The role of nitric oxide in resolution of vasospasam corresponding with cerebral vasospasms after subarachnoid haemorrhage: animal model.

Intracranial aneurysmal rupture is the common cause of spontaneous subarachnoid haemorrhage (SAH). This haemorrhage is typically diffuse and located in extracerebral subarachnoid space in which main cerebral arterial branches are situated. The intimate and long-term contact of arterial wall and blood products in the closed space causes the cerebral vasospasm as a serious and frequent complication of SAH. It is connected with significant morbidity and mortality due to developing of focal cerebral ischaemia and subsequently cerebral infarction. The aim of our experimental research was to create the animal model of vasospasm using the femoral artery due to examination of reduced basic dilator activity cause in arterial wall after SAH. The important characteristic of major cerebral arteries is their localization in the closed subarachnoid space which enables their to have long-term contact with blood products after haemorrhage. Thirty six femoral arteries (FA) of eighteen female rats weighing about 300 g were used. In vivo, femoral arteries are microsurgically prepared in both inguinal regions in all rats. Eighteen arteries were encompassed by polytetrafluoroethylene (PTFE) material forming closed tube and autologous blood was injected in the tube around the arterial wall. Additional eighteen arteries, as a control group, were also put in PTFE tube but without exposing to the blood. All rats are left to live for eight days. Afterwards, rats were sacrificed and their arteries were in vitro examined including an isometric tension measurement and histological changes analysis. The tension was measured during application of vasoconstrictors and vasodilatators (nitric oxide, NO). FA exposed to periadventitial blood exhibit hyper reactivity to constrictors (KCl, phenylephrine, acetylcholine) compared to control group. It was also found that NO donor (sodium nitroprusside) diminished arterial spasm induced by blood and vasoconstrictors. In conclusion, FA can be used as a model for vasospasm correlating with cerebral vasospasm after SAH and therefore this model can be utilized in future experiments assessing cerebral vasospasm. The reduced basic dilator activity of spastic femoral artery is caused by an absence of gaseous messenger NO next to the arteries but not by diminished response vasculature to NO. Absence of NO after SAH probably causes the reduced basic dilator activity of cerebral arteries as well. The guanylate-cyclase level in the arterial wall is consequently reduced after SAH primary due to absence of NO but not due to direct reduction of enzyme activities caused by process of blood degradation inside of subarachnoid space.

Biocompatibility of Plastic Clip in Neurocranium - Experimental Study on Dogs.

AIM: A potential advantage of the use of the plastic clips in neurosurgery is their property of causing fewer artifacts than titanium clips as assessed by computed tomography and magnetic resonance scans. The biocompatibility of plastic clips was demonstrated in the peritoneal cavity, but their behavior in the neurocranium is not known. MATERIAL AND METHODS: Twelve aggressive stray dogs designated for euthanasia were taken for this experimental study. The animals were divided into two groups. In all cases, after anesthesia, a craniotomy was performed, and after opening the dura, a proximal part titanium clip was placed on the isolated superficial Sylvian vein (a permanent Yasargil FT 746 T clip at a 90° angle, while a plastic Hem-o-lok clip ML was placed on another part of the vein). The first group of animals was sacrificed on the 7 < sup > th < /sup > postoperative day and the second group on the 60 < sup > th < /sup > postoperative day. Samples of tissue around the clips were taken for a histopathological evaluation. RESULTS: The plastic clip caused a more intensive tissue reaction than the titanium clip on the 7 < sup > th < /sup > postoperative day, but there was no statistical difference. Even on the 60 < sup > th < /sup > postoperative day there was no significant difference in tissue reaction between the titanium and plastic clips. CONCLUSION: These preliminary results confirm the possibility for the use of plastic clips in neurosurgery. Before their use in human neurosurgery, further studies are needed to investigate the long-term effects of the presence of plastic clips in the neurocranium, as well as studies of the aneurysmal model.

Attention and executive functions in microsurgically treated patients after subarachnoid hemorrhage.

