Intradural disc herniation at the T1-T2 level.

Intradural disc herniations comprise 0.26-0.30% of all herniated discs. Five percent are found in the thoracic, 3% in the cervical, and 92% in the lumbar region. Although intradural disc herniation may be suspected on preoperatively made CT scans, myelograms, and MRI scans, establishing the diagnosis prior to the surgery is difficult. We present a case of the patient with severe neurological deficits, caused by intradural thoracic disc herniation at T1-T2 interspace, which required surgical treatment. The symptoms were relieved immediately after surgery. This is the first description of an intradural disc herniation at that level.

The effect of implementation of guidelines for the management of severe head injury on patient treatment and outcome.

The authors retrospectively analysed two groups of consecutive patients who were similarly matched for brain injury severity. From a total of 39 severe head injury patients, 23 were treated according to the Guidelines for the Management of Severe Head Injury with intracranial pressure (ICP) monitoring ("Guidelines group"). Such an approach allowed the maintenance of ICP within normal values, especially in patients with intraventricular ICP monitoring allowing the release of cerebrospinal fluid (CSF) from the ventricular system. In the Guidelines group only two patients were administered barbiturates, after all other means of ICP lowering had been exhausted. The second group consisted of 16 patients who were not monitored for ICP ("non-Guidelines group"). In this group, management consisted of the prophylactic administration of barbiturates, high dose osmotic diuretics and hyperventilation usually at levels below 25 mm Hg. In the Guidelines group the mortality rate was 30% compared to 44% in the non-Guidelines group. Almost twice as many patients achieved a "favourable" (good recovery and moderate disability) outcome (49%) compared to the non-Guidelines treated patients (25%). Furthermore, there was a 32% decrease in severe neurological disabilities in those patients in the Guidelines group. It seems that the implementation of "Guidelines" in the treatment of severe head injury, based on the result of our clinical study, reduces death and disability rates in patients with severe head injury. The administration of therapy based on the "Guidelines principles" and monitoring of ICP, can minimise the application of those therapeutic modalities (barbiturate coma and prolonged hyperventilation) which, in addition to favourable effects, may also have harmful effects on patients with severe head injury.

[Recent modalities in the treatment of severe head injuries]. / Suvremeni principi u lijecenju teske ozljede mozga.

Intracranial pressure (ICP) monitoring represents today a critical point in the treatment of patients with severe head injuries. Medical therapy depends on the intracranial pressure level. The most important in therapy is to maintain the cerebral prefusion pressure at the level of 70 mmHg or above. The use of corticosteroids, prophylactic hyperventilation and prophylactic antiseizures drugs for the late posttraumatic seizures, is not recommended. High dose barbiturates can be used only in patients in whom other treatment modalities failed to decrease the raised intracranial pressure.

[Surgical treatment of lumbar disc hernias in athletes]. / Kirursko lijecenje lumbalne diskus hernije u sportasa.

In a 7-year period (1988-1995) a series of 55 patients was surgically treated at our Department for lumbar disk herniation following a certain sports activity, i.e. sports injury. The above number accounts for 2% of the total number of lumbar disk patients operated upon at our Department. The majority of patients in our series were amateur athletes, whereas a few of them were active or professional athletes. The most common cause of disk herniation among our patients was playing soccer (13 cases), which is followed by basketball (8), field athletics (7), tennis (6) and handball (4). In most cases our surgical method of choice was flavectomy (interlaminectomy). Most commonly seen intraoperative finding was intervertebral disk extrusion. In some athletes the onset of symptoms was due to a change of their usual sports activity, for example a tennis player who was injured in skiing. We believe that the onset of disk herniation in athletes is a consequence of numerous micro traumas of the intervertebral disk which are further compounded by the syndrome of overstraining. In the case of a positive indication, surgical treatment leads to a faster recovery in professional athletes.

Biomechanical analysis of the lumbar spine.

