Morphometry of cerebral arterial bifurcations harbouring aneurysms: a case-control study.

BACKGROUND: Conclusions from studies evaluating vessel dimensions and their deviations from values resulting from the principle of minimum work (PMW) on the formation of intracranial aneurysms (IAs) are still inconclusive. Our study aimed to perform a morphometric analysis of cerebral arterial bifurcations harbouring aneurysms. METHODS: The study comprised 147 patients with basilar artery (BA) and middle cerebral artery (MCA) aneurysms and 106 patients constituting the control group. The following morphometric parameters were evaluated: the radii of vessels forming the bifurcation, the junction exponent, the values of the bifurcation angles (Φ1 and Φ2 angles between the parent vessel trunk axis and the larger or smaller branches, respectively; α angle, the total bifurcation angle) and the difference between the predicted optimal and observed branch angles. RESULTS: The analysed parameters for internal carotid artery (ICA) bifurcations were not significantly different among the groups. The MCA and BA bifurcation angles and the radii of the parent MCA and BA vessels with aneurysms were significantly higher than those of the control group. The differences between the predicted optimal and observed branch angles were significantly higher for BA and MCA bifurcations with aneurysms compared to the control group. The mean junction exponent for bifurcations in the circle of Willis (i.e., ICA and BA bifurcations, respectively) and MCA bifurcations with aneurysms was significantly lower than the theoretical optimum and did not significantly differ among the groups. In a multilevel multivariate logistic regression analysis, the branch angles and the radius from the parent vessel were significant independent predictors of the presence of an IA. The ROC analysis indicated that the α angle was the best performer in discriminating between aneurysmal and nonaneurysmal bifurcations. CONCLUSIONS: The dimensions of the arteries forming the circle of Willis do not follow the PMW. Deviation from the energetically optimum geometry for bifurcations beyond the circle of Willis (particularly, a larger radius of the parent artery and a wider total bifurcation angle) may lead to the formation of IAs. Further studies are warranted to investigate the significance of vessel dimensions and the bifurcation angle on the magnitude of shear stress in the walls of arterial bifurcations.

"Extracorporeal Membrane Oxygenation for Greater Poland" Program: How to Save Lives and Develop Organ Donation?

The "ECMO for Greater Poland" program takes full advantage of the extracorporeal membrane oxygenation (ECMO) perfusion therapy opportunities to promote the health of the 3.5 million inhabitants in the region. The main implementation areas are treatment of patients with hypothermia; severe reversible respiratory failure (RRF); critical states resulting in heart failure, that is, cardiac arrest, cardiogenic shock, or acute intoxication; and promotion of the donor after circulatory death (DCD) strategy in selected organ donor cases, after unsuccessful life-saving treatment, to achieve organ recovery. This organizational model is complex and expensive, so we used advanced high-fidelity medical simulation tests to prepare for real-life experience. Over the course of 4 months we performed scenarios including "ECMO for DCD," "ECMO for extended cardiopulmonary resuscitation," "ECMO for RRF," and "ECMO in hypothermia." Soon after these simulations, Maastricht category II DCD procedures were performed involving real patients and resulting in 2 successful double kidney transplantations for the first time in Poland. One month later we treated 2 hypothermia patients (7 adult patients with heart failure and 5 patients with reversible respiratory failure) with ECMO for the first time in the region. Fortunately, we have discovered an important new role of medical simulation. It can be used not only for skills testing but also as a tool to create non-existing procedures and unavailable algorithms. The result of these program activities will promote the care and treatment of patients in critical condition with ECMO therapy as well as increase the potential organ pool from DCDs in the Greater Poland region of Poland.

Meningiomas of the upper and middle part of the clivus and surrounding structures: early and long-term outcome.

BACKGROUND AND PURPOSE: Meningiomas of the upper and middle parts of the clivus and surrounding structures are removed using petrosal approaches: anterior, posterior, combined and complete. The purpose of this study is to show the results of treatment of these meningiomas and to present our interpretation of the treatment strategy. MATERIAL AND METHODS: Twenty-six patients (17 women, 9 men) were included in the study. The neurological status of the patients was assessed before and after surgery as well as at the conclusion of the treatment. The following measurements and data were collected and recorded: approximate volume of the treated lesion, its relation to large blood vessels, cranial nerves and the brainstem, as well as tumour consistency and vascularisation. RESULTS: Symptoms duration ranged from 1 to 60 months (median: 16 months). In 57.7% of patients, imbalance was the predominant sign. Less frequent symptoms were: head-aches, dysacusis and hemiparesis. Approximate volumes of the tumours ranged from 4 to 65 mL (mean: 32 mL). Total or subtotal resection was achieved in 73.1% of patients. The patients' performance improved postoperatively in 34.5%, remained unchanged in 46.2% and deteriorated in 11.5% of patients. Two (7.8%) patients died after the surgery. CONCLUSIONS: The use of petrosal approaches in the surgical treatment of meningiomas of the upper and middle parts of the clivus and the surrounding structures facilitates good or at least satisfactory neurological outcome with a high proportion of complete resections and relatively low mortality.

