

RESULTS

We found that β‑blocker intake was significantly related to higher tortuosity of the cerebral arteries. Also, the intake of β‑blockers (OR, 0.41; 95% CI, 0.21-0.77; P = 0.01) and statins (OR, 0.23; 95% CI, 0.05-0.68; P = 0.01) significantly decreased the risk of aneurysm rupture, a result driven by a decreased rupture risk of anterior circulation aneurysms. No such association was found for the posterior part of the cerebral circulation.

CONCLUSIONS

Aneurysm located in the anterior cerebral circulation might be less likely to rupture if patients receive β‑blockers or statins.

Unruptured intracranial aneurysms: Why should we focus on small aneurysms? A comprehensive update of recent findings

Intracranial aneurysms (IAs) are a significant public health concern because they have the potential to cause deva-stating consequences, including death and disability. Despite advances in diagnostic and treatment modalities, the outcomes for patients with aneurysmal subarachnoid haemorrhage (aSAH) remain poor, with high rates of rebleeding, vasospasm, and cerebral ischaemia. IAs are a significant risk factor for aSAH, and it is estimated that up to 3% of the general population have IAs. Recent studies using novel imaging modalities have shown that the prevalence of IAs may be much higher, with 6.6% of adults aged 40-84 years having intradural saccular IAs ≥ 2 mm. The risk of rupture for IAs is difficult to predict, and the decision to treat them invasively is based on a balance between the estimated rupture risk and the procedural risks of the treatment. However, the mortality and morbidity rates among patients treated for IAs can be as high as 5%. There is a need for clear guidelines on the treatment of IAs, and this review aims to provide an update on recent findings in this area. To achieve this goal, the authors identified and summarized recent, high-impact studies on IAs. The review focuses on the diagnostic and treatment options for IAs, as well as the risks associated with these interventions. The authors also provide an overview of the natural history of IAs and discuss the challenges and uncertainties in managing these patients.

Association of Arterial Tortuosity with Hemodynamic Parameters-A Computational Fluid Dynamics Study

BACKGROUND

Tortuosity of intracranial arteries has been proven to be associated with the risk of intracranial aneurysm development. We decided to analyze which aspects of tortuosity are correlated with hemodynamics parameters promoting intracranial aneurysm development.

METHODS

We constructed 73 idealized models of tortuous artery (length: 25 mm, diameter: 2.5 mm) with single bifurcation. For each model, on the course of segment before bifurcation, we placed 1-3 angles with measures 15, 30, 45, 60, or 75 degrees and arc lengths 2, 5, 7, 10, or 15 mm. We performed computational fluid dynamics analysis. Blood was modeled as Newtonian fluid. We have set velocity wave of 2 cardiac cycles. After performing simulation we calculated following hemodynamic parameters at the bifurcation: time average wall shear stress (TAWSS), time average wall shear stress gradient (TAWSSG), oscillatory shear index (OSI), and relative residence time (RRT).

RESULTS

We found a significant positive correlation with number of angles and TAWSS (R = 0.329; P < 0.01), TAWSSG (R = 0.317; P < 0.01), and negative with RRT (R = -0.335; P < 0.0.01). Similar results were obtained in terms of arcs lengths. On the other hand, mean angle measure was negatively correlated to TAWSS (R = -0.333; P < 0.01), TAWSSG (R = -0.473 P < 0.01), OSI (R = -0.463; P < 0.01), and positively to RRT (R = 0.332; P < 0.01). On the basis of the obtained results, we developed new tortuosity descriptor, which considered angle measures normalized to its arc length and distance from bifurcation. For such descriptor we found strong negative correlation with TAWSS (R = -0.701; P < 0.01), TAWSSG (R = 0.778; P < 0.01), OSI (R = -0.776; P < 0.01), and positive with RRT (R = 0.747; P < 0.01).

CONCLUSIONS

Hemodynamic parameters promoting aneurysm development are correlated with larger number of smaller angles located on larger arcs.

Endoscopic treatment of cystic craniopharyngiomas in elderly patients. Report of three cases with a review

Craniopharyngiomas are rare tumors with peak incidence between 5-14 and between 65-74 years of age. Treatment of choice is surgical resection, sometimes associated with radiation therapy. Complete tumor resection may be challenging. Radical surgery is particularly risky in older patients. Authors evaluate three cases of large cystic craniopharyngioma in patients in their 7th and 8th decade of life operated with the use of endoscopic technique. The postoperative follow-up period in which out- patient controls with imaging examinations were performed was up to 6 years. Symptoms of intracranial hypertension resolved in all patients in the immediate postoperative period. Visual acuity improved in two patients. No cases of aseptic meningitis have been reported. One patient underwent subsequent radio- therapy. The well-being of the operated patients continued. Endoscopic transventricular approach to cystic craniopharyngiomas may be a safe and effective approach in older patients, being an alternative to microsurgical procedures.

Predictors of intraoperative intracranial aneurysm rupture in patients with subarachnoid hemorrhage: a retrospective analysis

PURPOSE

Intraoperative cerebral aneurysm rupture (IOR) is a common phenomenon with a frequency of around 19%. Research regarding IOR lacks an analysis of its predictors.

METHODS

We retrospectively examined all saccular aneurysms, in 198 patients with subarachnoid hemorrhage, surgically treated from 2013 to 2019. Operative reports, patient histories, blood test results, discharge summaries, and radiological data were reviewed. IOR was defined as any bleeding from the aneurysm during surgery, preceding putting a clip on its neck, regardless of how trivial.

RESULTS

The frequency of IOR was 20.20%. Patients with IOR had higher aneurysm dome size (9.43 ± 8.39 mm vs. 4.96 ± 2.57 mm; p < 0.01). The presence of blood clot on the aneurysm dome was significantly associated with IOR (12.50% vs. 2.53%; p < 0.01). We also associated lamina terminalis fenestration during surgery (7.50% vs. 21.52%; p = 0.04) and multiple aneurysms (5.00% vs. 18.35%; p = 0.038) with a lower risk of IOR. Glucose blood levels were also elevated in patients with IOR (7.47 ± 2.78 mmol/l vs. 6.90 ± 2.22 mmol/l; p = 0.04). Multivariate analysis associated that urea blood levels (OR 0.55, 0.33 to 0.81, p < 0.01) and multiple aneurysms (OR 0.04, 0.00 to 0.37, p = 0.014) were protective factors against the occurrence of IOR.

