SACRAL NEUROMODULATION IN TREATING OVERACTIVE BLADDER PATIENTS - FIRST-TIME APPLICATION IN CROATIA.

Sacral neuromodulation (SNM) is a safe, efficacious, and minimally invasive advanced therapy that involves electrical stimulation to sacral nerve root to modulate neural pathway. Indications for SNM include symptoms of overactive bladder (OAB), urinary incontinence, urinary retention, urgency and frequency and, regarding bowel dysfunction, fecal incontinence . In Europe and Canada, indication is also established for chronic constipation. The mechanism of action is still not fully elucidated and complete understanding is yet to be determined. It is proposed that SNM modulates neural circuits in both central and peripheral pathways, thus having an impact on the brain, as well as on the bladder-targeting neuronal activity. Another possible significant effect on irregular bladder activity is through inhibition of the bladder afferent pathways by stimulation of the pudendal nerve. Over the past two decades, with more than 300 000 treated patients, SNM has confirmed its efficacy to relieve refractory OAB symptoms, as well as urinary retention or fecal incontinence. First SNM applications in Croatia were uneventful and we are glad to offer our patients this novel therapy in the future.

Sexual Dysfunction in Croatian Patients with Obesity.

BACKGROUND: Patients with obesity may have symptoms of sexual dysfunction (SD). Little is known about these symptoms in obese patients in Croatia and the aim of this study was to explore them. SUBJECTS AND METHODS: This was a cross-sectional study carried out in tertiary healthcare centre at the Croatian Obesity Treatment Referral Center in University Hospital Center of Zagreb. 103 patients (72 female, 31 male, mean age 48.7±11.87 years, mean BMI 40.42) were included. SD symptoms were assessed using the internationally acclaimed questionnaire Arizona Sexual Experience Scale (ASEX), that was recently validated for Croatian language. Patients were also administered a questionnaire, prepared for this purpose, that enquired about their previous known chronic disorders. Statistical analyses included t-test, chi-squared test and bivariate Pearson's correlations. RESULTS: Average total response on the questionnaire was 12.4 (women 13.2, range 3-30; men 10.6, range from 5-19). A total score of 19 or more was present in 5 (4.8 %, range from 19-30, average 22.4; 1 man, 4 women), at least one question with a score 5 or greater on any item was found in 36 (34.9 %, 5 men, 31 women), while a score of 4 or more on three items was found in 20 patients (19.4 %, 2 men, 18 women). Overall median response was 3 (range 1-6). Women were found to have more pronounced symptoms of SD (p<0.05). The overall results on ASEX were found to be in significant correlation with regard to depression (r=0.22, p=0.03), as well as anxiety (r=0.2, p=0.04). Significant correlations were also found with regard to age (r=0.31), mobility (r=0.25), and pain/uneasiness (r=0.22) (p<0.05). CONCLUSIONS: This study brings valuable observations on the presence of SD symptoms in obese patients in Croatia. SD symptoms were found to be present in up to one-third of our patients, more pronounced in women, and in significant correlation with depression and anxiety. However, median response on ASEX suggests that overall SD symptoms in our group of patients are not that expressed.

Anxiety and Depression as Comorbidities of Multiple Sclerosis.

Multiple Sclerosis (MS), a chronic inflammatory neurodegenerative disease, is accompanied by a number of comorbidities. Among the psychiatric ones, depression and anxiety occupy a special place. It is estimated that the prevalence of anxiety in the MS population is 22.1% verus 13% in the general population; whereas the prevalence of anxiety levels, as determined by various questionnaires, reaches even 34.2%. Systematic literature reviews (SPL) show considerable data variations due to differences in study design, sample size, diagnostic criteria and extremely high heterogeneity (I2). Among the more conspicuous factors associated with anxiety disorder in MS are demographic factors (age and gender), nonsomatic depressive symptoms, higher levels of disability, immunotherapy treatments, MS type, and unemployment. Depression is the most common psychiatric commorbidity in MS and the lifetime risk of developing depression in MS patients is >50%. According to some research, the prevalence of depression in MS vary between 4.98% and 58.9%, with an average of 23.7% (I2=97.3%). Brain versus spinal cord lesions, as well as temporal lobe, fasciculus arcuatus, superior frontal and superior parietal lobe lesions in addition to the cerebral atrophy have been shown to be the anatomical predictors of depressive disorder in MS. Hyperactivity of the hypothalamic-pituitary-adrenal axis (HPA) and the consequent dexamethasone-insupressible hypercortisolemia, in addition to cytokine storm (IL-6, TNF-α, TGFß1, IFNγ/IL-4) present the endocrine and inflammatory basis for development of depression. Fatigue, insomnia, cognitive dysfunction, spasticity, neurogenic bladder, pain, and sexual dysfunction have shown to be additional precipitating factors in development of anxiety and depression in MS patients.