[Anterior petrosal approach - analysis of the surgical technique in cadavers simulation]. / Dostep skalisty przedni - analiza techniki operacyjnej na podstawie symulacji na zwlokach.

The aim of the study was to present consecutive stages of the anterior petrosal approach (APA). Eight simulations of APA were performed on non-fixed human cadavers without any known pathologies of the head and neck. The consecutive stages of the procedure were documented with photographs and schemes. The starting point for APA is a temporal craniotomy and extradural exposition of the base of the middle cranial fossa. Mobilisation of the trigeminal nerve allows for removal of the apex of the petrous bone. Approach to the upper part of the clivus is achieved by elevation of the temporal lobe and section of the tentorium and superior petrosal sinus with surrounding dura. Anterior petrosal approach is a reproducible technique, which provides surgical penetration of the upper clivus and related regions. This approach is particularly useful in the treatment of tumors of the mentioned above anatomical areas.

[Posterior petrosal approach - analysis of the surgical technique in cadavers simulation]. / Dostep skalisty tylny - analiza techniki operacyjnej na podstawie symulacji na zwlokach.

The aim of the study was to present consecutive stages of the posterior petrosal approach (PPA). Eighteen simulations of PPA were performed on non-fixed human cadavers without any known pathologies in the head and neck. The consecutive stages of the procedure were documented with photographs and schemes. The starting point for PPA is a temporal craniotomy, suboccipital craniectomy and mastoidectomy with keeping the bony labyrinth intact. Approach to the middle part of the clivus is achieved by raise of the temporal lobe and section of the superior petrosal sinus and tentorium and by mobilization the sigmoid sinus. Posterior petrosal approach is a reproducible technique, which provides surgical penetration of the middle clivus and related regions. It reduces the operating distance and allows to limit the cerebellum and temporal lobe traction and to preserve the anatomic integrity of the brain stem and cranial nerves of the cerebellopontine angle.

"True" aneurysm of the posterior communicating artery as a possible effect of collateral circulation in a patient with occlusion of the internal carotid artery. A case study and literature review.

"True" posterior communicating artery (PCoA) aneurysms are extremely rare. A case of a 63-year-old patient with a ruptured "true" aneurysm of the right PCoA associated with the occlusion of the right internal carotid artery is presented. For nine years before he suffered from subarachnoid hemorrhage, the patient had developed symptoms of transient ischemic attack (TIA) due to the occlusion of the right internal carotid artery. The left vertebral angiogram demonstrated a "true" right PCoA aneurysm and collateral flow from the right posterior communicating artery to the right internal carotid artery. The right internal carotid system was also fed by collateral circulation from the left carotid artery through the anterior communicating artery. Transcranial colour-coded real-time sonography (TCCS) demonstrated increased velocity and turbulent blood flow in both communicating arteries. The patient was operated on and the aneurysm was clipped successfully. This case report suggests that the blood flow disturbances resulting from the collateral circulation through the PCoA could be a conductive factor in the formation and development of the aneurysm. This is the first described case of a "true" aneurysm of the PCoA coexistent with the occlusion of the internal carotid artery.

[A case of complex development anomalies and aneurysm of the anterior part of arterial circles of the brain]. / Przypadek zlozonych nieprawidlowosci rozwojowych i tetniaka przedniej czesci kola tetniczego mózgu.

A case of complex developmental anomalies and an aneurysm of the anterior part of arterial circle of the brain is reported. Every developmental anomaly was analysed separately. Views on their embryologic conditions are quoted. Haemodynamic disturbances are pointed out as a reason of the occurrence of the aneurysm.

Approaches to posterior circulation aneurysms and results of the operations.

Surgical approaches and operative results in 32 operations of aneurysms of the vertebrobasilar system are presented. The orbitozygomatic and temporopolar approach was used for aneurysms of the bifurcation of the basilar artery lying high in the interpeduncular fossa. In aneurysm which neck was located less than 10 mm above or less than 5 mm below the anterior and posterior clinoid processes the pterional transylvian subtemporal and pterional anterior temporal approaches were performed. A large aneurysm with the neck lying 5 mm below the line connecting the anterior and posterior clinoid processes was operated on via pterional transcavernous approach. The used approaches made it possible to clip the aneurysms. Good and very good results were obtained in 82 per cent of cases. The perioperative mortality was 9 per cent.

[Tethered cord syndrome in adults]. / Zespól zakotwiczonego rdzenia kregowego u doroslych.