CONCLUSION

Large dome size of an aneurysm, a blood clot on the aneurysm dome and elevated glucose blood levels can be IOR predictive. Lamina terminalis fenestration, the appearance of multiple aneurysms, and high urea blood levels may be associated with a lower risk of such an event.

Subjective experience, cognitive functioning and trauma level of patients undergoing awake craniotomy due to brain tumor - Preliminary study

BACKUP AND OBJECTIVE

Awake craniotomy (AC) for brain tumors, when the patient is conscious during the operation, allows to reduce the risk of motor disability and aphasia, however, it may be a source of extreme stress. The aim of our study was to examine the patients' subjective experience of the surgery including the level of psychological trauma and cognitive functioning.

METHOD

Eighteen patients operated due to brain tumor were enrolled in this study. The Essener Trauma-Inventory Questionnaire and the Addenbrooke's Cognitive Examination (ACE III) were administrated. The patients' experience with awake craniotomy was evaluated with a qualitative descriptive survey.

RESULTS

All patients remembered the intraoperative neuropsychological examination and several sensations like: drilling, cold, head clamp fixation or having eyes covered. In most of the patients the postoperative psychological trauma experience did not reach the clinical level. The ACE III postoperative scores revealed partial cognitive deficits with the lowest scores in memory and word fluency domains. Slight amnestic aphasia was observed postoperatively only in two patients.

CONCLUSIONS

Awake craniotomy for resection of brain tumors is well-tolerated by patients and does not cause significant psychological trauma. Nonetheless, anxiety about the procedure warrants further study and individualized neuropsychological care is needed for the emotional preparation of the patient.

Increased tortuosity of basilar artery might be associated with higher risk of aneurysm development

Objectives

We analysed tortuosity of basilar artery (BA) to determine its relationship with the presence of aneurysm.

Methods

We retrospectively analysed 71 patients with BA aneurysms along with 71 age- and risk factors-matched control patients without BA aneurysm. From patients’ medical records, we obtained their history including previous and current diseases and medications. For each patient, we calculated relative length (RL), sum of angle metrics (SOAM), triangular index (TI), product of angle distance (PAD) and inflexion count metrics (ICM). We used t-test and Mann-Whitney U test for continuous variables and χ² test for dichotomised variables. To find independent predictors of BA aneurysm, we employed logistic regression analysis.

Results

We found significant positive correlation between age and SOAM (R = 0.195, p = 0.02) and PAD (R = 0.199, p = 0.018). Our study also showed that patients with BA aneurysm had significantly higher SOAM (0.21 ± 0.16 vs. 0.11 ± 0.08; p < 0.01), PAD (0.30 ± 0.19 vs. 0.18 ± 0.11; p < 0.01), TI (0.23 ± 0.23 vs. 0.10 ± 0.16; p < 0.01) and ICM (0.20 ± 0.16 vs. 0.15 ± 0.11; p = 0.045). In multivariate logistic regression analysis, after adjustment for all possible confounders, SOAM (OR = 1.086; 95% CI 1.046–1.136; p < 0.01) and TI (OR = 1.004; 95%C: 1.002–1.006; p < 0.01) remained independently associated with higher risk of BA aneurysm.

Conclusions

Increased tortuosity of BA is associated with higher risk of its aneurysm development.

Key Points

• Basilar artery sum of angle metrics and product of angle distance are correlated with age.

• Basilar artery tortuosity is independently associated with higher risk of its aneurysm development.

• Basilar artery tortuosity is positively correlated with its diameter and bifurcation angle.

Relation of Intracerebral Hemorrhage Descriptors with Clinical Factors

The association between intracerebral hemorrhage (ICH) shape and a poor treatment outcome has been established by few authors. We decided to analyze whether computationally assessed hemorrhage shape irregularity is associated with any known predictors of its poor treatment outcome. We retrospectively analyzed 48 patients with spontaneous intracerebral hemorrhage. For each patient we calculated Fractal Dimension, Compactness, Fourier Factor and Circle Factor. Our study showed that patients above 65 years old had significantly higher Compactness (0.70 ± 0.19 vs. 0.56 ± 0.20; p < 0.01), Fractal Dimension (0.46 ± 0.22 vs. 0.32 ± 0.20; p = 0.03) and Circle Factor (0.51 ± 0.25 vs. 0.35 ± 0.17; p < 0.01). Patients with hemorrhage growth had significantly higher Compactness (0.74 ± 0.23 vs. 0.58 ± 0.18; p < 0.01), Circle Factor (0.55 ± 0.27 vs. 0.37 ± 0.18; p < 0.01) and Fourier Factor (0.96 ± 0.06 vs. 0.84 ± 0.19; p = 0.03). In conclusion, irregularity resulting from the number of appendices can be a predictor of ICH growth; however, the size of those appendices is also important. Shape roughness better reflects the severity of brain tissue damage and a patient’s general condition.

Predictive factors of complications post intracranial meningioma surgery leading to early unplanned reoperations - a single center study

INTRODUCTION

Complications occurring after neurosurgical procedures which lead to reoperations are associated with poor treatment outcomes. The aim of our study was to establish predictive factors of unplanned early reoperations after intracranial meningioma removal.

MATERIALS AND METHODS

We retrospectively analyzed 177 patients who underwent craniotomy due to an intracranial meningioma. Early reoperation was de ned as reoperation during the same hospital stay. We used a χ2 test for proportional values and t-test and Mann-Whitney U tests as appropriate for continuous variables. To determine the potential predictors of early reoperation we used univariate and multivariate logistic regression analyses.

RESULTS

A total of 13 (7.34%) patients underwent unplanned early reoperation. These patients underwent retrosigmoid craniotomies (25.00% vs. 6.40%; p = 0.047), suffered from ischemic heart disease (66.67% vs. 6.64%; p <0.01) and atrial fibrillation (60.00% vs. 6.25%; p <0.01), were receiving heparin (50.00% vs. 6.74%; p <0.01) and anticoagulants (66.67% vs. 6.21%; p <0.01) significantly more often than the general study population. In multivariate logistic regression analysis anticoagulant use (OR: 31.463; 95% CI: 1.139-868.604; p = 0.04) and retrosigmoid craniotomy (OR: 6.642; 95% CI: 1.139-38.73; p = 0.034) remained independently associated with a higher risk of early reoperation.