Comorbidities in Patients with Multiple Sclerosis in Croatia.

BACKGROUND: Comorbidities in multiple sclerosis (MS) have a big role in management of this chronic demyelinating neurodegenerative disorder. The aim of this study was to evaluate comorbidities in patients with MS in Croatia. SUBJECTS AND METHODS: This was a prospective cross-sectional study carried out in an out-patient setting at a tertiary healthcare centre over 10 months, which included 101 consecutive patients with MS (mean age 42.09 (range 19-77) years, 75 female, 26 male, EDSS score 3.1 (range 0.0-7.0)). The average duration of the disease was 13.5±7.487 (range 1-42) years. Thirty-six patients were treated with disease modifying therapies (DMTs). Information on comorbidities was obtained during the medical interview. Data was analysed using software package IBM Corp. Released 2015. IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp. RESULTS: 33% (n=34) patients did not have any comorbidities, and there is an equal number of patients (n=34, 33%) that just had one comorbidity. 17.6% (n=18) of patients had two comorbidities, and 15.7% (n=16) three or more comorbidities. The most frequent comorbidity was depression found in 25 (24.75%) patients (19 (18.8%) women, 6 (5.9%) men), followed by the hypertension in 12.87% (n=13). Hyperlipidemia and migraine were each found in 6.93% (n=7), and hypothyreosis and arrhythmia each in 3.96% (n=4). The number of the comorbidities was found to significantly increase with the duration of MS (r=0.232, p=0.037). Women were found to have significantly bigger numbers of comorbidities than men (t=-2.59, df=74, p<0.05). Older patients with MS were found to have significantly more comorbidities (r=0.335, p<0.01). CONCLUSIONS: This study gives insight into the presence of comorbidities in Croatian patients with MS. Connection with comorbidities must be considered when managing patients with MS. Any other comorbidity in MS may also affect the condition of the patient in general, and also their quality of life, and requires a tailored approach in management.

Sexual Dysfunction in Patients with Epilepsy.

BACKGROUND: Patients with epilepsy commonly report sexual dysfunction (SD) and reproductive difficulties. This study aimed to evaluate the relationship between epilepsy, antiepileptic drugs (AEDs) and SD, and its association with the quality of life and depressive symptoms. SUBJECTS AND METHODS: This was a prospective study carried out in a tertiary healthcare centre. SD was evaluated using the internationally acclaimed questionnaire Arizona Sexual Experiences Scale (ASEX) that was successfully translated into Croatian and validated for this purpose. Depressive symptoms and quality of life were evaluated using the Hamilton Rating Scale for Depression (HAM-D17) and Quality of life in epilepsy-31 inventory (QOLIE-31). RESULTS: Of 108 patients (68 (63 %) women, 40 (37 %) men, mean age 39.54±15.91 (range18-80) years) with epilepsy, 16 (14.8%) had focal, 38 (35.2%) generalized and 44 (40.7%) both types of epilepsy. Mean overall total score on the ASEX questionnaire was 11.94±5.61 (mean total score women 12.85±6.00, mean total score men 10.4±4.55), with 48 reporting that they had sexual activity in the past week. Nine (8.33%) patients (7 (6.48%) women, 2 (1.85%) men, mean age 47.66±19.33 (range 25-80) years) had a score 19 and above, 38 (35.18%) patients (27 (25%) women, 9 (8.33%) men, mean age 46.82±17.78 (range 19-80) years) individual score 5 and above on any one item, and 33 (30.55%) patients (26 (24.07%) women, 7 (6.48%) men, mean age 48.87±17.8 (range 19-80) years) had an individual score 4 and above on any three items. Significant correlations were found between SD and older age (p=0.001) and between more pronounced symptoms regarding SD on ASEX and female gender (p=0.000). There were no significant correlations between the type of epilepsy and SD, nor between the AEDs (old generation vs. modern) and SD. Significant correlations were found between the SD and more pronounced depressive symptoms (p=0.003) and between the SD and a lower quality of life (p=0.001). CONCLUSIONS: Results of our study suggest SD is experienced by around one-third of patients in our group, which is similar to the previous percentage of SD reported in the community sample. Women were found to experience more pronounced symptoms of SD on ASEX. Symptoms of SD were found to be significantly correlated with older age, female gender, lower quality of life and depressive symptoms, while no significant correlations were found with the type of epilepsy and the AEDs.

