Dolichoectasia of Vertebrobasilar Arteries as a Cause of Hydrocephalus and Ischemic Cerebral Stroke.

INTRODUCTION: Dolichoectasia of vertebrobasilar artery is a rare vasculopathy, which is characterized by ectasia, elongation, and tortuosity of the basilar artery. CASE DESCRIPTION: A 85-year-old man was referred to the Clinic of Neurology with sudden-onset coma. A brain computed tomography scan showed remarkable fusiform dilatation with elongation of basilar artery, with compressive effect on brain stem. Autopsy confirmed existence of vertebrobasilar dolichoectasia, with organized old thrombus and partially with recent occlusive thrombosis. The histology and immunohistochemical staining were showing a loss of the elastic tissue with significant fibrosis in the tunica media and small groups of foam macrophages and cholesterol crystals in atherosclerotic plaque. CONCLUSIONS: We presented a case of dolichoectasia of vertebrobasilar artery with an obstructive hydrocephalus, due to direct compression on pons and midbrain, which is an extremely rare entity. This case had been analyzed during the patient's life through clinical, laboratory, and radiology examinations and after he died through autopsy.

Morphometric analysis of the stylohyoid complex.

PURPOSE: Stylohyoid complex is anatomical structure predisposed to numerous individual variations. These may result in its extreme elongation, medial deviation and finally Eagle's syndrome occurrence. The aim of this study was to measure the length, angulation, evaluate morphological variations of stylohyoid complex by computed tomography and, subsequently, relate obtained data to the gender and the age of the evaluated cases. MATERIALS AND METHODS: The material included CT scans of stylohyoid complexes of 282 individuals. The entire length, maximal thickness, and angulation of the stylohyoid complexes in the coronal, transverse, and sagittal planes were measured. RESULTS: According to their morphology, orientation and length, stylohyoid complexes were classified into six morphological types. Elongated, bent, segmented, and segmented with attached stylohyoid ligament for the lesser horns of the hyoid bone stylohyoid complex types were characterized by significantly greater length, while pseudoarticulated type was characterized by significantly lower length in relation to normal stylohyoid complex type. The elongated type was additionally significantly thicker and with significantly lower value of medial angle in transverse plain than the normal stylohyoid complex type. Elongated, bent, and segmented types were significantly more frequent in males than in females. Furthermore, the frequency of the elongated stylohyoid complex type increased, whereas normal and pseudoarticulated types decreased with age. CONCLUSIONS: In conclusion, elongated and more medially deviated stylohyoid complexes are more frequent in males than in females. Their more frequent presence in the older age groups indirectly connects this phenomenon with the aging process.

Results of open tibial fracture treatment using external fixation.

Introduction: Open lower leg fractures are the most common open fractures of the locomotor system and their treatment is associated with a number of complications. Objective: The aim of the paper was to present the results of the treatment of 68 patients with open lower leg fractures, as well as the complications that accompany the treatment of these fractures. Methods: In the analyzed group, there were 45 (66.18%) men and 23 (33.82%) women. The majority of patients ­ 33 (48.53%) of them ­ were injured in motor vehicle accidents, whereas 24 (35.29%) patients sustained injuries due to falls from heights. In two (2.94%) patients the cause of open tibial fractures was gunshot injuries. In the analyzed group, there were 18 (26.47%) type I open fractures, 21 (30.88%) type II open fractures, 19 (27.94%) type IIIA open fractures, seven (10.29%) type IIIB open fractures, and three (4.41%) type IIIC open fractures. Results: The tibial shaft fracture healed without serious complications in 50 (73.53%) patients, whereas in 18 (26.47%) patients we observed some complications. Nonunion was found in 10 (14.71%) patients, osteitis in four (5.88), malunion in two (2.94%) patients. Milder complications such as soft tissue pin tract infection developed in 13 (19.12%) patients, infection of the open fracture wound soft tissue was observed in four (5.88%) patients. Conclusion: Basic principles in the treatment of open lower leg fractures in this study are thorough primary open fracture wound treatment followed by the delayed wound closure, stable fracture fixation using unilateral external skeletal device, proper antibiotic treatment and tetanus prophylaxis. The results correlate with similar studies.