Physiological mobility of the lumbar spine, as a very important feature of this spinal segment biomechanics, has been defined, i.e., physiological instability has been proven on a sample of 35 fresh cadaveric human lumbar spine specimens which were tested in experimental conditions of both centric and eccentric static loads. The presence of physiological instability or physiological mobility of the lumbar spine in the form of so called relative oblique or tangential shifts was already been numerically quantified. The lumbar spine is continuously deformed through the action of static centric and eccentric loads ranging from 0-1000 N(ewton). Using a very sensitive method for detecting the lumbar spine deformities, based on measuring the angle of deflection of the laser beam on the screen, angular shifts of the spinal vertebrae can be defined within the sensitivity range of 0 degree to 1 degree (degree) with a standard error of +/-0.1 degree.

Cerebral venous angiomas: surgery as a mode of treatment for selected cases.

Eleven patients with venous angiomas, 6 males and 5 females ranging in age from 4 to 58, are presented. Four patients presented with intracerebral haematoma and 3 patients had associated cavernous angioma, respectively. Patients with intracerebral haematoma had signs and symptoms due to the localization of the haematoma. The other patients presented with headache, seizures, vertigo, ataxia and mental disturbances. Pre-operative diagnosis was based on computerized tomography, magnetic resonance imaging and cerebral angiography. In 9 surgical cases it was confirmed by histopathological examination of operative specimens. After establishing the type, size and location of the lesion decision for operative treatment was made in nine cases, in four of them because of the presence of an intracerebral haematoma and in 5 of them due to severe disability. Eight of these 9 patients recovered completely and one improved. No severe cerebral oedema was encountered after converging medullary veins were excised and main draining veins partially coagulated. In this small series we encountered an unexpectedly large percentage of venous angiomas causing intracerebral haemorrhage which are commonly considered more benign than other vascular malformations. After reviewing previously reported cases of venous angiomas causing intracerebral haemorrhage and severe neurological deficit we think that the term "benign" is worth reconsidering. We propose a thorough examination of each case of venous angioma and the operative treatment when appropriate taking into account patients state and location of angioma.

Cavernous angioma in cavernous sinus: case report of a rare location.

A case of cavernous angioma situated in the left cavernous sinus is presented. Occasional difficulties in accessing correct preoperative diagnosis with computerized tomography and angiography were encountered. Intraoperative relationships of neural and vascular structures of the cavernous sinus and tumor mass are described. An "en mass" extirpation was achieved without further neurological damage. A possible origin of cavernous angioma from the 6th cranial nerve is discussed.

Cranial vault and gigantic intracranial hydatid cyst in a young woman.

The case of a young woman (20 years) with a gigantic intracranial hydatid cyst (110 x 90 x 65 mm) is presented. The first manifestation was a grand mal seizure followed by symptoms of raised intracranial pressure. The origin of the cyst was in the diploe of the right cheek, frontal, temporal, and parietal bones. An osteoplastic craniotomy was performed, and more than 100 fertile daughter cysts were removed, together with the wall of the cyst. A modification in the standard operative procedure is proposed for gigantic cysts that emerge from the diploe of the cranial vault and extend intracranially. Therapy with dexamethasone and phenobarbital was instituted preoperatively and continued postoperatively. The 3-month follow-up showed no relapse.

Surgical approach to a large basilar artery bifurcation and upper basilar trunk aneurysm: case report.

The authors report a double aneurysm of the basilar artery located at the basilar artery bifurcation and upper basilar artery trunk between the posterior cerebral artery and the superior cerebellar artery. Clinical presentation, neuroradiological findings, surgical approach, and the operative technique are described and discussed.

Dysplastic granulo-molecular hypertrophy of the cerebellar cortex (L'hermitte-Duclos disease): report of three cases.

In this paper three cases with peculiar disease of the cerebellar cortex are presented. The disease is well known as L'hermitte-Duclos disease (LDD), but nowadays it is also called "dysplastic granulo-molecular hypertrophy of the cerebellar cortex" according to the modern theories of its etiology. Curious changes of the cerebellum in LDD are probably the result of a combination of delayed migration of Purkinje cells which occurs during the intrauterine period of cerebellar development, and of reactive hypertrophy of granular cells. Presented cases of L'hermitte-Duclos disease are, according to the literature, more or less typical by their clinical appearance and by their histological findings. Our electromicroscopical data support the findings of those authors who found only axodendritic sinapses on the hypertrophied ganglion cells, according to the idea that those cells are originally granular cells of the cerebellar cortex. CT scan of all our patients revealed parallel, worm-like, hyperdense formations in a hypodense process of the cerebellum. The same picture existed in some other described patients, but attention was paid to it. We consider this picture on the computed tomography to be characteristic, if not even patognomonic for the L'hermitte-Duclos disease, which gives us an entirely new scientific contribution in the process of the diagnosis of this peculiar disease.