CONCLUSIONS

Patients who underwent retrosigmoid craniotomy, those with a history of ischemic heart disease or atrial fibrillation and those who take heparin or anticoagulants are more likely to require early reoperation. Retrosigmoid craniotomy and anticoagulant use are independent risk factors for early reoperation.

Analysis of Anterior Cerebral Artery Tortuosity: Association with Anterior Communicating Artery Aneurysm Rupture

BACKGROUND

Many researchers have found a correlation between tortuous arteries and development of aneurysms in cerebral arteries. However, there are no studies analyzing the impact of tortuosity on risk of subarachnoid hemorrhage (SAH) occurrence. Therefore, we decided to determine whether tortuosity of the anterior cerebral artery can be related to the rupture of anterior communicating artery aneurysm and to severity and treatment outcome of SAH.

METHODS

We retrospectively analyzed anterior cerebral artery anatomy of 121 patients with anterior communicating artery aneurysms. From patients' medical records, we obtained their history including previous and current diseases and medications. For each patient we calculated relative length, sum of angle metrics, triangular index, product of angle distance, and inflection count metrics.

RESULTS

Patients with SAH had significantly higher relative length (0.70 ± 0.19 vs. 0.63 ± 0.22; P = 0.03) and significantly lower inflection count metrics (0.10 ± 0.08 vs. 0.16 ± 0.19; P < 0.01), respectively. In multivariate logistic regression analysis, after adjustment of all possible confounders, diabetes mellitus (odds ratio [OR], 0.154; 95% confidence interval [CI], 0.032-0.553; P < 0.01) and higher inflection count metrics (OR, 0.604; 95% CI, 0.357-0.909; P = 0.042) remained independently associated with lower risk of SAH. We also found an independent correlation between aneurysm dome size (R = -0.289; P = 0.02) and triangular index (R = 0.273; P = 0.03) and Glasgow Coma Scale score on admission.

CONCLUSIONS

Higher anterior cerebral artery tortuosity might be a protective factor against anterior communicating artery aneurysm rupture.

Computer-Assisted Analysis of Intracerebral Hemorrhage Shape and Density

BACKGROUND

Shape and density of intracerebral hemorrhage (ICH) are associated with a higher risk of poor treatment outcome. However, methods of assessment for the features are still inconclusive. Therefore, we decided to measure ICH shape irregularity using shape factors to achieve objective results.

METHODS

We retrospectively analyzed 48 patients with spontaneous ICH confirmed by head computed tomography (CT) scan. We obtained detailed medical history and blood test results from medical records. On admission patients were assessed using Glasgow Coma Scale score, and on discharge patients were assessed using Glasgow Outcome Scale (GOS) score. GOS score of less than 3 was defined as poor outcome. For each slice of CT scan with visible ICH, we extracted its contour and calculated the fractal dimension (FD), compactness (C), and Fourier factor (FF). We also calculated the circle factor (CF), which was defined as the contour perimeter/perimeter of the biggest circle that can be inscribed into the contour, and density heterogeneity, defined as the variance of pixel density.

RESULTS

A total of 28 patients (58.33%) had poor treatment outcome. Those patients had significantly higher C (0.71 ± 0.09 vs. 0.59 ± 0.09; P < 0.01), FD (1.42 ± 0.12 vs. 1.27 ± 0.09; P < 0.01), and CF (3.59 ± 0.92 vs. 2.63 ± 0.63; P < 0.01). In multivariate logistic regression analysis, FD (odds ratio, 4.176; 95% confidence interval, 1.551-15.577; P = 0.012) remained independently associated with higher risk of poor treatment outcome.

CONCLUSIONS

Each of the shape descriptors, except FF, was associated with treatment outcome after ICH. FD can be used as an independent predictor of outcome.

The relation of pituitary adenomas invasiveness and the proliferative index measured by immunoexpression of topoisomerase IIα

INTRODUCTION

Cavernous sinus invasion by pituitary adenoma affects surgical procedure radicality and consequently the postoperative course and prognosis in pituitary adenoma treatment. The search for pituitary adenoma aggressive behaviour markers is still a matter of debate.

MATERIAL AND METHODS

This study evaluates the relation of pituitary adenoma invasiveness to the expression of topoisomerase IIα in 72 patients who underwent transsphenoidal pituitary surgery. The assessment of tumour growth was conducted according to the Hardy scale as modified by Wilson and the Knosp scale. Topoisomerase IIα expression in tumour specimens was evaluated using immunohistochemical staining.

RESULTS

There was a correlation between the Knosp scale degree and the topoisomerase IIα expression (Spearman R = 0.3611, p < 0.005). The Kruskal-Wallis H test (p = 0.0034) showed that there was a statistically significant topoisomerase IIα expression increase in tumours classified as grade E on the Hardy scale. The topoisomerase IIα expression correlated also with tumour size (Spearman R = 0.4117, p < 0.001). Higher levels of expression were observed in macroadenomas, as compared to microadenomas (p < 0.05, Mann-Whitney test). Topoisomerase IIα expression correlated with cavernous sinus invasion.

CONCLUSIONS

The topoisomerase IIα expression correlated more with invasiveness than with extensiveness, which might make it an eminently useful marker in the assessment of aggressive pituitary adenoma behaviour.

Computer-aided analysis of middle cerebral artery tortuosity: association with aneurysm development

OBJECTIVEBlood vessel tortuosity may play an important role in the development of vessel abnormalities such as aneurysms. Currently, however, there are no studies analyzing the impact of brain blood vessel tortuosity on the risk of aneurysm formation. Therefore, the authors performed a computer-aided analysis of middle cerebral artery (MCA) tortuosity, especially among patients diagnosed with MCA aneurysms.METHODSAnatomy of the MCAs of 54 patients with unruptured MCA aneurysms was retrospectively analyzed, as was that of 54 sex-, age-, and vessel side-matched control patients without MCA aneurysms. From medical records, the authors obtained each patient's medical history including previous and current diseases and medications. For each patient, they calculated the following tortuosity descriptors: relative length (RL), sum of angle metrics (SOAM), triangular index (TI), product of angle distance (PAD), and inflection count metric (ICM).RESULTSPatients with an MCA aneurysm had significantly lower RLs (0.75 ± 0.09 vs 0.83 ± 0.08, p < 0.01), SOAMs (0.45 ± 0.10 vs 0.60 ± 0.17, p < 0.01), and PADs (0.34 ± 0.09 vs 0.50 ± 0.17, p < 0.01). They also had significantly higher TIs (0.87 ± 0.04 vs 0.81 ± 0.07, p < 0.01) and ICMs (3.07 ± 1.58 vs 2.26 ± 1.12, p < 0.01). Female patients had significantly higher RLs (0.76 ± 0.11 vs 0.80 ± 0.09, p = 0.03) than male patients.CONCLUSIONSMiddle cerebral artery aneurysm formation is strongly associated with blood vessel tortuosity parameters, which can potentially be used to screen for patients at risk for MCA aneurysm formation.