OBJECTIVES: This research aimed to assess attention and executive functions in subarachnoid hemorrhage (SAH) patients. METHODS: The prospective, controlled, longitudinal study was conducted. There were two groups of patients (SAH and lumbar microdiscectomy groups), and all of them were operated on by a single neurosurgeon (KD) in the same institution. Preoperatively, SAH patients were in the Hunt-Hess Grade I and II. They did not develop any focal neurological deficit or hydrocephalus postoperatively. The patients were tested in 2-time points: 15 and 45 days after microsurgery with a battery of tests and questioners consisting of the Trail Making Test, the Sustained Attention to Response Task, the Hayling Sentence Completion Test, The Attention/Concentration test of Attention, the Wechsler Adult Intelligence Scale (verbal part). Results between groups were compared (sex, age; years of education and verbal IQ). RESULTS: It was found the presence of lower attention and executive function test scores in the SAH group of patients with a trend of improving during the time. CONCLUSION: The detailed neuropsychological assessment of operated patients who sustained SAH and were without the focal neurological deficit postoperatively, showed declination in their attention and executive function with a trend of cognitive recovery as time passes by.

Everyday memory in microsurgically treated patients after subarachnoid hemorrhage.

BACKGROUND: Memory declines measured by traditional tests in patients after subarachnoid hemorrhage (SAH) are well documented. Classic examinations of memory problems sometimes do not significantly correlate with memory functions in everyday life. The objective of the study was to assess the specific type of everyday memory loss in patients after microsurgical treatment of ruptured intracranial aneurysm causing SAH. METHODS: The prospective controlled, randomized study was conducted using the specific tests for everyday memory measure with high ecological validity. All patients were operated on by the same neurosurgeon (KD). Preoperatively, patients were in a good grade (Hunt-Hess I or II), with no neurological deficit and no hydrocephalus postoperatively. Patients were tested at two phases: 15 and 45 days after microsurgery with the Rivermead behavioral memory test (RBMT) and the cognitive failure questionnaire (CFQ). RESULTS: We compared the results of the tests administered in subjects that underwent microdiscectomy surgery for SAH to a control group that underwent surgery for lumbar disc herniation (DH). CONCLUSION: Neuropsychological assessment of operated patients who sustained SAH showed a decline, compared to the DH group, in everyday memory function. Also, we found failures in perception and motor function in operated SAH patients with a trend of cognitive recovery as time progresses.

Low back and lumbar radicular syndrome: comparative study of the operative and non-operative treatment.

AIM: To compare the effectiveness of the discectomy and conservative treatment in patients with disc related low back and lumbar radicular syndrome. METHODS: We performed retrospective-prospective cohort study enrolling 100 patients. According to our extended criteria all of them had operative indications. We operated 50 patients, 50 patients refused operation and they were treated non-operatively. The following measures of outcome were used: Sciatica Bothersomeness Index, leg and back pain depending on the activity, Lasègue test, contralateral Lasègue test, neurological deficit. Data were assessed at the beginning of the treatment and after 2 months, 7 months, and 18 months. RESULTS: Treatment results were in favor of surgery for majority of outcome measures as well as for all periods of assessment. After 18 months there was significant difference between operated and non-operated patients related to Sciatica Bothersomeness Index (p less than 0,05), Lasègue test (p=0,002), neurological deficit (p less than 0,05) and leg and back pain depending on the activity (p=0,009). There was no significant difference between the groups related to contralateral Lasègue test (p=0,206). CONCLUSION: We expended formerly accepted operative indications. There were better treatment results in the operated group of patients. A fast reduction of symptoms is the main advantage of the operative treatment strategy. Patients whose pain is controlled in a manner that is acceptable for them may decide to postpone surgery. Patients preference for the type of treatment is crucial for an ultimate surgical decision in cases without widespread neurologic deficits.

Giant craniopharyngioma: 9-year follow up after stereotactic Yttrium -90 instillation and microsurgical resection.