Depression and Quality of Life in Patients with Epilepsy - Single Centre Experience.

BACKGROUND: Patients with epilepsy commonly report depressive symptoms. The main aim of this study was to evaluate the relationship between epilepsy, antiepileptic drugs (AEDs) and depression. We also wanted to evaluate possible association between depressive symptofigms in patients with epilepsy with the quality of life (QoL). MATERIAL AND METHODS: This was a prospective cross-sectional study carried out at the tertiary teaching hospital (University Hospital Centre Zagreb, Croatia) with Ethics committee approval. Questionnaires evaluating depressive symptoms and QoL were administered to consecutive patients treated in the Referral Centre of the Ministry of Health of the Republic of Croatia for Epilepsy. Depressive symptoms were evaluated using Hamilton Rating Scale for Depression (HAM-D17). Quality of life was assessed using Quality of life in epilepsy-31 inventory (QOLIE-31). RESULTS: 108 patients (63% women, 37% men; mean age 39.54±15.91 years, range 18-80 years) with epilepsy were included. 14.8% of patients had focal, 35.2% generalised and 40.7% both types of epilepsy. Majority of patients (65.74%) were on two and more AEDs and quarter was on monotherapy (25%); 42% were on newer, 19% on older and 39% on both AEDs. Mean total score on HAM-D17 was 9.94±8.18 (men - mean total score 10.16±8.85, women - mean total score 9.81±7.84). There were no significant differences on HAM-D17 regarding gender and age. We didn't find statistically significant differences regarding AEDs (older vs. newer AEDs, or both types AEDs) and results on HAM-D17, nor between the type of epilepsy and results on HAM-D17. We found strong negative correlation between the higher QoL and HAM-D17 (p=0.000). CONCLUSIONS: Results of this study evaluating depressive symptoms in patients with epilepsy demonstrate that our patients mainly experience mild depressive symptoms, with no significant differences on HAM-D17 regarding gender and age. Patients with epilepsy with less pronounced depressive symptoms were found to have higher QoL. We did not find statistically significant differences regarding the type of epilepsy and results on HAM-D17, nor between the AEDs (older vs. newer AEDs, or both types AEDs) and results on HAM-D17.

QUALITY OF LIFE IN PATIENTS WITH EPILEPSY - SINGLE CENTRE EXPERIENCE.

A prospective study was carried out at the Zagreb University Hospital Centre to evaluate the relationship between epilepsy, antiepileptic drugs (AEDs) and quality of life (QoL) in patients with epilepsy (PE), and its association with depressive symptoms and sexual dysfunction (SD). QoL was assessed by use of the Quality of Life in Epilepsy-31 Inventory (QOLIE-31), SD by the Arizona Sexual Experiences Scale (ASEX), and depressive symptoms by the Hamilton Rating Scale for Depression (HAM-D17). The study included 108 PE (women 63% and men 37% men), mean age 39.54±15.91 years. Focal type epilepsy was diagnosed in 14.8%, generalized type in 35.2%, and both types were present in 40.7% of study patients. Drug-resistant epilepsy (DRE) was present in 44/108 and vagus nerve stimulation (VNS) was implanted in 27/44 patients. The mean response on QOLIE-31 was 62.88±17.21 with no significant differences according to gender, type of epilepsy, and age. A statistically significantly lower QoL was found in the 'Overall QoL' domain (35-55 vs. <35 age group). Patients taking both types of AEDs had a significantly lower QoL compared to those on newer types of AEDs. Higher QoL was associated with less pronounced depressive symptoms (p=0.000). Significant correlations were found between lower QoL and SD (p=0.001). In 27 patients with DRE having undergone VNS, a favorable effect of VNS implantation on the QoL and mood was observed as compared with 18 patients without VNS (p=0.041).