Emergency Reoperations in Cranial Neurosurgery

BACKGROUND

Complications after neurosurgical procedures that lead to reoperation are associated with poor outcome and economic costs. Therefore the aim of our study was to establish predictors of reoperation due to complications after cranial neurosurgery.

METHODS

We retrospectively analyzed 875 patients who underwent a cranial neurosurgical procedure. We used univariate and multivariate logistic regression analysis to determine the possible predictors of reoperation.

RESULTS

A total of 78 (8.91%) patients underwent emergency reoperation. Those patients more often were operated due to brain tumor (50.65% vs. 38.43%; P = 0.036) and least often due to head trauma (22.08% vs. 32.99%; P = 0.049). Reoperated patients more often underwent frontal craniotomy (26.47% vs. 13.46%; P < 0.01) and least often had burr hole surgery (7.35% vs. 19.21%; P = 0.016). Patients who did not require reoperation were more often operated during a weekend (5.29% vs. 16.99%; P < 0.01). After adjustment for confounders, weekend surgeries (OR: 0.309; 95% CI: 0.111-0.861; P = 0.025) remained independently associated with reduced risk of reoperation and frontal craniotomy (OR: 1.355; 95% CI: 1.005-1.354; P = 0.046) and lower mean cell hemaglobin concentration (OR: 2.227; 95% CI: 1.230-4.033; P < 0.01) remained independently associated with higher risk of reoperation.

CONCLUSIONS

Brain tumor surgery and frontal craniotomy are associated with a higher risk of emergency reoperation. Patients with head trauma, operated on during a weekend, and those who underwent burr hole surgery are less likely to be reoperated. Frontal craniotomy and lower mean cell hemoglobin concentration are independently associated with a higher risk of reoperation and operation during a weekend with lower risk of reoperation.

[In the 100 birth anniversary of the pioneer of stereotactic brain surgery in Poland professor Oskar Liszka. Functional neurosurgery in Poland and in Krakow]

This article is the report from the meeting of the Medical Society of Cracow, that has been devoted to the 100 birth anniversary of Oskar Liszka, Assoc. Prof., MD. In the course of the meeting Professor Oskar Liszka's figure has been reminded and his work as a pioneer of stereotactic surgery in Poland has been discussed. In the next two sections, the development of functional neurosurgery in Poland and achievements in this field in the Department of Neurosurgery and Neurotraumatology of Jagiellonian University Collegium Medicum in Krakow have been presented.

[Intramedullary spinal cord cavernous malformations--clinical presentation and optimal management]

Spinal cord cavernous malformations (scCM) are rare vascular malformation representing approximately 5-12% of all intramedullary lesions. The authors reviewed over 20 publications available and have consolidated existing knowledge on the pathology, epidemiology, clinical and radiological characteristics scCM. scCM management and treatment methods have been outlined concisely and achieved outcomes have been presented. The average age of onset is 42 years without sexual predilections. scCM statistically most commonly occur in the thoracic region--57%, in 9% of patients familiar prevalence is present, in 27% of patients the co-existence of intracerebral vascular malformation is diagnosed. The most common clinical symptoms are the sensory and motor deficits (respectively 65% and 63%). The course of the disease in 54% of cases, is a progressive, slow neurologic deterioration, although it is also observed a rapid onset associated with cavernoma hemorrhage. The risk of hemorrhage is estimated at 2.5% annually. scCM that are located intramedullary, are asymptomatic should be the subject to observation. Cavernomas that are symptomatic, having contact with the surface of spinal cord or exophytic should be subject to surgical treatment that is intended to complete removal. Results of surgical treatment are satisfactory, in about 60% of patients clinical improvement has been observed.

[History of Jagiellonian University Clinic for Nervous and Mental Diseases in 100 anniversary]

In the paper there have been presented the creation and activities of the Clinic of Neuropsychiatry in the period of 1914-1950 and the scientific and organizational work of professor J. Piltz (1870-1930).

[Optic nerve sonography - the non-invasive evaluation of intracranial pressure]

Intracranial hypertension is a common life-threatening syndrome caused by a variety of neurological and non-neurological diseases. Enlargement of the optic nerve sheath has been described in patients with raised intracranial pressure (ICP). Optic nerve sonography offers rapid bedside assessment of the optic nerve sheath diameter (ONSD) and has recently been introduced for the noninvasive detection of raised ICP. This study explains the pathophysiology of optic nerve sheath enlargement as a result of intracranial hypertension, describes the technique and clinical use of optic nerve sonography.

Tumours and tumour-like lesions of the spinal canal and spine. A review of 185 consecutive cases with more detailed close-up on some chosen pathologies

OBJECTIVES

Spinal canal tumours constitute a minor part of CNS invading neoplasm. However, due to their damaging influence on the spinal cord and the spinal roots, they cause serious clinical problems and can lead to severe disability. The aim of this study is to review material collected on tumours of the spine and the spinal canal at the Department of Neuropathology over the past ten years.

MATERIAL AND METHODS

One hundred and eighty five histopathological examinations of spinal tumours were evaluated between August 1997 and August 2007. The group of patients included 94 females and 91 males between the age of 18 and 79 years with a mean age of 53.

RESULTS

Apart from typical intraspinal tumours (i.e. astrocytomas and ependymomas), and extraspinal tumours, (i.e. meningiomas, schwannomas, neurofibromas), rare neoplastic and non-neoplastic tumour-like changes occur in the same localizations. These rare conditions include: capillary haemangioma, paraganglioma of filum terminale, meningeal gliomatosis, different variants of cysts such as the dermoid cyst, synovial cyst and aneurysmatic bone cyst, neoplastic and non-neoplastic bone tumours like the giant cell tumour, chordomas, and intramedullary metastatic carcinomas.