Apparent diffusion coefficient in the evaluation of cerebral gliomas malignancy.

BACKGROUND/AIM: Magnetic resonance imaging (MRI) is a key modality not only for lesion diagnosis, but also to evaluate the extension, type and grade of the tumor. Advanced MRI techniques provide physiologic information that complements the anatomic information available from conventional MRI. The aim of this study was to determine whether there is a correlation between apparent diffusion coefficient (ADC) maps of intracranial glial tumors and histopathologic findings and whether ADCs can reliably distinguish low-grade from high-grade gliomas. METHODS: This retrospective study included 25 patients with MRI examination up to seven days before surgery, according to the standard protocol with the following sequences: T1WI, T2WI, FLAIR, DWI and post contrast T1WI. Data obtained from DW MRI were presented by measuring the value of ADC. The ADC map was determined by utilizing Diffusion-Perfusion (DP) Tools software. All the patients underwent surgical resection of the tumor. Histological diagnosis of tumors was determined according to the World Health Organization (WHO) classification. The ADC values were compared with the histopathologic findings according to the WHO criteria. RESULTS: The ADC values of astrocytomas grades I (0.000614 +/- 0.000032 mm2/s) were significantly higher (< 0.001) than the ADC values of anaplastic astrocytomas (0.000436 +/- 0.000016 mm2/s) and the ADC values of glioblastomas multiforme (0.000070 +/- 0.000008 mm2/s). The ADC values of astrocytomas grades II (0.000530 +/- 0.000114 mm2/s) were significantly higher (< 0.001) than the ADC values of anaplastic astrocytomas (0.000436 +/- 0.000016 mm2/s) and glioblastomas multiforme (0.000070 +/- 0.000008 mm2/s). The ADC values of anaplastic astrocy-omas (0.000436 +/- 0.000016 mm2/s) were significantly higher (< 0.001) than the ADC values of glioblastomas multiforme (0.000070 +/- 0.000008 mm2/s). The ADC values in the cystic part of the tumor for astrocytomas grades I (0.000775 +/- 0.000023 mm2/s) were significantly higher (< 0.001) than the ADC values of anaplastic astrocytomas (0.000119 +/- 0.000246 mm2/s) and glioblastomas multiforme (0.000076 +/- 0.000004 mm2/s). The ADC values astrocytomas grades II (0.000511 +/- 0.000421 mm2/s) were significantly higher (< 0.001) than the ADC values of glioblastomas multiforme (0.000076 +/- 0.000004 mm2/s). CONCLUSION: DWI with calculation of ADC maps can be regarded as a reliable useful diagnostic tool, which indirectly reflects the proliferation and malignancy of gliomas. The ADCs maps can both predict the results of histopathological tumor and distinguish between low- and high-grade gliomas, and provide significant information for presurgical planning, treatment and prognosis for patients with high-grade astrocytomas.

Analysis of the symmetric configuration of the circle of Willis in a series of autopsied corpses.