Outcomes following percutaneous tibial nerve stimulation (PTNS) treatment for neurogenic and idiopathic overactive bladder.

PURPOSE: Percutaneous tibial nerve stimulation is a minimally invasive neuromodulation technique for treating overactive bladder symptoms. The aim of this study was to assess safety, efficacy and impact on quality of life of percutaneous tibial nerve stimulation in neurological patients reporting overactive bladder symptoms. METHODS: In this retrospective evaluation over 18 months at a tertiary healthcare centre, patients finding first-line treatments for overactive bladder ineffective or intolerable underwent a standard 12-week course of percutaneous tibial nerve stimulation (Urgent PC, Uroplasty). Symptoms were evaluated using standardised International Consultation on Incontinence Questionnaires and bladder diaries. RESULTS: Of 74 patients (52 women, 22 men, mean age 56 years), 49 (66.2%) patients had neurological disorder [19 (25.7%) multiple sclerosis and 30 (40.5%) other neurological conditions] and 25 (33.8%) idiopathic overactive bladder. Overall for the entire cohort significant improvements were recorded after 12 weeks in the following domains: 24-h frequency on bladder diary - 1.67 (- 3.0, 0.33) (p = 0.002), number of incontinent episodes on bladder diary - 0.0 (- 1, 0) (p = 0.01), incontinence severity on bladder diary 0 (- 0.33, 0) (p = 0.007), OAB symptoms - 3 (- 11.5, 5) (p = 0.01), and quality of life - 16 (- 57, 6.5) (p = 0.004). There were no significant differences in outcomes between patients with idiopathic and neurogenic overactive bladder. CONCLUSIONS: Percutaneous tibial nerve stimulation appears to be a possible promising alternative for patients with neurological disorder reporting overactive bladder symptoms who find first-line treatments either ineffective or intolerable. However, a properly designed study is required to address safety and efficacy.

Management of idiopathic normal pressure hydrocephalus (iNPH) - a retrospective study.

Background: Normal pressure hydrocephalus (NPH) is communicating hydrocephalus characterised by normal intraventricular pressures. It presents with the triad of gait impairment, cognitive decline, and urinary incontinence. The term idiopathic normal pressure hydrocephalus (iNPH) is used in cases where the etiology is unknown. The aim of this study was to assess the prevalence and management of iNPH in our institution.Method: This was a retrospective study carried out at a tertiary health care center. Retrospective case series analysis was conducted using the existing electronic medical record data (2009-2017) on patients with hydrocephalus.Results: Forty-two (6.7%) patients with iNPH were identified, mean age 71.5 ± 8.8 years, 21 male (mean age 71.5 ± 9.3 years) and 21 female (mean age 71.5 ± 8.5 years). Ataxia was recorded in 39, symptoms of dementia in 31, and urinary incontinence in 29 patients. Forty patients were treated surgically by placing a ventriculoperitoneal (VP) shunt. One of the two patients treated by endoscopic third ventriculostomy (ETV) was subsequently treated by placing a VP shunt due to clinical deterioration. Significant improvements were noticed in cognitive and urinary symptoms, in the triad symptom sum score on the Japanese NPH scale, as well as in Evans' index and callosal angle (CA) on brain MRI (p < 0.05). Significant positive correlation was found between age and gait disturbance (Spearman's rho = 49.86% p = 0.0017), age and incontinence (Spearman's rho = 35.22%, p = 0.0351), age and triad symptom sum score (Spearman's rho = 44.67%, p = 0.0056), female gender and dementia (Spearman's rho = 34.94%, p = 0.0367), and among all three variables on the Japanese NPH scale (p < 0.0001).Conclusions: Treatment of iNPH with VP shunt showed significant improvement. A properly designed study is required to address the efficacy of ETV in the treatment of iNPH.