[Computerized management of medical documentation for use in the surgery department: what, where and how?]. / Kompjutorizirano vodenje medicinske dokumentacije za potrebe kirurskog odjela: sto, gdje i kako?

Actual medical recording shows to be inadequate for daily use as well as for computer elaboration. The problem oriented medical records are being used worldwide. They consist of a problem list, data base, initial plan and course of cure. All the parts need to be acceded permanently and in the proper way. Computer elaboration of data enables the physical diminution and easier understanding of immense amount of data, especially if the input mode differs from the output one. The same relevance have what- and where-factors for any moment of usage. That depends on medical processing, so this article treats the problem of medical recording at a typical Department of Surgery.

Surgical approach to upper basilar trunk aneurysms: a case report.

The authors report on a double aneurysm of the basilar artery (BA), located at the basilar artery bifurcation and upper basilar-artery trunk Between the posterior cerebral artery (PCA) and superior cerebellar artery (SCA). The clinical presentation, neuroradiological findings, surgical approach and operative technique are described and discussed.

[Evaluation of the use of the CO2 laser in 134 patients with expansive processes in the central nervous system]. / Evaluacija primjene CO2--lasera na 134 bolesnika s ekspanzivnim procesima CNS-a.

The laser began to be used in neurosurgery towards the end of the 60s. The early experience of their clinical use did not promise much; but from the first half of the 70s with the improvement of the laser and the accumulation of laboratory and clinical experiences, the new technology began irrepressibly to spread throughout the world. Three lasers are in use today: CO2, ND.YAG and Argon laser. Each one of them, due to their different wave length and electromagnetic radiation, gave separate characteristics of employment, i.e., the interaction between the biologic tissues and the radiation is different. Depending upon the type of intraoperative needs we will choose one of the lasers. Presently the CO2-laser is the most used in neurosurgery due to its characteristics of low penetration into the tissue and the vaporization of the tissue which is exposed to the radiation. That is why such a laser (Sharplan 1060) has been acquired by our clinic. During one year we performed 134 operations due to expansive processes in the CNS with a partial or complete use of the laser during every phase of the operation. The accumulated experiences showed that the laser is a fairly useful new tool during the various surgical situations with a wide use of the everyday work of the neurosurgeon; with its implementation we have significantly improved the surgical technique in the tumors of the CNS, both in terms of radicality as well as in sparing the healthy tissue. We believe that the laser has an absolute indication in all the glioma tumors regardless of the localization, thereafter in all remaining tumors which are not extremely supplied by blood, while at the same time reducing the time needed for the surgical procedure. In time we spread the use of the laser on arteriovenous malformations as well, which, until now, has not been suggested in literature. Our results on 4 smaller superficial angiomas fully justified the use of a laser in such cases. But it also showed us that generally the laser is still a fairly unresearched surgical innovation, and that in the future wil bring about the wider implementation of this technology in the neurosurgical operating rooms. The final results of our operations and the experiences the other neurosurgical centers in the world that use the laser, regardless of which kind have justified investment of this new surgical technology.

[Glioblastoma of the cerebrum. Clinical course of the disease with special reference to tumor site]. / Das Glioblastom des Grosshirns. Klinischer Verlauf der Krankheit mit besonderer Rücksicht auf den Tumorsitz.

Glioblastomas are radiation-resistant tumours which react only rarely to radiotherapy. Radiotherapy was employed in such cases only where the condition was not clinically dramatic or terminal. A certain degree of improvement was noted in the patients who had been selected in this manner. Chemotherapy has not yielded any success to date.