The primary goal in craniopharyngioma treatment is a gross total neurosurgical resection. This paper presents a case with good outcome following a gross total removal of giant juvenile craniopharyngioma. There is a strong relationship between surgical experience in treating these lesions and the probability of total tumor resection without significant morbidity and mortality. The discussion on usefulness of stereotactic instillation of radioactive Yttrium-90 in the tumor cyst and bilateral fronto-orbital microsurgical approach utilized in 12-year-old male patient was conducted. A detailed description of the operative procedure was provided with comparison to other approaches commonly used for giant craniopharingioma. The long term (9 years) and intensive follow up showed good outcome without tumor recurrence. The patient has been receiving lifelong hormones substitution.

Modified Lund concept versus cerebral perfusion pressure-targeted therapy: a randomised controlled study in patients with secondary brain ischaemia.

PURPOSE: Secondary brain ischaemia (SBI) usually develops after aneurysmal subarachnoid haemorrhage (SAH) and severe traumatic brain injury (TBI). Current approaches to managing these conditions are based either on intracranial pressure-targeted therapy (ICP-targeted) with cerebral microdialysis (CM) monitoring according to the modified Lund concept or cerebral perfusion pressure-targeted therapy (CPP-targeted). We present a prospective, randomised controlled study comparing relative effectiveness of the two management strategies. METHODS: Sixty comatose operated patients with SBI following aneurysmal SAH and severe TBI were randomised into ICP-targeted therapy with CM monitoring and CPP-targeted therapy groups. Mortality rates in both groups were calculated and tissue biochemical signs of cerebral ischaemia were analysed using CM. Measured CM data were related to outcome (Glasgow Outcome Scale [GOS] score 1, 2 and 3 for poor outcome or GOS score 4 and 5 for good outcome). RESULTS: Patients treated with ICP-targeted therapy with CM monitoring had significantly lower mortality rate as compared with those treated with CPP-targeted therapy (P=0.03). Patients monitored with CM who had poor outcome had lower mean values of glucose and higher mean values of glycerol and lactate/pyruvate ratio as compared with those who had good outcome (glucose: P=0.003; glycerol: P=0.02; lactate/pyruvate ratio: P=0.01). There was no difference in the mortality outcome between aneurysmal SAH and severe TBI in the two groups (P=0.28 for ICP-targeted therapy with CM monitoring, P=0.36 for CPP-targeted therapy). Also, there were no differences in the CM values between patients with aneurysmal SAH and severe TBI who underwent ICP-targeted therapy (glucose: P=0.23; glycerol: P=0.41; lactate/pyruvate ratio: P=0.40). CONCLUSION: The modified Lund concept, directed at bedside real-time monitoring of brain biochemistry by CM showed better results compared to CPP-targeted therapy in the treatment of comatose patients sustaining SBI after aneurysmal SAH and severe TBI.

Cerebral microdialysis: perioperative monitoring and treatment of severe neurosurgical patient.

The early signs of brain ischemia are key indicators of secondary brain injury and their recognition on time can ultimately save life. Direct recording of cerebral ischemia is possible using the method of cerebral microdialysis (CM). This paper presents results of the five-year experience in applying this method at University Department of Neurosurgery, Sarajevo University Clinical Center in Sarajevo. In this observational prospective clinical study, the treatment and outcome of 51 patients with subarachnoid hemorrhage (SAH) and traumatic intracranial hemorrhage (tICH) undergoing neurosurgery and consequently treated conservatively at Neurosurgical Intensive Care Unit (NICU) were analyzed. All patients were followed up by unified monitoring at NICU and additionally by the CM method. Between December 2006 and September 2010, CM monitoring was performed in 51 patients: 18 patients with SAH and 33 patients with tICH. In all patients, samples were obtained on 367 occasions, yielding a total of 3314 samples for biochemical parameters (mean 64.98 per patient, range 42-114 samples). Positive correlation was found between glucose level and outcome at one-year follow up (when glucose level was lower, the patient Glasgow Outcome Scale (GOS) score was worse). The correlation coefficient for glycerol was negative (r=-0.81), and so was for the lactate/pyruvate ratio. There was a significant difference in patient outcome in favor of the group of patients monitored by use of CM in terms of poor and good outcome graded according to GOS score 12 months after the injury compared with the group of patients not monitored with CM (P<0.028). According to our experience, we believe that CM enables early initiation of appropriate therapeutic strategies to overcome cerebral ischemia and secondary brain damage, eventually leading to better patient outcome.