Lower Urinary Tract Symptoms in Croatian Obese Patients.

BACKGROUND: Patients with obesity may experience lower urinary tract symptoms (LUTS). Little is known about these symptoms in obese patients in Croatia. The aim of this study was to asses LUTS in this group of patients. SUBJECTS AND METHODS: This cross-sectional study was carried out in a tertiary healthcare centre. 111 participants were included (81 women and 30 men, age 23-78 years), with BMI>30 kg/m2. LUTS were evaluated using International consultation on incontinence questionnaires (ICIQ) investigating symptoms of overactive bladder (OAB) and urinary incontinence (UI): ICIQ-OAB and ICIQ-UI Short Form (SF). We evaluated also some of the questions on the EQ-5D-5L questionnaire. RESULTS: On ICIQ-OAB patients most often reported:UI (46.85% (N=52)), nocturia (42.34% (N=47)) and increased frequency of urination (34.23% (N=38)), and on ICIQ-UI SF: UI when coughing and sneezing (44.44% (N=32)), urgency UI (43.06% (N=31)) and UI during exercise/physical activity (22.22% (N=16)). Women were found to be more significantly affected by OAB symptoms (p<0.05). Significant correlations were found between the overall results on ICIQ-OAB and hypertension (r=0.32). CONCLUSIONS: The results of this study confirm that obese patients in Croatia experience LUTS as well. A higher incidence of LUTS was found among women and gender-independent among hypertensive obese patients.

Lower Urinary Tract Symptoms and Depression in Patients with Multiple Sclerosis.

BACKGROUND: Both depression and lower urinary tract symptoms (LUTS) may be present in patients with multiple sclerosis (MS). The objective of this study was to give an insight on depression and LUTS in patients with MS in Croatia and to determine the possible association between LUTS and depression in patients with MS. SUBJECTS AND METHODS: This was a prospective cross-sectional study conducted in a tertiary healthcare center in Croatia. Hundred and one consecutive patients with MS (75 female, 26 male, mean age 42.09 (range 19-77) years, mean Expanded Disability Status Scale (EDSS) score 3.1 (range 0.0-7.0)) participated in this study. We evaluated LUTS and related quality of life (QoL) using three International Consultation on Incontinence Questionnaires (ICIQ) enquiring about overactive bladder (ICIQ-OAB), urinary incontinence short form (ICIQ-UI SF) and lower urinary tract symptoms related quality of life (ICIQLUTS-QoL). ICIQ-OAB and ICIQLUTS-QoL were for this purpose with permission successfully translated and validated into Croatian, while ICIQ-UI SF was already previously validated for the Croatian language. Information regarding treatment for depression was obtained during the medical interview. Data were analyzed and interpreted using IBM SPSS Statistics for Windows, version 23.0 (IBM Corp., Armonk, N.Y., USA). RESULTS: 89.10% (N=90) patients with MS reported urgency with urge urinary incontinence (UUI) present in 70.29% (N=71). 81.18% (N=82) patients reported nocturia, and 90.09% (N=91) reported feeling drowsy or sleepy during the day due to bladder symptoms. Neurological deficit measured by EDSS was found to positively correlate with LUTS on all three questionnaires: ICIQ-OAB (r=0.390, p<0.05), ICIQ-UI SF (r=0.477, p<0.01) and ICIQ-LUTSQoL (r=0.317, p<0.05). 25 patients were in treatment for depression. There were no significant differences between female and male patients regarding treatment for depression (χ2=0.018, df=1, p>0.05). Results on ICIQ-UI SF showed that depressive patients had more pronounced LUTS (t=2.067, df=99, p<0.05), which was also true for the ICIQ-LUTSQoL (t=-2.193, df=99, p<0.05). Positive correlations were found between depression and LUTS on ICIQ-UI SF (r=0.203, p<0.05) and ICIQ-LUTSQoL (r=0.215, p<0.05). CONCLUSION: This study gives insight into the presence of depression and LUTS in Croatian patients with MS for which purpose ICIQ-OAB and ICIQ-LUTSQoL were with permission successfully translated and validated into Croatian. The connection between depression and LUTS must be considered when managing patients with MS.

Sexual Dysfunction and Depression in Patients with Multiple Sclerosis in Croatia.