The authors present a description of three patients in whom symptoms of spinal cord injury developed late after opening of the dural sac of the spinal canal. The material comes from two female and one male patients of age 37-47 years. In the first case the symptoms included increased paraesthesia, pain, paraparesis and sphincter disorders, which appeared 16 years after stab wound of meninges and the spinal cord at Th10. In the second patient, operated on for myelomeningocele at L3-4 at the age of five, sphincter disorders, trophic changes of feet and paraparesis appeared. The third patient was operated on for intra- and extramedullary lipoma at Th9-12. Seven months after the operation symptoms of sphincter disorders, pain, paraesthesia and paraparesis developed. The MR examination showed in all patients an adhesion of the posterior or posterolateral surface of the spinal cord with the dura mater at the sites of injury, which was confirmed intraoperatively. An operative treatment improved the clinical state. The tethering of the cord by the scar was the cause of a non-physiological stretching of the spinal cord on flexion of the body and head. It led to spinal circulation disorders and symptoms of myelopathy. It has been observed that the onset of the symptoms is often caused by sudden stretching of the spinal cord during fall or intense physical exercises. In such cases operative release of the spinal cord from the adhesion is a method of choice.

[Surgical treatment of intramedullary tumors: preliminary results]. / Leczenie operacyjne guzów sródrdzeniowych--doniesienie wstepne.

Since 1995 in the Department of Neurosurgery, Mining Hospital in Sosnowiec a surgical technique has been used of total or gross total removal of tumour. It includes the use of CO2 laser for myelotomy and tumour vaporisation as well as ultrasonic aspirator, microsurgical techniques and intraoperative monitoring of SSEP. Ten patients 11-61 years of age were operated on. Four tumours were located in the cervical part of the spinal cord, three in the cervico-thoracic area while the remaining three in the thoracic part. The condition of four patients before the operation was assessed as I-II degree on the McCormick scale, of one patient as--III degree--and of the other five patients as IV-V degree. Only in two cases the removed tumour was ependymoma; in six cases these were benign astrocytomas and in two other--anaplastic tumours. After the treatment, the clinical condition of almost all patients improved. Pain and trouble some paraesthesias subsided. Five patients are completely self-dependent and three other walk with the aid of handrails. The treatment proved unsuccessful in one patient with an anaplastic tumour in whom paralysis of lower limbs occurred before the operation. Six months after the operation the patient died of tumour metastasis. The observation period ranged from 6 months to 3 years. On the basis of our own observations it is suggested that total safe removal of even infiltrating intramedullary tumours is possible when proper surgical techniques are used. Best results are obtained in patients in good clinical condition irrespective of tumour extent.

Occlusion of radicular arteries - reasons, consequences and anastomotic substitution pathways.

AIM OF STUDY: To investigate the cause of radicular artery occlusion. METHOD: Fifty specimens of spinal cords were taken at postmortem from individuals in whom no symptoms of spinal cord and spine injuries were present in life. The spinal cord arterial system was filled with colour contrast material and then each radicular antery was studied individually at 5 - 25 operative microscope magnification. RESULTS: Two hundred and fifty two anterior radicular arteries joining the anterior spinal artery and 525 posterior radicular arteries joining the posterior spinal arteries were examined. There were five obstructed vessels: four were anterior radicular arteries including the artery of Adamkiewicz and one of the initial branches of the spinal artery originating from the vertebral artery. CONCLUSIONS: As the presented examples show, the formation of a fully efficient collateral circulation is possible.

[The use of pedicle periosteal flap in plastic surgery of anterior skull base]. / Zastosowanie uszypulowanego plata okostnowego w plastyce podstawy dolu przedniego czaszki.

In 12 cases of large traumatic defects of the anterior skull base plastic surgery was performed using large periostial flap to separate the nasopharynx from the extradural area. After a large biauricular scalp flap was formed, precise preparation of periostial flap was done. The bifronto-transfrontal sinus or transfrontal sinus approach was performed. Next cranialization of the frontal sinus was done and then it was filled with muscle. Afterwards the floor of the frontal sinus and skull base with defect were covered with periostial flap pedicled along supraorbital ridge. Finally irradiated homograft of dura or fascia lata was glued intradurally onto the place of the dural defect. In all of the patients CSF-rhinorrhea stopped immediately after surgery. Among patients observed from 2 to 4 years after surgery neither recurrent rhinorrhea nor infection appeared.

The accessory anterior cerebral artery: case report and anatomic analysis of vascular anomaly.