Management of a comatose patient with multiple intracranial aneurysms--lessons learned.

The perioperative management of a deeply comatose patient (Glasgow Coma Score, GCS 5) following a spontaneous subarachnoid hemorrhage is presented. Six intracranial aneurysms of the anterior circulation were discovered at operation, contrary to angiographic findings. These were successfully clipped by the author (KD). Postoperatively, the patient's cerebral energy metabolism was monitored by bedside cerebral microdialysis in real time. The ICP (volume)-targeted therapy (Lund concept) was utilised in accordance with findings of intrinsic brain biochemistry. Three-month follow-up showed excellent outcome (Glasgow Outcome Score, GOS 5).

Transmandibular approach to the malignant neoplasms of the mouth base, tongue root and oropharynx.

Tumors of the mouth basis, tongue root and oropharynx present a challenge for surgical treatment. High recurrence rates, poor survival, and significant postoperative alterations in speech and swallowing function are common experiences for patients with malignancies in these anatomic sites. This paper reviews the evaluation of displayed patients: pathologic features, surgical approaches and postoperative complications reported in recent managing patients with these neoplasms. A modification of usual surgical techniques has been used by the author to treat 30 tumors in this region and it is presented in this paper. Out of the 30 tumors, 4 were benign lesions and 26 were malignant neoplasms. Transmandibular approach was the method of choice. The wide field of access offers a lot of advantages: wide direct and indirect visualization, better manipulation, and good control of bleeding and light insertion of free and related composites used in primary reconstruction of postoperative defects.

Pineal region tumors--neurosurgical review.

The treatment for the pineal region tumors depends on tumor histology. Nowadays, germinomas can be cured by radiotherapy and chemotherapy without surgical resection but the other pineal region tumors should be primary treated by surgery. Two microsurgical approaches, the infratentorial supracerebellar and the occipital transtentorial, are accepted as the main standard accesses to the pineal region. For benign pineal tumors (pineocytoma, meningioma, mature teratomas, symptomatic pineal cysts, etc.) radical surgical resection can be curative. For malignant tumors radical surgical resection is not an objective. Serum and CSF markers contribute to the diagnosis of pineal parenchymal tumors. b-HCG is mainly positive in choriocarcinomas, embryonal carcinomas and mixed germ cell tumors and AFP is expressed by yolk sac tumors, embryonic carcinomas, immature teratomas and mixed germ cell tumors, b-HCG is usually low in germinomas which are often positive for PLAP on immunohistochemistry. Fifty-one pineal region tumors were surgically treated by senior author (NdT). Only 17 of them were the neoplasms originating from pineal body (pineal tumors). In conclusion it can be stressed that management of pineal tumors requires a multidisciplinary cooperation. With the exception of germinoma where only a biopsy is needed, the role of the surgeons still remains prominent as resection of pineal tumors requires high technical skill and experience as well as precise clinical judgment.

Severe traumatic brain injury: clinical research into management used in Bosnia-Herzegovina.

Trauma is number one cause of death in young population in Bosnia & Herzegovina. Department of Neurosurgery, Clinical Center Unversity of Sarajevo (CCUS), as a representative of Bosnia & Herzegovina, participated in the International Research-Treat-Traumatic brain injury project over a span of three years with the main objective to save the lives of patients sustained the traumatic brain injury (TBI) and to improve the quality of life of survivors through research in factors determining the outcome and through changing current clinical practices to provide better care. The scores used to measure the compliance to TBI guidelines at individual patient were developed and tested. The scores were successfully tested on all the patients entered into the database. The patients satisfying the selection criteria were only included into this study. The criteria of severe TBI were used according to the National Traumatic Coma Database established in the US: Glasgow Coma Scale (GCS) score of 8 or less following resuscitation, which may include endotracheal intubation; or GCS score deteriorating to 8 or less within 48 hours of injury. The implementation of Scientific Evidence Based Medicine procedures is followed by a research in efficacy of changed medical practice. This was facilitated by developing a guidelines compliance measurement tool, which evaluates how closely the guidelines are followed in the treatment of individual case. When evaluating the compliance and when discussing the guidelines implementation one of the major problems surfaced is lack of financial support. In the future, we should tend to establish the scientifically basis for dissemination of the Scientific Evidence Based knowledge to all Hospitals in Bosnia& Herzegovina which deal with severe TBI patients. The financial obstacles and misunderstanding could be overcome through creation of public awareness campaign. Reducing mortality of TBI patients, who are youngest and most active part of population, must be priority for our whole community.