BACKGROUND: Both depression and sexual dysfunction (SD) may be present in patients with multiple sclerosis (MS). OBJECTIVE: The aim of this study was to evaluate a possible association between SD and depression in patients with MS in Croatia. SUBJECTS AND METHODS: This was a prospective cross-sectional study carried out in tertiary healthcare centre over 10 months, which included 101 consecutive pwMS (mean age 42.09 (range 19-77) years, 75 female, 26 male, EDSS score 3.1 (range 0.0-7.0)). SD was assessed using Multiple Sclerosis Intimacy and Sexuality Questionnaire (MSISQ), which was for this purpose successfully translated and validated into Croatian. Information on treatment for depression was obtained during the medical interview. Data were analysed and interpreted using parametric statistics (IBM Corp. Released 2015. IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp.). RESULTS: 89 patients completed MSISQ. 25 patients were in treatment for depression, while 75 did not have depressive symptoms. On MSISQ 57 (43 women, 14 men) patients had responded with 'almost always/ always' suggestive of SD. Majority of patients reported primary SD, followed by secondary and tertiary SD. Most difficulties were found regarding difficulty in getting or keeping a satisfactory erection (34.6% (N=9) men), followed by 32.9% (N=27) reporting that it takes too long to orgasm or climax, followed with bladder or urinary symptoms in 32.6% (N=29). There were no significant differences between female and male patients regarding treatment for depression (χ2=0.018, df=1, p>0.05). Results in all subcategories on t-test found that depressive patients had higher impact on SD when compared to non-depressive: overall (t=-2.691, df=87, p<0.01) and in regards to primary (t=-2.086, df=87, p<0.05), secondary (t=-2.608, df=87, p<0.05) and tertiary (t=-2.460, df=86, p<0.05) SD. Depressive patients on 7 questions showed significantly (p<0.05) higher SD symptoms: Muscle tightness or spasms in my arms, legs, or body; Tremors or shaking in hands or body; Pain, burning, or discomfort in their body; Feeling less attractive; Fear of being rejected sexually because of MS; Lack of sexual interest or desire; Less intense or pleasurable orgasms or climaxes. CONCLUSIONS: This study gives insight into the presence of depression and SD in Croatian patients with MS for which purpose valid questionnaire for the assessment of SD in MS patients MSISQ was with permission successfully translated and validated into Croatian. The connection between depression and SD must be considered when managing patients with MS.

Endoscopic third ventriculostomy (ETV) for idiopathic normal pressure hydrocephalus (iNPH).