BACKGROUND: The term "accessory artery" was formulated to describe one of the developmental anomalies of the middle cerebral artery. This anomaly consisted of the incidence of a vessel that branched off close to the anterior communicating artery and supplied a part of the cortex in the region of the middle cerebral artery vascularization. METHODS: A panangiography of the cerebral vessels was carried out, using the subtraction method, on a woman who suffered from subarachnoid hemorrhage. An aneurysm of the anterior communicating artery and developmental anomaly of the right anterior cerebral artery were found. During the aneurysm operation, the existence of the developmental anomaly was confirmed. It was revealed also during a control angiography. RESULTS: An atypical branch of the right internal carotid artery was found branching off from section C2, and passing below the right optic nerve and the anterior communicating artery. This branch ended with a division into the orbitofrontal and frontopolar artery. CONCLUSIONS: The atypical branch of the internal carotid artery that partly performs the function of the existing proper right anterior cerebral artery, has been defined as the accessory anterior cerebral artery.

[Views on the etiology and pathogenesis of intracranial saccular aneurysms]. / Poglady na etiopatogeneze workowatych tetniaków wewnatrzczaszkowych.

The anatomical structure of intracranial arteries may favour the development of aneurysms because of poorly developed external elastic lamina and adventitia, gaps in the muscular layer and great number of collagenous fibres. However, the haemodynamic factor has the principal significance in initiation, growth and rupture of the aneurysms. The importance of this factor is especially great in cases of coexistence with developmental abnormalities of the arteries, arterial occlusion, hypertension, atherosclerosis or hereditary connective tissue disorders.

[Extramedullary erythropoiesis in cerebellar hemangioblastomas]. / Pozaszpikowa erytropoeza w naczyniakach plodowych mózdzku.

Three patients operated on for cerebellar haemangioblastoma are reported. Rarely observed extramedullary erythropoiesis was found in tumour tissue. One patient had erythrocytosis (solid form of the tumour), the remaining patients with cystic tumour had normal erythrocyte count.

[Application of alteplase in prevention of cerebral vasospasm and its sequelae in patients after aneurysmal subarachnoid hemorrhage from ruptured cerebral aneurysm]. / Zastosowanie rekombinowanego tkankowego aktywatora plazminogenu w profilaktyce skurczu naczyniowego oraz jego nastepstw u chorych po krwotoku podpajeczynówkowym z peknietego tetniaka mózgu.

15 patients after SAH from ruptured cerebral aneurysm were operated on within 72 hours after SAH. During the operation after clipping of aneurysm 10 mg of rtPA was administered into basal cisterns, Control group consisted of patients who did not receive rtPA. All the patients on the basis of CT scan were classified to III grade according to Fisher's classification. Control CT scan revealed dissolution of most clots in basal cisterns. In comparison with control group the patients who received rtPA rarely experienced radiological signs of vasospasm and delayed neurological deficit.

[Vascular regions of the spinal cord]. / Obszary naczyniowe rdzenia kregowego.

In a material of 50 spinal cord specimens obtained from adults the radicular-anastomotic arteries were studied. After an analysis of the situation, diameter and connections of these arteries seven vascular regions were discerned in the cord: upper cervical region C1-C3, middle cervical region C4-C5, cervical intumescence region C6-C8, upper thoracic region Th1-Th3, middle thoracic region Th4-Th7, thoracolumbar intumescence region Th8-L4, and lumbosacral region L5-Co. Arterial systems found in these regions are described.

[Aneurysm of the anterior communicating artery as a possible late complication of internal carotid artery ligation]. / Tetniak tetnicy laczacej przedniej jako mozliwe pózne powiklanie podwiazania tetnicy szyjnej wewntrznej.

A case of a 55-year-old woman with anterior communicating artery aneurysm has been described. The aneurysm led to subarachnoid haemorrhage 8 years after ligation of the right internal carotid artery in order to turn off an aneurysm of this artery. Angiography showed the existence of collateral circulation through the arterial circle of the brain with haemodynamic disturbances, confirmed by Doppler ultrasonography. According to the views found in the literature these disturbances are considered the probable factor of initiation of the described aneurysm.

[Two cases of colloid cysts of the third ventricle with nasal rhinorrhea]. / Dwa przypadki torbieli koloidowej III komory z plynotokiem przez nos.

The authors present 2 cases of tumours of third ventricle with intracranial hypertension and cerebrospinal fluid rhinorrhea. The cause of the CSF rhinorrhea most often was thinning of lamina ethmoidalis and dura mater and rarely intussusception of arachnoidea into the intrasellar space in patients with oval orifice for the stalk of pituitary body due to prolonged intracranial hypertension. Efficacious treatment of CSF rhinorrhea comprises not only removing of the tumor but also introducing the valve and in some cases tightening of the base of the anterior and middle fossa.

[A case of lumbar glomeruloma]. / Przypadek klebczaka okolicy ledzwiowej.

A case of the patient with atypical localization of glomus tumor in lumbar region is reported. Trigger pain of unusual intensity resistant to pharmacological treatment ceased immediately after the operation.