[Subarachnoid hemorrhage: neurosurgical treatment modalities and etiological analysis]. / Subarahnoidalna hemoragija: Modaliteti neurohirurskog tretmana i analiza uzroka.

INTRODUCTION: The subarachnoid hemorrhage (SAH) is excess presence of blood in the subarachnoid space. The most frequent cause of SAH is cerebral aneurysm rupture and neurotrauma. The treatment strategy is specific for the different forms of SAH but all therapeutic options are based on the prevention of secondary ischemic brain injury generating after initial hemorrhage. OBJECTIVE: To point out the varieties of SAH etiology and different modalities of its treatment, especially presenting the aneurismal SAH. PATIENTS, METHODS AND RESULTS: The retrospective-prospective study was performed at the Department of Neurosurgery in Sarajevo (DNS). Over a span of two years, from January 1st 2003 to December 31st 2004, 161 patients with etiologically different SAH were treated. The higher number of patients was treated during 2004 compared with a year before, respectively 101 and 60 patients. Totally, eighty three patients were operated on (52%, 83/161). The surgery was performed in 60% (61/101) of cases in the second year but only 37% in the first year of study (22/60). The most frequent cause of SAH was the rupture of cerebral aneurysm (48%). The other causes were trauma (28%), brain arteriovenous malformations (4, 3%) and hypertension with atherosclerosis (1.8%). The cause is not found in 18% of cases (29/161) and this SAH category is defined as an idiopathic SAH. A total of 64 patients with ruptured aneurysms were operated on by the author (KD) during two years 17 in 2003, and 47 in 2004. DISCUSSION: We use the defined treatment protocols for the different forms of SAH which are based on current knowledge and particulars of locality aiming to decreased possibilities of repeated bleeding and delayed ischemia. The higher number of patients with aneurysmal SAH compared to those with traumatic SAH was admitted. The reason for this is the fact that systematic management of patients with cerebral aneurysms in Bosnia and Herzegovina has been doing exclusively in our Department. CONCLUSION: The number of treated patients with SAH, especially aneurismal SAH, is significantly increased in DNS during two last years. Our patients received the standard and current treatment which implies micro neurosurgery and conservative care at the separate Neurosurgical intensive care unit. The introduction of endovascular neurosurgery and developing of neuroanesthesia as a subdiscipline is expected to increase the quality of our serves.

[Craniofacial surgical treatment of the gigantic plasmacytoma of the skull base: case report]. / Kraniofacijalni hirurski tretman gigantskog plazmocitoma baze lobanje.

The complex craniofacial surgery of solitary bone plasmacytoma (SBP) of the skull base with excellent postoperative outcome was presented. This surgical management was result of the team approach and strategy of neurosurgeon (KD) and maxillofacial surgeon (TM). SBP of the skull base is very rare condition which should be treated by radical microsurgical resection and postoperative radiotherapy.

[Operative treatment of the vestibular schwannoma (acoustic neuroma): correlation between the microsurgical approach and cranial nerve lesion]. / Schwannoma vestibulare (neurinoma acustici)--operativni tretman: korelacija izmedu vrste mikroneurohirurskog pristupa i lezije kranijalnih nerava.