BACKGROUND: Idiopathic normal pressure hydrocephalus (iNPH) is a type of communicating hydrocephalus also known as non-obstructive hydrocephalus. This type of hydrocephalus is caused by impaired cerebrospinal fluid reabsorption without any obstruction in the ventricular system and is associated with normal cerebrospinal fluid pressure. It is characterised clinically by gait disturbance, cognitive dysfunction, and urinary incontinence (known as the Hakim-Adams triad). The exact cause of iNPH is unknown. It may be managed conservatively or treated surgically by inserting a ventriculoperitoneal (VP) or ventriculoatrial (VA) shunt. However, a substantial number of patients do not respond well to surgical treatment, complication rates are high and there is often a need for further surgery. Endoscopic third ventriculostomy (ETV) is an alternative surgical intervention. It has been suggested that ETV may lead to better outcomes, including fewer complications. OBJECTIVES: To determine the effectiveness of ETV for treatment of patients with iNPH compared to conservative therapy, or shunting of CSF using VP or VA shunts.To assess the perioperative and postoperative complication rates in patients with iNPH after ETV compared to conservative therapy, VP or VA shunting. SEARCH METHODS: We searched for eligible studies using ALOIS: a comprehensive register of dementia studies, The Cochrane Central Register of Controlled Trials (CENTRAL) and several bibliographic databases such as MEDLINE (Ovid SP), EMBASE (Ovid SP), PsycINFO (Ovid SP), CINAHL (EBSCOhost) and LILACS (BIREME).We also searched the Database of Abstracts of Reviews of Effects (DARE) to identify potentially relevant reviews. The search strategy was adapted for other databases, using the most appropriate controlled vocabulary for each. We did not apply any language or time restrictions. The searches were performed in August 2014. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of ETV treatment of iNPH. Patients had to have at least two symptoms of the Hakim-Adams triad. Exclusion criteria were obstructive causes of hydrocephalus, other significant intracranial pathology and other confirmed causes of dementia. The eligible comparators were conservative treatment or shunting using VP and VA shunts. DATA COLLECTION AND ANALYSIS: Two review authors independently screened search results, selected eligible studies, assessed risk of bias and extracted data. We contacted trial authors for additional data. MAIN RESULTS: Only one study met the inclusion criteria: an RCT comparing effectiveness of ETV and non-programmable VP shunts in 42 patients with iNPH. The study was conducted in Brazil between 2009 and 2012. The overall study risk of bias was high. The primary outcome in the study was the proportion of patients with improved symptoms one year after surgery, determined as a change of at least two points on the Japanese NPH scale. Due to imprecision in the results, it was not possible to determine whether there was any difference between groups in the proportion of patients who improved 3 or 12 months after surgery (3 months: odds ration (OR) 1.12, 95% confidence interval (CI) 0.26 to 4.76, n = 42; 12 months: OR 2.5, 95% CI 0.62 to 10.11, n = 38). We were unable to estimate the effect of treatment on other efficacy outcomes (cognition, balance, function, gait and mobility) because they were inadequately reported. Of the 26 patients in the VP shunting group, 5 developed subdural hematoma postoperatively, while there were no complications among the 16 patients in the ETV group (OR 0.12, 95% CI 0.01 to 2.3, n = 42), but the estimate was too imprecise to determine whether this was likely to reflect a true difference in complication rates. This was also the case for rates of further surgical intervention (OR 1.4, 95% CI 0.31 to 6.24, n = 42). There were no deaths during the trial. We judged the quality of evidence for all outcomes to be very low because of a high risk of selection, attrition and reporting bias and serious imprecision in the results. AUTHORS' CONCLUSIONS: The only randomised trial of ETV for iNPH compares it to an intervention which is not a standard practice (VP shunting using a non-programmable valve). The evidence from this study is inconclusive and of very low quality. Clinicians should be aware of the limitations of the evidence. There is a need for more robust research on this topic to be able to determine the effectiveness of ETV in patients with iNPH.

Reversible Peripheral Facial Nerve Palsy During Airplane Travel.

BACKGROUND: Facial baroparesis is reversible palsy of the facial nerve that may occur due to a pressure change in the middle ear when ascending in an airplane or during scuba diving. The objective is to present a rare case of facial paresis during airplane travel.CASE REPORT: We report a 49-yr-old female patient who presented with a 30-min episode of transient right facial paresis with loss of taste during airplane travel. Brain magnetic resonance imaging (MRI) showed a small left parietal developmental venous anomaly, extensive inflammation of the paranasal sinuses, which were almost completely obstructed with thickened mucosa and mastoid cell secretion bilaterally. Nasal decongestants and antibiotics were prescribed. No new neurological signs or symptoms were noticed.DISCUSSION: Reversible facial baroparesis due to the pressure change in the middle ear should be considered in cases where present medical history includes ascent/airplane takeoff or prolonged diving and should not be mistaken for transitory ischemic attack.Mikus K, Tudor KI, Pavlisa G, Petravic D. Reversible peripheral facial nerve palsy during airplane travel. Aerosp Med Hum Perform. 2020; 91(8):679-681.

[Unusual open craniocerebral injury caused by sickle's tip]. / Neobicna otvorena kraniocerebralna ozljeda zetelackim srpom.

A nine years old girl suffered an unusual penetrating injury to the head caused by a sickle's tip sticked into the skull bones during a lavender harvest on island of Hvar. GCS score was 15. A sickle's blade and its handle were clearly seen coming out of the frontal bone, hanging free, while its tip was firmly sitting in the skull bones! After a neuroradiological diagnostical work up (skull x rays and CT scans) that confirmed intracranial penetration she was operated as an emergency. An osteoclastic craniotomy was done, a and a sickle thereafter easily extracted. Lacerated and contused brain and the penetrating canal were debrided and dura defect covered with a patch. Broad spectrum antibiotics were administered after antitetanic prophylaxis. Postoperative course was uneventful especially regarding infection. One year after the accident she goes normaly to school.