CONCLUSIONS

This paper presents and discusses spinal lesions from collected data with special attention paid to the rare conditions, which are reviewed in more detail.

[Spontaneous third ventriculostomy in obstructive hydrocephalus with composed aetiology: a case report]

Third ventriculostomy (TV) is the most common neuroendoscopic procedure for restoration of near physiological circulation of cerebrospinal fluid in obstructive hydrocephalus. Among 70 adults operated on using this technique, the authors encountered one case of spontaneous TV. Only a few case reports of spontaneous ventriculostomy revealed by ventriculography, flow-sensitive phase-contrast cine magnetic resonance imaging (MRI) or at autopsy have been published. A 43-year-old woman with symptoms of hydrocephalus and signs of chronic obstructive hydrocephalus secondary to aqueductal stenosis on MRI was qualified for TV. Enlarged infundibulo-mammillary triangle with perforation was noted intraoperatively. During the postoperative course, the condition of the patient partially improved although radiological appearance remained unchanged. Three weeks later symptoms of hydrocephalus recurred and the patient underwent an infusion test which revealed increased cerebrospinal fluid outflow resistance. Implantation of a ventriculo-peritoneal shunt yielded stable improvement. Spontaneous TV should be taken into consideration during selection of patients for TV, especially in cases with chronic obstructive hydrocephalus.

Gene Expression Profiles in Human Ruptured and Unruptured Intracranial Aneurysms

Background and Purpose— Mechanisms underlying development and rupture of intracranial aneurysms (IA) are poorly recognized. The majority of studies on human tissue have focused on predefined pathways. We sought to analyze global gene expression patterns of ruptured IA, unruptured IA, and control vessels.

Methods— Transcription profiles were studied in human ruptured (n=8) and unruptured (n=6) IA, as well as in control intracranial arteries (n=5), using oligonucleotide microarrays. Real-time reverse-transcription polymerase chain reaction was used for confirmation. Functional analysis for determination of over-represented ontological groups among gene expression profiles was also performed.

Results— The expression of 159 genes differed among the studied groups. Compared to the controls, 131 genes showed common directions of change in both IA groups. The most impacted biological processes for IA are: (1) the muscle system; (2) cell adhesion (downregulation); and (3) the immune system and inflammatory response (upregulation). Ruptured and unruptured IA differed in genes involved in immune/inflammatory processes; expression was reduced in ruptured IA.

Conclusions— Decreased expression of genes related to muscle system and cell adhesion is important for the development of IA. The role of immune/inflammatory processes is unclear. Inflammation may participate in the healing process within IA while playing a protective role against IA rupture.

[Effects of deep brain stimulation on dysfunctions of the autonomic nervous system in Parkinson's disease]

BACKGROUND

Deep brain stimulation (DBS) for alleviation of motor symptoms in advanced Parkinson's disease (PD) is well established. However, autonomic effects of DBS are less clear.

AIM

To review published data on autonomic dysfunctions in DBS-treated patients with PD.

METHODS

Medline bibliographic search was performed with the selected relevant keywords, through June 10th, 2010. Thirty three original papers meeting the criteria were identified.

RESULTS

Effect of DBS on autonomic dysfunctions observed in PD differs depending on the underlying etiology. DBS of the subthalamic nucleus has no direct effects on cardiovascular functions. Relative improvement results from reduced levodopa intake. Majority of gastrointestinal and urinary tract disorders improve with neurostimulation. However, prolonged body weight gain is observed. Furthermore, urinary tract functions normalize, and in male patients with Parkinson's disease sexual satisfaction increases. Sweating disorders are markedly reduced. On the contrary, chronic stimulation in the area of STN may induce autonomic adverse effects including sialorrhea and urinary retention. In exceptional cases withdrawal of medication before planned DBS surgery may result in life-threatening parkinsonism-hyperpyrexia syndrome. Thus discontinuation of levodopa should be an inpatient procedure.

CONCLUSIONS

Selection of patients who undergo DBS should weigh potential benefits and risks resulting from multidirectional effects of neurostimulation on autonomic nervous system.

Colloid cysts of the third ventricle. Endoscopic and open microsurgical management

BACKGROUND AND PURPOSE

The endoscopic approach to colloid cysts of the third ventricle is receiving increasing interest. However, its effectiveness is a matter of discussion. The aim of the study was to present direct and long-term outcome after endoscopy of colloid cyst vs microsurgery.

MATERIAL AND METHODS

Medical records of 23 patients with colloid cysts were retrospectively analyzed. This group consists of 10 patients treated endoscopically and 13 patients treated using a transcortical-transventricular approach. Sex and age distributions were similar in both groups. Clinically, symptoms of raised intracranial pressure predominated. All patients had hydrocephalus. Tumour diameter ranged from 1.5 to 3 cm. Mean follow-up period was 31 months.

RESULTS

In 6/10 endoscopically treated patients, tumours were completely removed. In 3 patients, small capsule remnants, adherent to the choroid plexus and veins, were left. In one case, a portion of capsule, obstructing the intraventricular foramen, was finally removed microsurgically. Postoperatively, 2 patients complained of memory deficits, which became permanent in one case. One patient developed temporary mutism. In one case, with symptoms of hydrocephalus without colloid cyst recurrence, a ventriculoperitoneal shunt was implanted 6 months after the initial surgery. In all microsurgically treated patients tumours were completely removed. One patient was reoperated because of intracerebral haematoma. Two patients suffered from temporary hemiparesis and 2 developed epilepsy. Within one year after surgery 3 patients were shunted because of hydrocephalus; one patient required antiepileptic treatment.

CONCLUSIONS

The endoscopic approach to colloid cysts of the third ventricle is safe, effective and carries a low complication rate. Endoscopy may be recommended as a treatment option.

[A comparison of the results of treatment in young and elderly patients with chronic subdural hematoma depending on the method of surgery]

INTRODUCTION

Chronic subdural hematoma (CSDH) generally occurs in patients past the age of 50 years but may develop at any age, also in young persons. The aim of this study was to compare the results of treatment in young and elderly patients with CSDH depending on the method of surgery: burr hole (group A) or craniotomy (group B).