INTRODUCTION: The forming of the blood vessels network configuration at the base of the brain and interconnecting of blood vessels during the embryogenesis is directly related to the phylogenetic development of the brain and brain structures. A blood vessel configuration at the brain base, in the form of a ring or a hexagon, stands in direct relation to the perfusion needs of certain parts of the brain during its primary differentiation. The aim of this paper was to determine the incidence of certain blood vessel configurations at the base of the brain and understanding their symmetry or asymmetry. METHODS: Analysis of the blood vessels at the base of the brain was performed on the autopsied subjects. The object of observation was the anterior segment of the circle of Willis consisting of C1- a. carotis interna (ICA), above a. communicaus posterior (PcoA), the segment A1 a. cerebri anterior (ACA) from a. carotis interna bifurcation to the a. communicans anterior (AcoA) and a communicans anterior itself, as well as the posterior segment consisting of PcoA and the segment P1--a. cerebri posterior (PCA) from the a. basilaris bifurcation to the PcoA. For the purpose of grouping the findings, the four basic configuration types of the circle of Willis were identified based on its symmetry or asymmetry. Type-A (symmetric circle of Willis), type-B (asymmetric circle of Willis' due to the unilateral hypoplastic A1-ACA); type-C (symmetric circle of Willis with bilateral symmetric changes on PcoA) and type-D (asymmetric circle of Willis due to the asymmetric changes on PcoA). RESULTS: Autosy was performed on 56 corpses. A total of 41 (73.2%) subjects were recorded with a symmetric configuration of the circle of Willis', of which 27 (48.2%) subjects had type A and 14 (25%) type C. The asymmetric configuration was present in 15 (26.8%) subjects, of whom 9 (16%) had type B and 6 (10.8%) subjects, of whom 9 (16%) had type B and 6 (10.8%) type D. The symmetric Willis group (73.2%) did not have a homogeneous finding that would fit into the schematic presentation of the symmetric type A and type C. A total of 17 (30.4%) findings were classified in this group of the so-called conditionally symmetric configurations. In all the cases, type B (16%) had unilaterally reduced diameter A1 and hyperplastic AcoA. CONCLUSION: The presence of asymmetric Willis configuration in 26.8% of the cases, which makes up more than one fourth, indicates that the asymmetric configurations do not represent a pathological form of connecting the blood vessels at the base of the brain, but rather one aspect of its adaptation. The forming of the basic types of configurations of the circle of Willis is associated with a tendency toward certain types of hemodynamic disorders and more frequent pathological changes in places of reduced resistance.

Alternaria-Associated Fungus Ball of Orbit Nose and Paranasal Sinuses: Case Report of a Rare Clinical Entity.

Alternaria-associated fungus ball of maxillar, ethmoidal paranasal sinuses, nasal cavity and orbit with bone erosion is extremely rare. Till recently, only two cases of this infection in immune competitive patients have been reported. We are herein describing the case of immune-competent woman who suffered of nasal congestion for 10 years. Patient was treated for tumor-like lesion in right maxillar sinus, where propagation in right nose cavity, right ethmoidal cells and right orbita was present. The organism that was seen in surgical removal of fungal debris by histological study, in using mycological testing, was proven as Alternaria alternata. Combination of surgical intervention and treatment with itraconazole eradicated fungal infection, and the disease was not relapsed in follow-up period of 2 years.

Asymptomatic flow of Rosai-Dorfman disease.

INTRODUCTION: Sinus histiocytosis with massive lymphadenopathy is a rare benign self-limiting disease of unknown etiology. The salivary gland involvement, indicating the extranodal character of the disease, often presents a diagnostic dilemma requiring immunohistochemical staining of surgically removed tumor to confirm the diagnosis. CASE REPORT: We report a 43-year-old man presented with an asymptomatic mass in the left mandibular angle. On physical examination, the lesion was described as a painless, mobile, firm-elastic consistency nodule, which measured 4 x 3 cm in diameter, with normal overlying skin. A mass with the same characteristics, dimensions 2 x 2 cm, was also noted in the right parotid region. No other changes in regional lymph nodes were detected. On macroscopic examination the lesion was firm, multilobulated, yellowish and rounded, while on microscopic examination the lesion was composed almost entirely of polygonal histiocytes with abundant cytoplasm, emperipolesis, plasma cells arranged in sheets, and lymphocytes scattered or within clusters. The observed histiocytes were found to be CD68 and S100 protein positive. CONCLUSION: Rosai-Dorfman disease is a beningn and frequently overlooked clinical and pathological entity that may be misinterpreted as a neoplastic disease.

Second look procedure for large burn defect by banana peel pericranial flap based on one artery.