INTRODUCTION: Vestibular schwannoma (VS) is a benign tumour of cerebellopontine angle which total microsurgical resection is considered as a complex surgery. In Bosnia, VS microsurgical resection is performed occasionally and exclusively at the University Neurosurgical Depart. in Sarajevo, but radiosurgery of these tumours is completely absent. METHODS AND RESULTS: The role of microsurgery in resection of VS is being presented. Through analyzed series of operated patients (MJLink), we evaluated the correlation of VII and VIII nerves postoperative lesion with different operative approaches. House-Brackmann grading scale is used for VII nerve deficit appraisal. Current postoperative results of recognized experts are compared with our series and the similar morbidity rates are found. DISCUSSION: Microsurgery is a dominant and superior way of VS treatment. However, the most frequently used microsurgical approaches (retrosigmoid, translabyrinthine and extradural subtemporal) are still connected with certain morbidity rate, especially regarding the postoperative VII and VIII nerves lesion. CONCLUSION: Team approach, intraoperative cranial nerves monitoring and microsurgery with utilizing different surgical approaches optimize the outcome of VS neurosurgical treatment. In Bosnia, we are just stepping in the field of serious approach to this problem.

[Neurofibromatosis type 2--case report]. / Neurofibromatoza tip 2--prikaz slucaja.

Young female patient, diagnosed and treated by ophthalmologist and neurosurgeon, are presented. Through this case the basic characteristics of NF 2 are stressed. The different clinical implications and similarities of NF I as a neurocutaneous disorders and NF 2 as a central form of disease are pointed out.

[Early and urgent (micro)surgery of single and multiple intracranial aneurysms of anterior and posterior circulation and total mortality rate after operative and conservative treatment]. / Rana i hitna (mikro)hirurgija pojedinacnih i multiplih intrakranijalnih aneurizmi prednje i straznje cirkulacije i ukupni mortalitet poslije operativnog i konzervativnog tretmana.

INTRODUCTION: The early and urgent ruptured cerebral aneurysm microsurgery principle is being presented. In Bosnia, this principle was pioneered by author (KD) as a part of aneurysmal subarachnoid hemorrhage treatment. The main goal of this strategy was to prevent the rehemorrhage which mortality rate is up to 80%. PATIENTS AND RESULTS: A one-year (April 2003-April 2004) prospective study of 24 no selected patients with 33 anterior and posterior circulation aneurysms was conducted. Patients were operated on early (42%) and urgently (58%) regardless of their Hunt-Hess grade, age and vasospasm, but also localization, size and number of aneurysms. Twenty four ruptured aneurysms underwent the clip occlusion (100%). A total of 30 (91%) aneurysms were clipped with only one intraoperative rupture (3.3%). The overall mortality rate for anterior circulation aneurysms regardless of HH grade was 12.5%. All patients with HH gr I and II had excellent outcome (100%). Mortality rate of patients with HH gr III harboring anterior circulation aneurysms was 7.6%. The patients with HH gr IV and V died in 50% of cases despite surgical treatment. Multiple aneurysms increased mortality rate of operated patients. DISCUSSION: Ruptured aneurysm should be occluded immediately although the operative outcome of early and urgent surgery is worse than late surgery. Especially urgent surgery has bad outcome because it is mainly performed during cerebral vasospasm. But the overall outcome is the worst after utilizing the principle of late surgery. In one month period of time, no operated patients have 50% of chance to experience rehemorrhage (80% mortality rate), 36% of chance to develop symptomatic vasospasm with 7-15% mortality, and 20-50% possibility of occurring the hydrocephalus. According to recent studies, the overall mortality rate of untreated patients with aneurysmal SAH is over 50%. Mortality of surgically and conservatively treated patients is 20-30%. The survival rate of patients with HH gr IV and V who are exclusively treated by conservative therapy is only 10%. CONCLUSION: Early and urgent aneurysm microsurgery resulted in outcome improvement of operated patients up to 30% compared with expected outcome of patients without surgery. The justification for early and urgent aneurysm surgery was found in almost all patient groups, HH gr I&II patients had benefit in 23-30% of cases, HH gr IV&V had benefit in 20-40% and HH gr III with anterior circulation aneurysms had benefit in 15-20% of cases.