MATERIAL AND METHODS

This retrospective study was based on medical histories and computed tomography findings in patients with CSDH operated at the Department of Neurotraumatology, Jagiellonian University, in 1983-2003. Altogether, 114 patients were analyzed including 35 (30.7%) patients under the age of 40 years and 79 (69.3%) patients over the age of 75 years.

RESULTS

A significant correlation between the result of treatment and age of patients with CSDH was demonstrated. The best result (Glasgow Outcome Scale = 5) was achieved in 73.9% of young patients in the trepanation group and in 66.7% in the craniotomy group as opposed to just 15.5% of elderly patients in the trepanation group and 4.8% in the craniotomy group. The difference between young and elderly patients was significant (p = 0.00001 for burr hole surgery, p = 0.0006 for craniotomy). Burr hole evacuation offered better results than craniotomy.

CONCLUSIONS

(1) The results of treatment were much better in young than in elderly patients. (2) Comparison of the results of treatment of chronic subdural hematoma shows that burr hole surgery is the preferable procedure.

Neuroendoscopic third ventriculostomy in the management of noncommunicating hydrocephalus secondary to giant basilar artery bifurcation aneurysm - case report and review of literature

Recently neuroendoscopic third ventriculostomy has become a well-established procedure for the treatment of noncommunicating hydrocephalus. However, morphological changes of the third ventricular floor can make endoscopic fenestration technically difficult, and increase the risk of injury to the basilar artery and perforators. The risk is especially high in patients with basilar artery bifurcation aneurysms, in whom aneurysm exclusion should precede treatment of hydrocephalus. If definitive aneurysm treatment is impossible or hazardous, endoscopic septostomy or shunting may be beneficial. However, reduction of intracranial hypertension may induce aneurysmal growth and rupture. We report upon a case of obstructive hydrocephalus produced by a non-ruptured partially thrombosed giant basilar artery bifurcation aneurysm, in which definitive treatment was considered impossible, successfully treated with neuroendoscopic third ventriculostomy. To the authors' knowledge this is the first reported case of its kind. The authors conclude that in similar cases neuroendoscopic ventriculostomy is worth trying if anatomical landmarks are identifiable.

[An outline of the history of neuroendoscopy]

Almost 200 years ago, German doctor Philipp Bozzini introduced the idea of endoscopy as a method of permitting visualisation of body cavities through their natural openings. First experiences with the use of this new method in different fields of medicine began in the early 20th century. Development of neuroendoscopy was related to the treatment of hydrocephalus. In 1910 Victor Lespinasse conducted the first neuroendoscopic intervention. He executed coagulation of choroid plexus in two children diagnosed with communicating hydrocephalus. The method was further developed by Walter Dandy who implemented ventriculography, worked out by himself in 1918, into the procedure of choroid plexus removal in hydrocephalic patients. For many, he is considered the father of neuroendoscopy. In 1923, William Mixter executed the first successful endoscopic ventriculostomy of the third ventricle. Spinal endoscopy began in the 1930's, but did not excite such interest as intracranial interventions. Introduction of the so-called shunt surgery for the treatment of hydrocephalus and application of operating microscopes in neurosurgery delayed progress of neuroendoscopy. It was not until the technical advances in optics and related fields of physics, that the neuroendoscopy resurged and has added a new dimension to neurosurgery. In 1963 GBrard Guiot described widespread possibilities of using endoscope in neurosurgery. In 1966 Harold Hopkins applied solid rod lenses in the construction of the endoscope, bringing it to its current standard of excellence. The introduction of the neurofiberoscope in 1973 by Takanori Fukushima opened further possibilities in the field of neuroendoscopy. The renaissance of endoscopy observed nowadays results from a general intention to limit invasiveness in neurosurgery.

[Results of neuroendoscopic treatment of arachnoid cysts in adults]

BACKGROUND AND PURPOSE

Most arachnoid cysts (ACs) are asymptomatic, but some of them cause mass effect, mainly in adults. Surgery of ACs is controversial, especially regarding the choice of the best method of treatment. The authors present short- and long-term outcome of endoscopic surgery of ACs.

MATERIALS AND METHODS

There were 19 adults with symptomatic ACs treated surgically in the last 6 years. 16 cysts were located supratentorially, and 3 infratentorially. Cystocisternostomy was carried out in 7 patients, cystocisternostomy with catheter implantation was performed in 5 patients, cystoventriculostomy in 3 patients, and cystoventriculostomy with catheter implantation was carried out in 2 patients. In one case additional endoscopy combined with shunt was necessary, and in another one endoscopy converted to microsurgery. Outcome was assessed by means of neurological examination and computed tomography (CT).

RESULTS

During the short-term follow-up, 11 (57.9%) cases improved neurologically, and in 6 (33.0%) ACs were significantly smaller in CT. During the long-term follow-up, 14 (73.7%) patients improved significantly, and the size of ACs was reduced in 16 (84.2%). In two cases subdural haematoma was observed.

CONCLUSIONS

Outcome after endoscopic surgery of ACs in adults is good, and the complication rate is low. Endoscopy should be recommended as the treatment of choice in patients suffering from ACs.

[The use of neuroendoscopy in the treatment of intraventricular and paraventricular brain tumors]

BACKGROUND AND PURPOSE

Because of their deep location, intra- and para- ventricular brain tumors pose an important therapeutic issue. Technical difficulties during the operation often result from the alteration of anatomy produced by the tumor, which brings about the risk of injury to functionally important structures. The authors assess clinical usefulness of neuroendoscopy in the treatment of discussed tumors.

MATERIAL AND METHODS

Medical records of 16 adult patients treated between 2000 and 2003 were analyzed. The diagnosis was based on CT with 3D reconstruction and MRI. In 7 cases the tumor was located in the third ventricle, in 4--in lateral ventricles, in 5--paraventricularly. Surgery was performed using a rigid neuroendoscope and/or neurofiberscope equipped with the basic set of endoscopic instruments. The efficacy of the procedure was evaluated by clinical, CT and MRI follow-up examinations. The intended and achieved aim of the operation as well as the remote outcome were analyzed.

RESULTS

The planned aim of the procedure was achieved in 12 (75%) patients. In 3 cases the tumor was removed totally, in 5--tumor mass was reduced restoring the cerebro-spinal fluid passage, in 4--tumor biopsy was performed. In 4 patients different obstacles made it impossible to achieve the intended aim of the procedure. 1 patient died in the direct postoperative course. In the long-term postoperative follow-up ranging from 8 to 44 months (median: 23 months), the clinical condition improved or was stable in 10 patients, 2 patients were reoperated, 2 became dependent and 1 was lost for follow-up.