INTRODUCTION: Scalp and calvarial defects may result from trauma, thermal or electrical burns, resection of benign or malignant tumors, infections or radionecrosis. Reconstruction of large scalp defects is a demanding procedure. The reconstructive "ladder" are applicable to scalp and calvarial defects reconstruction. CASE OUTLINE: A 68-year-old female was admitted to our clinic due to the nine-day old scalp burn wound, incurred under unclear circumstances. Third degree burn wound affected the left frontal-parietal, temporal and part of the occipital region with carbonification of the whole left ear lobe.The treatment was carried out in two stages. Radical full thickness necrectomy of the scalp was performed, the defect margins were curetted to the active bleeding, and the ear lobe was amputated.The defect sized 23 x 15 cm was reconstructed using the"banana peel"transposition galea-cutaneous flap from the remainder of the scalp, which was based only on the right occipital artery.Two months after the surgery the appearance was satisfactory, and all wounds were healed. CONCLUSION: Designing of large-scale flaps is very hazardous, especially in elderly people. Scalp reconstruction based on one artery has to be planned in detail and performed when the possibility of complication is reduced to minimum. Our case report underlines possible reconstruction as delayed procedure even with the exposed bone (second look procedure), as well as the reconstruction of half scalp with the local flap based on one pericranial artery.

Bilateral giant angiomyolipomas revealed after massive retroperitoneal hemorrhage - A case report.

INTRODUCTION: Angiomyolipomas (AML) are benign neoplasms composed of fat, smooth muscle and thick-walled blood vessels in varying proportions. These tumors have a significant female predominance. CASE REPORT: We reported a 61-year-old man with spontaneous rupture of AML. Computerized tomography revealed a change in morphology of both kidneys. Multiple lesions of fat density with dilated blood vessels were found in the left kidney. The right retroperitoneum was obliterated with a giant heterogeneous mass originating from the right kidney with a massive hemorrhage, active extravasations, compression of inferior the vena cava and intraperitoneal collections. After radical nephrectomy, histological examination revealed that the tumor was composed of relative proportions of fat, smooth muscle and blood vessels. We incidentally found small renal adenoma. CONCLUSION: The true nature of AML is unclear, but they are usually classified as hamartomas. Angiomyolipomas are generally benign lesions, although the epithelioid angiomyolipoma, a subtype that occurs in about 3% of cases, can behavior aggressively.

De novo mutation in the NOTCH3 gene causing CADASIL.

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy (CADASIL) is one of the most common hereditary forms of stroke, and migraine with aura, mood disorders and dementia. CADASIL is caused by mutations of the NOTCH3 gene. This mutation is inherited as an autosomal dominant trait. Most individuals with CADASIL have a parent with the disorder. In extremely rare cases, CADASIL may occur due to a spontaneous genetic mutation that occurs for unknown reasons (de novo mutation). We report a new case of patient with de novo mutation of the NOTCH3 gene and a condition strongly suggestive of CADASIL (migraine, stroke, and white matter abnormalities), except that this patient did not have any first-degree relatives with similar symptoms.

Similarities and dissimilarities of the blood supplies of the human sciatic, tibial, and common peroneal nerves.

The aim was to investigate the arterial supply of the sciatic, tibial, and common peroneal nerves. Thirty-six lower limbs of 18 human fetuses were studied. The fetuses had been fixed in buffered formalin and the blood vessels injected with barium sulfate. Fetal age ranged from 12 to 28 weeks of gestation. Microdissection of the fetal lower extremities was done under ×5 magnifying lenses. The sciatic nerves of 10 lower extremities were dissected and excised and radiographs taken. The extraneural arterial chain of the sciatic nerve was composed of 2-6 arterial branches of the inferior gluteal artery, the medial circumflex femoral artery, the perforating arteries, and the popliteal artery. The extraneural arterial chain of tibial nerve was composed of 2-5 arteries, which were branches of the popliteal, the peroneal, and the posterior tibial arteries. Radiographs showed the presence of complete intraneural arterial chains in the sciatic and tibial nerves, formed from anastomosing vessels. Dissection showed that, in 97.2% of the specimens, the common peroneal nerve was supplied only by one popliteal artery branch, the presence of which was confirmed radiologically. The sciatic and tibial nerves are supplied by numerous arterial branches of different origins, which provide for collateral circulation. In contrast, the common peroneal nerve is most frequently supplied only by one elongated longitudinal blood vessel, a branch of the popliteal artery. Such a vascular arrangement may make the common peroneal nerve less resistant to stretching and compression.