[Amusia and aphasia of Bolero's creator--influence of the right hemisphere on music]. / Amuzija i afazija tvorca Boléra--utjecaj desne hemisfere na glazbu.

OBJECTIVES: The experience with cortical localization (BA 44, 45, 22) of language (Broca, Wernicke and others) in the left hemisphere has been repeatedly tested over the last 150 years and is now generally accepted. A single case report with autopsy findings (Leborgne, Tan tan), has enabled to localize the seat of spoken language in the left third frontal convolution. As music and language have a lot in common and even share the same hearing system, it is logical to try to localize the cognitive centers for music too. METHODS: The disabling neurological disease illness of Maurice Ravel (1875-1937), a French impressionist composer, is not the right example to localize music center as that of Broca's language center, but it demonstrates the role of the right hemisphere in music production. In the last five years of his life, Ravel suffered from an unknown disease that affected the left hemisphere causing aphasia, apraxia, alexia, agraphia and amusia. It was the reason why Ravel could not compose during the last years of his life. In contrast to Ravel, Shebalin and Britten continued writing music works of their own although aphasic after having sustained two strokes to the left hemisphere. While lacking clinical cases with selective ablative brain lesions, research into the music localization can be done using modern imaging technologies such as fMRI and PET. RESULTS: Exercising music (professionally) develops analytical process in the left hemisphere whereas other individuals process music in their right hemisphere. There is right ear (left hemisphere) predominance in musicians and vice versa in musical amateurs. Music lateralization towards the right hemisphere is seen in women and in inattentive listeners. It can be subject to cultural influence, so the Japanese process their traditional popular music in the left hemisphere, whereas Westerners process the same music in the right hemisphere. Music and language are processed separately; they are localized in homologous regions of the opposite hemispheres. In 1937, Ravel underwent neurosurgical procedure performed by Vincent; autopsy was not done. It is believed that the cause of hi disease was primary progressive aphasia associated with Pick's disease. CONCLUSION: Boléro and Concerto for the Left Hand were the last Ravel's works (the onset of his disease), so it is possible that the projected the influence of the healthy right hemisphere onto his music (and on the creative process) because Ravel's left hemispher was damaged. Indeed, in these last music works one can feel the predominance of changes in pitch (timbre), i. e. right hemisphere, in comparison to only few changes of melody (left hemisphere).

[Electrosurgery, the cornerstone of current achievements of brain tumor surgery--on the occasion of 80th anniversary]. / Elektrokirurgija, temelj suvremenih dosega operacija tumora mozga--prigodom 80. Obljetnice.

Neurosurgical pioneers had so many obstacles that prevented safe work and favorable outcome of the patients operated on. The mortality rate was high and discouraging. The operations were fast and rude whereafter the patients were dying or suffered prolonged hemorrhagic shock. The three cornerstones of neurosurgery, i. e. cerebral localization, asepsis and narcosis, had not yet been discovered and the only diagnostic tools available were recently discovered x-rays, ventriculography and angiography. However, the greatest challenge for the neurosurgeon was that even if luckily localized through a craniotomy, how to remove the brain tumor while avoiding uncontrollable bleeding. Therefore, an array of techniques and tricks were developed such as bone wax, Cushing silver clips, packing of the wound, etc. but all of them were insufficient in case of intracerebral hemostasis. Electrosurgery revolutionized this unacceptable situation thoroughly. It was introduced in neurosurgery 80 years ago (on October 1, 1926) by great Cushing, whereupon its usage has spread rapidly worldwide. The mortality rate was lowered to 13%! The coagulator was constructed by Harvard's physicist Bovie, after whom is named. Owing to the new technique, the control of bleeding in neurosurgery has become much safer, craniotomies are larger than before and the operation time is esentially longer. Since the perfection of bipolar coagulation (by Greenwood and Malis brothers), and after the introduction of the operating microscope (Donaghy, Krayenbühl, Yasargil) in 1970, this half of a century-long monopolar era was over, and the new time of microneurosurgery has begun. It enables better, easier and more precise hemostasis of the magnified brain blood vessels (microscope).