CONCLUSIONS

Neuroendoscopy offers new options in the treatment of intraventricular and paraventricular brain tumors allowing for their removal, reduction, histopathological verification and restoration of the cerebrospinal fluid passage. The outcome is good with a low complication rate.

[Endoscopic treatment of the spontaneous intracerebral hematomas]

BACKGROUND AND PURPOSE

Surgical evacuation of spontaneous intracerebral hematomas (ICH) performed in a traditional way usually increases primary brain tissue damage due to the hemorrhage. On the other hand, symptoms of the intracerebral pressure and secondary brain tissue destruction close to the hematoma are the basis for making a decision about surgical treatment. In order to limit surgical trauma we started research to evaluate the usefulness of endoscopic surgery in the treatment of ICH.

MATERIAL AND METHODS

Twenty three cases were included in the study. Patients with consciousness disorders and/or focal neurological deficit and different systemic diseases were qualified for endoscopic evacuation. The diagnosis of hematoma was based on computed tomography (CT). ICHs were lobar and in certain cases they extended to the basal ganglia. All patients were operated on within one week from the onset of symptoms. Neuroendoscope was introduced to the hematoma cavity through the burr hole and the puncture of the cerebral surface over the hematoma. The hematoma was evacuated by fractionated rinsing. Bigger clots were fragmentized but those which were adjacent to the cavity wall were left. Postoperative assessment of the hematoma evacuation was based on CT performed immediately and in the second week after surgery.

RESULTS

Total evacuation of the ICH was achieved in 6 patients, and its volume was reduced in 17 cases. Symptoms of brain edema resolved in all patients. A significant trend to reduce focal neurological deficits was observed: 16 patients improved and 3 remained unchanged. Four patients died.

CONCLUSIONS

Endoscopic surgery allows a complete hematoma evacuation or reduction of its volume, reduces symptoms of brain edema and accelerates the improvement of focal neurological deficits.

[Endoscopic method in etiological diagnosis of spontaneous intracerebral hemorrhage. Case report]

The etiology of cerebral hemorrhage is not always easy to diagnose and modern neuroimaging methods may be deceptive. The authors report on a 48-year-old previously healthy male admitted to hospital with a first-time severe generalized epileptic seizure. The patient presented with aphasia, confusion, headaches, nausea, right hemianopia and early papilledema. CT revealed an intracerebral hematoma in the left occipital lobe but MRI and MRA failed to provide any further insight into the etiology of the hemorrhage. Due to persisting intracranial hypertension, the patient underwent neuroendoscopic removal of the hematoma. After blood clots were evacuated, pathologic vascularity was found. Tissue samples were collected from the walls of the hematoma cavity. Neoplastic cells adjacent to the blood vessels were identified in one of the samples. The patient was reoperated and a glioma-like tumor was removed. The diagnosis of cerebral intratumoral hemorrhage is difficult especially when there are no previous clinical signs of a tumor. Neuroendoscopy may speed up the diagnostic process which usually extends past resorption of the haematoma and the technique may be an alternative to stereotactic surgery.

[Surgery of the ruptured distal anterior cerebral artery aneurysms]

INTRODUCTION

Distal anterior cerebral artery aneurysms (DACAA) are the particular group of the aneurysms of anterior circle of Willis. The characteristic factors are: different location on the distal anterior cerebral artery, specific surgical approach and rare occurrence.

AIM

Retrospective analysis of the outcome and attempt to find risk factors in DACAA surgical treatment were goals of this report.

MATERIAL AND METHOD

The authors report a series of 49 cases with DACAA who were operated on in the Department of Neurosurgery, Jagiellonian University in Kraków, in the period of 16 years. There were 29 women (59.2%) and 20 men (40.8%) with a mean age of 49 years. Multiple aneurysm were in 12 cases (24.5%), in which ruptured DACAA were always the cause of the haemorrhage. We investigated age, sex, Hunt and Hess grade, arterial hypertension, timing of operation, coexistence of intracerebral haematoma (ICH), intraventricular haemorrhage (IVH), cerebral ischaemia, hydrocephalus, multiple aneurysms, intraoperative aneurysmal rupture, use of temporary parent vessel clipping, significant brain oedema during surgery, anatomical variability of anterior cerebral artery as a potential risk factors.

RESULTS

There were 29 patients (59.2%) in good and very good clinical state and 11 (22.4%) in poor clinical state on discharge. Nine (18.4%) patients died. Statistically significant factors such as age (p<0.035), arterial hypertension (p<0.0035), Hunt and Hess grade (p<0.0073), IVH (p<0.0054), cerebral ischaemia (p<0.036) affected the direct outcome of patients.

CONCLUSIONS

There are typical risk factors in surgically treated DACAA: age, arterial hypertension, clinical status, intraventricular haemorrhage, cerebral ischemia. Most of treated cases remain in good and very good condition. Haemorrhagic and ischaemic complications were most frequent causes of operating losses in DACAA patients.

[Cerebral vasospasm after subarachnoid hemorrhage. Current possibilities of prevention and treatment]

Cerebral vasospasm is a complication diagnosed in angiography among about 2/3 of patients after subarachnoid haemorrhage with ruptured cerebral aneurysm. In half of the cases it appears in disturbances of consciousness, neurological deficits and vegetative disturbances. It's final result can be ischemic stroke. Among patients with symptomatic cerebral vasospasm around 1/3 fully recover in 1/3 of cases persistent neurological deficit remains and 1/3 of the patients die. Authors basing on literature and taking into consideration their own experience, reviewed and estimated current methods of prevention and treatment of cerebral vasospasm. Discussed mainly were methods which had been used in every day clinical practice, however some of them still remain controversial. The accepted model of treatment suggests as follows: 1. The exclusion of the aneurysm which was the cause of haemorrhage from the circulation and clot removal from the subarachnoid space; 2. Nimodipine administration; 3. Undertaking hemodynamic treatment; 4. Aminosteroid administration; 5. Performance of angioplasty in the case of lack of reaction to previous types of treatment of cerebral vasospasm.