Association of stress hyperglycemia and atrial fibrillation in myocardial infarction.

BACKGROUND: Stress hyperglycemia has an untoward effect on prognosis in acute myocardial infarction (AMI). Evidence on the interrelationship between stress hyperglycemia and atrial fibrillation (AF) in AMI is sparse. We hypothesized that stress hyperglycemia and AF, both being markers of worse in-hospital prognosis, may be interrelated and we therefore analyzed the relationship between stress hyperglycemia and AF in AMI. PATIENTS AND METHODS: The study was a retrospective analysis of 543 patients with AMI. The average age was 63.8 +/- 10.6 years and 54.9% were male. RESULTS: AF was more prevalent in 200 AMI patients with admission glucose >or= 8.0 mmol/l (15.00%) than in 343 patients with admission glucose < 8 mmol/l (7.87%), Pearson's chi-squared P = 0.010, OR 2.07 (95% CI 1.180-3.637). In AMI patients with neither stress hyperglycemia nor AF, in-hospital mortality was 1.67%; in patients with stress hyperglycemia without AF, the mortality was 3.85%. In patients with AF without stress hyperglycemia, mortality was high at 13.04%, and in patients with both stress hyperglycemia and AF it was extremely high at 24.14%. Hyperglycemia (r = 0.1680, P = 0.0472) but not AF correlated with the size of the AMI. Compared with an AF prevalence of 8.28% in the normoglycemic group, AF was found more often (14.65%) in a group with diabetes mellitus (DM), Pearson's chi-squared P = 0.02, OR = 2.04 (95% CI 1.06-3.93). There was no significant difference in the occurrence of AF between patients with previously diagnosed DM and those with new-onset DM (Fisher's exact test P = 0.34). CONCLUSIONS: Stress hyperglycemia is associated with increased prevalence of AF in AMI. Patients with both stress hyperglycemia at admission (>or= 8.0 mmol/l) and AF had almost 14.5 times higher in-hospital mortality than patients who had neither stress hyperglycemia nor AF. Stress hyperglycemia was an independent predictor of the in-hospital mortality in multivariate regression analysis, but AF was not.

[The relationship between clinical findings and therapeutic approach in the treatment of fractured frontal sinus walls].

INTRODUCTION: The incidence of fractured frontal sinus walls vary from 6% to 12% of all craniofacial injuries. OBJECTIVE: Estimated relation between clinical findings and performed therapeutic procedures in treating fractured frontal sinus walls. To estimate success in performed therapeutic procedures, according to the incidence of postoperative complications and the integrity of injured regions from the functional and esthetical aspect. METHOD: We analyzed, by retrospective clinical investigation, 19 patients with fractured frontal sinus walls and dislocated fragments, treated at the Department for Maxillofacial Surgery, Clinic of Dentistry in Nis, in the period March 1995-March 2006. The success of therapy was estimated based on the incidence and type of complications and esthetical results in relation to preoperative findings. RESULTS: Predominant etiological factor in fractures of frontal sinus walls is trauma sustained in traffic accidents, which occurred in 52.6% of patients in our investigation. In clinical findings, the impression was the predominant sign, present in 16 patients. In 6 cases soft tissue access through already present lacerations or their extensions was employed, in 4 cases it was done by supraciliary access and in 9 by bicoronal access. As a therapeutic measure, drainage was performed in 5 cases, cranialisation in one, ostheoneogenetic access in 11 cases and a simple reposition of fragments in 2 patients with fractured frontal sinus walls. Infection as a complication was absent. All patients were satisfied with postoperative esthetical appearance of the injured region. CONCLUSION: The infection, the lacerations and the direction of fractured lines are dominant factors in the determination of therapeutic procedures used to treat fractured frontal sinus walls. This will result in the low incidence of infection as a postoperative complication and in patient's satisfaction with postoperative esthetical result of the injured region.