[Risk factors for surgical treatment of supratentorial cerebral arterio-venous angiomas]

The authors present the influence of the selected risk factors in surgical treatment of supratentorial cerebral arterio-venous angiomas. The material represents 38 patients treated in the Neurosurgical Department Collegium Medicum of the Jagiellonian University in the last decade. In 28 of the patients the first sign of angioma was subarachnoid haemorrhage (SAH) and the remaining 10 were revealed with seizures. The assessment of the patients when admitted to the Department was graded using the WFNS scale. The diagnosis was established based on clinical symptoms, the results of computerized tomography and cerebral angiography. The extent of the SAH was graded by the Fisher's scale. The detected angiomas were classified according to the Spetzler scale. All patients were operated on using the microsurgical technique. After occluding the feeding arteries, a selective excision was made into the angiomas and the pathological cerebral tissue. The radical of the operation was controlled by cerebral angiography. The results of the surgical treatment were graded by the modified "outcome" Spetzler scale. The following risk factors were analysed: age, WFNS grade, Fisher's grade and Spetzler's grade. The statistical calculations were made using the chi square test and the Mann-Whitney U-test (p < 0.05). In 7 of the patients the results were very good (18.4%), in 12 the results were good (31.6%), and in 14 the results were bad (36.8%). Five of the patients died (13.2%). There was no statistically significant relationship between the risk factors and the results of treatment of supratentorial cerebral arterio-venous angiomas. In the percentage analysis, the best results were obtained from young patients without SAH and with superficial pattern of venous drainage.

[Intradural clivus chordoma: surgical treatment with no tumor regrowth 12 years after surgery]

We present a case of a 19-year-old woman treated in the Neurosurgery Department of Collegium Medicum of the Jagiellonian University in Kraków because of the clival chordoma. The patient with one year anamnesis, treated surgically and then rehabilitated, was examined 12 years after she left our department. Radiologically we did not find tumor regrowth. We only found diplopia, but this sign was present from the time of the operation. Such a long time of katamnesis proves possibility of total removal in this type of tumors.

[Chordomas. Analysis of 24 cases]

Chordoma is a relatively rare neoplasm originating from the remnants of the embryonic notochord. We analysed 24 cases of chordoma. The patients were divided into groups depending on the localisation. We analysed the results of different methods of therapy: surgical treatment, radiation therapy and combined surgical and radiological treatment. The results were compared with the data from the references.

[Current diagnostic methods in normotensive hydrocephalus]

Based on literature of the last 30 years we present the current view concerning diagnosis of the communicating hydrocephalus. Till now various methods of the assessment of hydrocephalus have been used in order to select patients for shunt treatment. No single factor, considered apart from the other diagnostic criteria, is sufficient to undertake the decision of shunting. According to current opinion the lumbar infusion test is the most valuable in the assessment of hydrocephalus, supporting us with the data of pressure-volume relations in patient. Based on our own experience the infusion test is not only useful in the preoperative investigation, but also for the assessment of proper shunt function.

[Significance of CT in the assessment of risk due to cerebral vasospasm following subarachnoid hemorrhage]

The relationship between the amount and localization of blood in the subarachnoid space and the occurrence of vasospasms was studied in 100 patients with aneurysmal subarachnoid haemorrhage with cerebral vasospasm as complication. In the control group comprised 100 patients in whom angiography revealed no vasospasm. Within one week of subarachnoid haemorrhage all patients underwent computerized tomography of the head. The examination was initially conducted without and subsequently with the administration of contrast medium in a 2 mm thick layer. The amount and distribution of blood were evaluated according to Fisher scale. Follow-up cerebral angiography was performed in most cases in the second week after haemorrhage. In the studied group the occurrence of blood in the subarachnoid space was disclosed in 71 (71%) of the patients. In most cases it was present as clots in basal cisterns. In the control group the presence of blood was found in 32 (32%) of patients, this being usually diffused in subarachnoid space. The results obtained, as well as those quoted from other works, confirm the usefulness of computerized tomography in prognosing the risk of cerebral vasospasms following subarachnoid haemorrhage. However, the method is not to be overestimated.

Primary balloon cell malignant melanoma of the right temporo-parietal region arising from meningeal naevus

An unusual case of primary balloon cell malignant melanoma (BCMM) in brain arising from melanoblastic meningeal (or diffuse meningeal) naevus in a 30-year-old woman has been presented. The characteristic balloon cells were amelanotic or focally extremely weakly melanotic. The large, uniformly looking, tightly packed, pale "balloon cells" formed the homomorphic texture of the spherical well demarcated tumor lying in the white matter of right temporo-parietal region beneath the nevoid-looking partially melanotic diffuse meningeal and cortical infiltrate. Positive melanoma antigen HMB-45, S-100 protein and vimentin along with negative epithelial membrane antigen EMA and markers for macrophages like alfa-1-antitrypsine and CD-68 proved that balloon cells belong to and may form a peculiar type of melanoma. The lack of suspected skin or mucosal naevi and coexisting meningeal naevus speak for the primary character of the balloon cell melanoma. According to our knowledge it is the first primary balloon cell melanoma of the brain. Differential diagnosis and the pathogenesis are discussed.

[Thrombosis of the cavernous sinus]

The authors describe a case of cavernous sinus thrombosis in a female aged 59 years referred to hospital with suspected tumour at the base of the brain. With the present broad use of sulphamides and antibiotics the incidence of septic thrombosis of the cavernous sinus has decreased considerably. In the reported case the infectious focus giving rise to the thrombosis was in the palatine tonsils or in teeth with gangrenous changes. The thrombosis was associated with infarction of the left hemisphere. The correct diagnosis was established after CT of the head.

[Clinical-radiological correlations of cerebral vasospasm and cerebral infarction in patients after subarachnoid hemorrhage]

The correlation was studied between angiographically demonstrated vasospasm, ischaemic focus demonstrated by computed tomography and the clinical condition in 100 patients within 2 weeks after spontaneous subarachnoid haemorrhage. The control group comprised 50 patients after subarachnoid haemorrhage without vasospasm. The clinical condition of the patients with vasospasm was more serious than in the control group. The proportion of patients with clinical grade I was 24% in the group of vasospasm and 50% in the control group. Ischaemic foci were found in computed tomograms four times as frequently in the group with vasospasm than in the control group. Neurological deficit was noted in 41% of patients with vasospasm and in 26% in the control group. The study confirmed correlations between vasospasm, cerebral infarction and neurological deficit but these correlations were not strong.